Use of Chlorhexidine Following Scaling and Root Planing

QUESTION: Should chlorhexidine be used after scaling and root planing?

ANSWER: Mouthrinse containing 0.12% chlorhexidine gluconate is both bacteriostatic—interfering with biofilm growth—and bactericidal— disrupting bacterial cell walls. Additionally, chlorhexidine interferes with bacterial adherence to the oral soft tissues, reducing recolonization. Chlorhexidine has a high substantivity, as the positively charged chlorhexidine molecule can adhere to the negatively charged periodontal tissues for hours. Other commercially available mouthrinses do not adhere to the soft tissues for any significant length of time. Clinical research on chlorhexidine mouthrinses has demonstrated a reduction of supragingival plaque accumulation and gingival inflammation. As bacterial plaque is the etiology of periodontitis, chlorhexidine is viewed as a valuable therapeutic medicament.

Subgingival scaling and root planing is a well-documented and effective treatment for chronic periodontitis. It reduces probing depths, improves clinical attachment levels, and reduces gingival inflammation/ bleeding on probing. In addition, scaling and root planing significantly reduces the red complex subgingival bacteria.¹

As chlorhexidine reduces supragingival plaque accumulation and soft tissue inflammation, it would seem logical to assume that this would be a beneficial adjunctive treatment to combine with scaling and root planing.

To determine whether this assumption is valid, investigators have looked at clinical parameters comparing scaling and root planing alone or in combination with chlorhexidine mouthrinses over time. Two parameters most often utilized in evaluating the effects of scaling and root planing are a reduction in probing depth and an improvement in clinical attachment level. Pocket depth reduction is measured by comparing probing depths prior to treatment with probing depths measured at various intervals after scaling and root planing. Clinical attachment level is a measurement from the cementoenamel junction to the base of the pocket. An improvement in clinical attachment level would be revealed by decreasing measurements made at various intervals subsequent to completion of scaling and root planing.

A 2017 meta-analysis analyzed previous studies comparing scaling and root planing alone with adjunctive chlorhexidine rinses.² The eight studies included in the evaluation were 6 months in length. Probing depths prior to treatment were compared with probing depths measured at various points. In all of the studies included, the investigators examined the impact of chlorhexidine as an adjunct to treatment on measurements of probing depths reduction and improvement in clinical attachment level. The analysis indicated that chlorhexidine did result in improvements in pocket depth reduction when used as an adjunct to scaling and root planing. The average gains, although statistically significant, should not be regarded as clinically significant. On average, pocket depth reduction was 0.33 mm at 40 days to 60 days. Moreover, the measurements reduced to an average of 0.24 mm at 6 months. Regarding improvement in clinical attachment levels, no statistically significant differences were reported.

In conclusion, recent evidence indicates that the benefits of chlorhexidine rinses in conjunction with scaling and root planing are extremely slight relative to pocket depth reduction and negligible relative to improvement in clinical attachment levels. In addition, chlorhexidine rinses also have the potential to stain, create taste alterations, and add increased cost. Oral professionals may consider using chlorhexidine for patients with limited capability for good oral hygiene or in the presence of severe inflammation prior to scaling and root planing. For all other patients, it may be more practical to review and stress good self-care regimens.

REFERENCES

1. Haffajee AD, Patel M, Socransky SS. Microbiological changes associated with four different periodontal therapies for the treatment of chronic periodontitis. Oral Microbiol Immunol. 2008 Apr;23:148–157.
2. da Costa LFNP, Amaral CDSF, Barbirato DDS, Leão ATT, Fogacci MF. Chlorhexidine mouthwash as an adjunct to mechanical therapy in chronic periodontitis: A meta-analysis. J Am Dent Assoc. 2017;148:308–318.

From Dimensions of Dental Hygiene. July 2018;16(7):52.