The Effect of a 0.

125%
Chlorhexidine Rinse on
Inflammation After Periodontal
Surgery
M. E.
Vaughan*
and J. J.
Garnickt
The purpose of this study was to determine the effect of a 0.125% Chlorhexidine
gluconate
rinse
on inflammation and bacterial
plaque
formation after
periodontal surgery.
Nine
patients
who
required
two periodontal surgeries
in two
posterior
areas were selected. The
first
surgical
site was
randomly assigned
into either
1)
active or
2) placebo groups.
The
patient's
second site was
assigned
to the alternate
group.
In
Group
1 the
patients
rinsed with
Chlorhexidine
(CH)
and in
Group
2 with
placebo solution,
both for 14
days.
No
periodontal
dressing
was used and at least 1 month
elapsed
before the second
surgery
was
performed.
Plaque index, gingival index,
and crevicular fluid
flow measurements were obtained
at
baseline,
and at 1 and 2 weeks after
surgery.
The Chlorhexidine rinse
significantly
reduced
the amount of
plaque
at both 1 and 2
weeks,
and
gingival
inflammation remained similar
to base line measurements at
2 weeks. Neither solution had
any
effect on the amount of
crevicular fluid flow. There was an increase in amount of
perceived postoperative pain
and
gingival swelling
with the use of the Chlorhexidine
rinse,
but no difference in the number of
pain pills
taken
during
this
study.
The Chlorhexidine rinse was an effective
plaque preventive
agent
after
surgical procedures. (Journal ofPeriodontology 1989;60:704-708)
Active treatment of
periodontal
disease consists of
plaque
control
by
the
patient,
with root
planing
and
surgery performed by
the dental
practitioner. Plaque
control
following surgery
is essential for successful heal-
ing. Immediately
after
surgery
it is
especially
difficult
and uncomfortable for
patients
to
perform
mechanical
oral
hygiene
at the
surgical site,
and
they
tend not to
clean the site for
approximately
2 weeks.
Thus,
the
desirability
for
plaque
control becomes obvious.
Clinical trials have shown that careful
plaque
control
is
necessary
to avoid the recurrence of disease
following
periodontal surgery.1-2
Burke3 demonstrated that bac-
terial contamination of a wound surface resulted in
delayed healing
due to an increased
inflammatory
re-
sponse
and
granulation
tissue formation.
Hamp
et al.4
provided
histometric evidence in
dogs
that showed
increased
gingival
inflammation
following
standardized
biopsies
if
plaque
was
regularly present
in the wound
healing
area.
Plaque control, therefore,
has a
significant
effect on
surgical healing.
In
addition,
clinical trials have shown that a
signifi-
cant amount of
plaque
formed under conventional
periodontal dressings.5'6
Since it has also been estab-
lished that Chlorhexidine
(CH) mouthrinsing
does not
influence the amount of
plaque
that forms under
peri-
*
Private
practice,
Marietta, GA.
t Department of Periodontics and
Periodontology
Section, Dental
Research Center, School of
Dentistry,
Medical
College
of
Georgia,
Augusta,
GA.
odontal
dressings,7
other methods must be
developed
to control the
plaque.
Chlorhexidine rinse is the most effective
antiplaque
agent
available
today.
Numerous clinical trials in hu-
mans have shown it to be effective
against plaque
and
gingivitis.8"11 Moreover,
recent research indicates that
even reduced concentrations of CH can reduce
plaque
formation.
Segreto
et al.12 found that a 0.12% CH
mouth rinse
provided
the same clinical benefits as a
0.2% rinse when used twice
daily.
Grossman et al.13
confirmed that 0.12% CH
gluconate significantly
re-
duced
gingivitis (both
inflammation and
bleeding sites)
and
plaque
accumulation for 6 months.
Using
the same
subjects
as
Grossman,
Briner et al.1415found that 0.12%
CH treatment did not
produce a detectable shift in
supragingival
microbial
populations
or an increase in
resistance to the rinse.
A number of studies have evaluated the use of
CH in the
postoperative healing
of
periodontal
wounds.4'516'17"21 CH
incorporated
into
dressings
or
ap-
plied topically,
has been
compared
with conventional
periodontal dressings,
and with
professional prophy-
laxis.
Newman and
Addy5 compared
CH with
periodontal
pack
on
healing during
the first week after
periodontal
surgery.
In 15
patients
who
required comparable
bilat-
eral
flap procedures they
found less inflammation in
the CH treated sides. In addition most of the
patients
preferred
the mouthrinse.
Asboe-Jorgensen
et al.16 in-
corporated
CH
(0.2%)
into
periodontal dressings
and
704
Volume 60
Number 12
compared
it to
dressings
without CH. The
dressings
were worn for 11
days
in 10
patients
with reverse bevel
flap operations. Throughout
the 35
day
observation
period,
the CH treated sites showed less
gingival
exdate
and a decreased
tendency
to bleed.
They
concluded
that CH did not affect the
healing
rate.
Hamp4
found
that 0.2% CH
applied topically
once
daily provided
ideal conditions for
healing following biopsy by
remov-
ing existing plaque
and
preventing
new
plaque
forma-
tion. He also stated that the use of CH
following surgery
had no adverse side effects. Bakeen et al.17
compared
CH
(1.0%)
and
placebo gels applied
with a toothbrush.
In 15
patients
with bilateral
surgeries they
found no
significant
differences in
gingival
fluid
flow, gingival
inflammation, plaque index,
and
pocket depths.
CH
reduced the
degree
of
pain
and
swelling
but more
patients preferred
the
placebo.
Westfelt et al.18
compared
CH
mouthrinsing (0.2%)
with
regularly performed professional
tooth
cleaning
as
a
plaque
control measure after
periodontal surgery.
Seven
patients
rinsed with 0.2% CH twice a
day
for 6
months.
During
the same
period
another seven
patients
received
professional
tooth
cleaning every
2 weeks.
Following
reexamination at 6 months all 14
patients
received a
professional cleaning every
3 months for 18
months.
They
concluded that
self-performed
mouthrin-
sing
with CH
may
be an
acceptable
alternative to
professional
tooth
cleaning following periodontal
sur-
gery.
On the other
hand,
some results of
published
research
indicated no or adverse effects with the of CH. Bassetti
and
Kallenberger19 applied
0.5% CH to
open
mucosal
osseous wounds in 60 rats.
They
found that in
surgery
where bone was
exposed
CH 0.5% resulted in
delayed
and disturbed wound
healing. They
state that 0.1 % and
0.2% CH would
only slightly delay healing. Addy
and
Dolby20 compared
0.2% CH mouthrinse with conven-
tional
periodontal dressings.
In 21
patients
with bilat-
eral
gingivectomies they
found no
clinically significant
difference in clinical
pocket depth
1 month after the
surgeries.
Other
investigators
showed adverse effects on tissue
studied in vivo. Lindhe et al.21
applied
0.2% CH to
intact and dekeratinized hamster
cheek-pouch
mucosa.
They
found
hemolysis,
intravascular
granulocytosis,
and thrombus formation in the dekeratinized mucosa
while the intact mucosa was not disturbed. Neiders and
Weiss22 found an inhibition of adhesion of Ehrlich
ascites cells to tooth surface in vitro. Goldschmidt et
al.23 found that
exposure
of cell cultures of human
gingival
fibroblasts and Hela cells to concentrations of
CH
equal
to or
greater
than 0.01 % resulted in the death
of these cells.
The
conflicting
results
published
in the literature
indicated the need to
study
the effect of a 0.125% CH
solution on bacterial
plaque
and tissue after
periodontal
surgery.
The
specific
aims of this
study
were to deter-
Effect of
Chlorhexidine
After
Periodontal
Surgery
705
mine the effect of
mouthrinsing
with a 0.125% CH
solution on
1) plaque
formation,
2) gingival
inflam-
mation,
and
3)
crevicular fluid flow
during
the first 2
weeks
following periodontal surgery.
MATERIALS AND METHODS
Ten
patients
were selected for the
study
from a
pool
of
patients
who had
completed
initial
therapy
at the
Department
of
Periodontics,
Medical
College
of Geor-
gia.
Each
patient
selected had at least two
posterior
areas that
required surgery
where
primary
closure was
anticipated. Osteotomy
and
ostectomy
were
permitted.
The
surgeries
were
performed by
different
periodontic
residents,
but all measurements were
performed
inde-
pendently by
the
principal investigator.
Additional
pa-
tient
requirements
were no antibiotics in the last 3
months,
no
systemic diseases,
and no current use of
anti-inflammatory
medications. The initial
procedures
consisted of a
comprehensive
clinical
examination,
oral
hygiene instructions,
root
planing,
and
polishing.
A Chlorhexidine rinse and a
placebo
were used. The
active rinse contained 0.125%
CH,
Peridex.* The
pla-
cebo rinse contained the same
ingredients
as the
exper-
imental rinse
except
for CH and the
wetting agent,
sorbitan
diisostearate; Quinidinef
was used to simulate
the bitter taste of Chlorhexidine. The rinses were
pre-
coded
utilizing
a table of random numbers in such a
way
that each
patient
utilized the active rinse for one
surgery
and the
placebo
for the other. The second
surgery
was
performed
at least 1 month after the first
surgery
to reduce the effect of the first rinse. The
experiment
was conducted in a double blind manner.
Immediately prior
to each of two
surgical procedures,
the
patient
received a baseline examination at the mid-
buccal of one tooth. Successive examinations at 7 and
14
days postoperatively
were
performed
at the same
site. Crevicular fluid was collected with a filter
paper
strip
held at the
gingival margin
for 10 seconds and
immediately
measured with a Periotron
60004
Also
the
Plaque
Index
(PI)24
and
Gingival
Index
(GI)25
at
the site were obtained.
Each
patient
had a
surgical quadrant randomly
as-
signed
to Active
Group
1 and Placebo
Group
2. In
Group
1 the
patients
rinsed with 15 ml of CH twice a
day
for 14
days beginning
the
day
of
surgery.
In
Group
2 the
patients
used the same procedure
but rinsed with
15 ml of
placebo.
The
patients
were instructed to rinse
for 30 seconds after their normal oral
hygiene proce-
dures at
night
and in the
morning.
Each
patient
was
issued 16 ounces of solution. No
periodontal dressing
was used. Patients were instructed to resume their
normal oral
hygiene procedures
at the
surgical
site as
*
The Procter
& Gamble
Company, Cincinnati,
OH.
t Lederle Laboratories,
Wayne,
NJ.
X
Harco Electronics
Limited, Winnipeg,
MB.
706
Vaughan,
Garnick
J. Periodontol.
December 1989
soon as
possible.
Sutures were removed 7
days
after the
surgery.
Reexaminations were
performed
at 7 and 14
days following surgery
and consisted of crevicular fluid
flow, PI, and GI. The
surgical
sites were
professionally
cleaned at 7 and 14
days immediately
after the exami-
nation.
Each
patient
was
given
a
diary
in which to
daily
record and rank
pain, swelling,
and the amount of rinse
used. Pain and
swelling
were evaluated
using
a scale of
one to
10;
one was none
(0)
and 10 was severe. Pain
was also evaluated on the basis of the number of
pain
tablets used
by
the
patient.
Patient
compliance
was
monitored
by
the use of the
diary
and
by measuring
the amount of rinse that was returned at the end of the
14
day rinsing period.
A
pilot study
on five additional
patients
was used to
perform duplicate PI, GI,
and crevicular fluid flow
measurements. The examiner's overall
accuracy
for
both PI and GI
readings
was 85%. The standard error
of the estimate for
crevicular fluid flow
readings
was
+0.84%.
The crevicular fluid
flow measurements were ana-
lyzed
with Wilcoxon's
signed
rank test. The baseline PI
and GI were
analyzed
with McNemar's
Chi-square
test.26 Since the values of PI and GI at 1
and 2 weeks
fell into three
categories,
a
generalization
of McNemar's
test,
the Fleiss and Everitt
Chi-square test,27
was uti-
lized.
Subjective
data from the
patient's diary
were
obtained
by summing
the
daily entry
and
analyzed
with
Wilcoxon's
signed
rank test.
Significance
was
accepted
at P< .05.
RESULTS
In this
study,
9 out of 10
patients completed
both the
surgery
and
postoperative appointments.
There were
seven females and two males
ranging
in
age
from 22 to
61
years
with a mean of 42
years.
One
patient
withdrew
from the
study
because of
objections
to the taste of the
rinse. As a result of the random
sampling,
five
patients
started with the
placebo
and four started with the active
rinse. The
analysis
of the baseline
examinations' re-
vealed that there were no
significant differences in the
PI
{P
=
0.22),
Gl
(P
=
0.48),
and crevicular fluid flow
(P
=
0.82)
between the
groups.
The amount of
plaque
accumulated was
significantly
less with the CH rinse at 1
(
=
0.024)
and 2 weeks
(P
=
0.049)
than with the
placebo
rinse
(Table 1).
The
amount of
plaque apparently
increased after
surgery
in
the control
(P
=
0.02)
but not in the
experimental
group (P
=
0.16) (Table 1).
The
gingival
index increased
significantly
after sur-
gery
with
only
the
placebo
rinse and remained
high
after the second week
(P
=
0.03).
In the active rinse
group
the GI remained similar to baseline levels
throughout
the 2 weeks
(P
=
0.48).
In
comparing
the
two
groups, the index was
significantly
lower for the
active rinse
compared
with the
placebo
rinse
by
the
second week
(P
=
0.02)
with a
tendency
to
significance
at 1 week
(P
=
0.095) (Table 1).
The data on crevicular fluid flow measurements in-
dicated that crevicular fluid flow in both
groups
in-
creased
significantly
at 1 and 2 weeks
(active rinse,

=
0.004; placebo rinse,

=
0.01).
There were no
signifi-
cant differences between the two
groups
at either time
periods,
7
day (P
=
0.65);
14
day (P
=
0.87) (Table 1).
Slight staining
of the teeth and
tongue
with the active
rinse occurred in most
patients by
the end of 2 weeks.
In addition there were
significant differences in
post-
operative pain (P
=
0.016),
seven
subjects rating pain
greater
with the active rinse.
However,
there were no
significant
differences
(P
=
1.0)
in the number of
pain
pills
utilized. The amount of
perceived swelling
of the
active rinse
group
was
significantly greater (P
=
0.016)
Table 1
Comparison of Changes
in Clinical Assessments
After
Periodontal
Surgery for Both Chlorhexidine
and Placebo Rinse
Groups
Clinical
n
Chlorhexidine Placebo Level of
Assessment Mean s.e. Mean s.e.
Significance
Plaque
Index
0 0.67

0.17 0.22 0.15
=
0.220
7 0.22 0.22 1.67 0.24

=
0.024
14
0.22
0.22 1.22 0.22
=
0.049
=
0.16*
=
0.02*
Gingival Index 0 0.55
0.18 0.56 0.18
=
0.480
7
0.77
0.22 1.33 0.17
=
0.095
14 0.33 0.17 1.11
0.11

=
0.020

=
0.48*
=
0.03*
Crevicular Fluid 0 44.33 07.21 45.33 06.82
=
0.82
7
89.22 06.41 83.00 14.51
=
0.65
14 93.44 06.42 92.00 07.60
=
0.87
= 0.004*
=
0.010*
Level of
significance between 0 and 14
days.
Volume 60
Number 12
than the
placebo group;
seven
subjects indicated more
swelling
with CH rinse.
DISCUSSION
A 0.125% Chlorhexidine rinse has
recently
been ad-
vocated
by
the manufacturer to treat some forms of
gingivitis.
In addition some
periodontists
have
sug-
gested
its use after
periodontal surgery
to
prevent
dis-
ruption
of the
healing process
by plaque
formation.
This
study
tests the
ability
of a 0.125% CH rinse to
maintain a
relatively plaque
free
environment until the
patient
can clean the area
adequately.
It is estimated
that the
patient
can renew
good plaque
control
proce-
dures
by
the end of 2 weeks with well
adapted flap
closure.
In this
study,
the
surgical procedures
were
similar,
utilizing flaps
to attain closure of the wound. The
flaps
were
replaced
to the
original position
after extensive
instrumentation of the root surface.
However,
four
different
periodontal residents
performed
the
surgeries
which
may
have introduced
variability. Nevertheless,
every
effort was made to standardize the
surgical pro-
cedures and one
investigator
evaluated the
parameters
used in the
study, thereby reducing
these
possible
vari-
ations in the research
protocol.
The
distribution of
patient's
sites to the two
groups
was
assigned randomly.
The
placebo
rinse differed from the active rinse
by
containing
no sorbitan
diisostearate or Chlorhexidine
gluconate
but did contain
quinidine
sulfate to simulate
the bitter taste of
Chlorhexidine. The
similarity
of sur-
gical procedures,
taste of the
solutions,
and the random-
ization of
patient's
sites tended to
eliminate variables
in the evaluation of the effectiveness of active and
placebo
rinses.
Crevicular fluid
flow measurements for both
groups
were
occasionally high during
the first week because of
the
difficulty
in
obtaining
a
dry gingival
surface im-
mediately
after
surgery. Drying
the surface was
painful
to the
patient
and
achieving
an
acceptable
surface was
difficult.
However,
this
variability
was not
significant
in that the fluid flow measurements for the first week
did not differ from the second week.
The use of the active rinse
significantly
reduced the
amount of
plaque compared
to the
placebo
at both 1
and 2 weeks. This
plaque-inhibiting
effect of 0.125%
CH has
only
been shown with a limited number of
studies.1213 The active rinse
significantly
reduced the
gingival
index at 2 weeks. This result did not
agree
with
Bakeen et al.17 who found little effect on the
gingival
index
using
a 1.0%
gel.
In this
study,
neither solution had an effect on the
amount of crevicular fluid flow. The amount increased
at 1 and 2 weeks with no
significant differences between
the two
groups.
This
agrees
with the
findings
of Bakeen
et al.17
Apparently by
the second week the reduction of
Effect of
Chlorhexidine
After
Periodontal
Surgery
707
plaque
affected the inflammation of the
gingival margin
as
expressed by
the
gingival index,
but not the
deeper
tissue as shown
by
the crevicular fluid flow. Sandalli et
al.28 and Arnold et al.29 found that the increase in fluid
flow lasted
approximately
4 to 5 weeks after
surgery.
Therefore,
the elimination of
plaque
at 2 weeks resulted
in a small effect on crevicular fluid flow
compared
to
the tissue
change
caused
by
the
surgical
wound.
The
subjects
were asked to maintain a
diary
to
pro-
vide additional
subjective
information and to encour-
age compliance
with the
protocol.
In
addition, they
were asked to return
any remaining
rinse so that the
amount used could be determined. The
resulting
com-
pliance,
as evaluated
by
the
investigators
was excellent.
There was an increase in the
patients' perception
of
postoperative pain although
no difference was obtained
in the number of
pain pills
used. This
disagrees
with
the results of Bakeen et al.17 who found a reduction in
pain
with CH. Our data also indicated that the
experi-
mental solution
produced
more
perceived swelling.
In
our
study, however,
the differences in
perceived pain
and
swelling
were not sufficient to cause an increase in
the use of
pain pills.
These
conflicting
results need
further research for
clarification.
This
study
has shown that
immediately
after
peri-
odontal
surgery
a 0.125%
CH rinse achieved better
control of
plaque
than the use of a
placebo
rinse. Since
both
groups
used
customary
mechanical
plaque
control
methods in addition to the
rinse,
the
suggested impli-
cation is that the CH rinse is more effective in the
control of
plaque immediately
after
surgery
than the
customary
methods.
By
2
weeks,
the reduction of
plaque
had an effect on inflammation of the
gingival
margin
but little on the
healing
of the wound as indi-
cated
by
crevicular fluid flow measurements.
ACKNOWLEDGMENTS
The authors
acknowledge the
help
of Mr. Rollie
Harp,
Office of
Research
Computing and
Statistics, Medical
College of
Georgia,
Augusta, for the
analysis
of data.
REFERENCES
1.
Nyman S, Rosling B,
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cleaning on
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1975;2:80.
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J, Jern B. The
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periodontal
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in
plaque-free dentitions. A
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M. A
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1975;2:136.
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December 1989
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Send
reprint requests
to:
Dr.
J. J. Garnick,
Medical
College
of
Georgia,
School of Dentistry, Department
of
Periodontics, Augusta,
Georgia,
30912.
Accepted
for publication June 22, 1989