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One-Time Subgingival Irrigation

Should I use chlorhexidine or stabilized chlorine dioxide for one-time subgingival irrigation after scaling and root planing?

Chlorhexidine gluconate (0.12%) is known as the gold standard for antimicrobials due to its demonstrated efficacy. Prescription mouthrinses containing chlorhexidine are indicated for gingival inflammation, caries, and in-office preprocedural rinsing. Two systematic reviews revealed significant plaque and gingivitis reductions when using a chlorhexidine mouthrinse as compared to placebos.1,2 However, chlorhexidine mouthrinses can cause staining of tooth surfaces, restorations, and the tongue, as well as taste alterations.

Stabilized chlorine dioxide mouthrinses are used in plaque reduction and oral malodor prevention. They do not seem to cause staining. One product containing this compound has earned the American Dental Association Seal of Acceptance for oral malodor. A 2020 systematic review and meta-analysis concluded that chlorine dioxide reduces both plaque and gingival indices, and bacterial counts similar to other commonly used mouthrinses.3 The available evidence is limited, however, and large scale randomized controlled trials and additional clinical data are needed.3 

Research on one-time subgingival irrigation with antiseptics post-scaling and root planing (SRP) does not support its use at this time. A 2020 systematic review found that subgingival irrigation with antiseptics did not show significant improvements in bleeding on probing, probing depth, or clinical attachment levels with a follow-up of at least 6months.4 Factors affecting a single episode of subgingival irrigation with antiseptics post-SRP are the deactivation of agents by blood and crevicular fluids, gingival tissue tone and pocket depth affecting penetration, type of delivery method, and short-term suppression of microbes. Although microbes are suppressed by antimicrobial subgingival irrigation, they might not be eliminated and can return to baseline in a short time.

A relative question is “What is the purpose of subgingival irrigation after SRP?” For lavage of periodontal pockets, subgingival irrigation with water via a syringe, pulsating device, or ultrasonic instrumentation might be adequate. For reducing the microbial count between professional visits, repeated applications over time are most likely necessary. To treat gingival inflammation, an efficacious antimicrobial mouthrinse could be recommended for daily patient use. For treating clinical indicators of periodontitis, research does not support this one-time treatment for periodontitis. 

The gold standard of nonsurgical periodontal therapy is SRP to disturb or remove plaque biofilms and remove calculus. In most cases, this therapy alone is adequate to initiate the expected healing. Cases that do not result in healing are reevaluated for patient self-care practices, residual calculus deposits, and need for adjunctive therapy. 

In conclusion, for a single episode of antimicrobial subgingival irrigation to be effective, it should enhance the clinical effects of instrumentation alone. Research to date does not demonstrate a beneficial effect at 6 months regardless of the agent used. Controlled-release delivery (chips, fibers, gels) is thought to produce a more constant and prolonged concentration of the agent compared to systemic (oral antibiotics) and topical delivery (irrigation).

References

1. Van Strysonck D, Slot DE, Van Der Velden U, Van Der Weijden GA. Effect of a chlorhexidine mouthrinse on plaque, gingival inflammation and staining in gingivitis patients: a systematic review. J Clin Periodontol. 2012;39:1042–1055.

2. James P, Worthington HV, Parnell C, et al. Chlorhexidine mouthrinse as an adjunctive treatment for gingival health. Cochrane Database Syst Rev. 2017;3:1–247.

3. Kerémi B, Márta K, Farkas K, et al. Effects of chlorine dioxide on oral hygiene—a systemic review and meta analysis. Curr Pharm Des. 2020;26:3015–3025. 

4. Ramanauskaite E, Machiulskiene V. Antiseptics as adjuncts to scaling and root planing in the treatment of periodontitis: a systematic literature review. BMC Oral Health. 2020;20:143.

The Ask the Expert column features answers to your most pressing clinical questions provided by Dimensions of Dental Hygiene’s online panel of key opinion leaders, including: Jacqueline J. Freudenthal, RDH, MHE, on anesthesia; Nancy K. Mann, RDH, MSEd, on cultural competency; Claudia Turcotte, CDA, RDH, MSDH, MSOSH, on ergonomics; Van B. Haywood, DMD, and Erin S. Boyleston, RDH, MS, on esthetic dentistry; Michele Carr, RDH, MA, on ethics and risk management; Erin Relich, RDH, BSDH, MSA, on fluoride use; Kandis V. Garland, RDH, MS, on infection control; Mary Kaye Scaramucci, RDH, MS, on instrument sharpen­ing; Stacy A. Matsuda, RDH, BS, MS, on instrumentation; Karen Davis, RDH, BSDH, on insurance coding; Cynthia Stegeman, EdD, RDH, RD, LD, CDE, on nutrition; Olga A.C. Ibsen, RDH, MS, on oral pathology; Jessica Y. Lee, DDS, MPH, PhD, on pediatric dentistry; Timothy J. Hempton, DDS, on periodontal therapy; Ann Eshenaur Spolarich, RDH, PhD, on pharmacology; and Caren M. Barnes, RDH, MS, on polishing. Log on to dimensionsofdentalhygiene.com/asktheexpert to submit your question.

From Dimensions of Dental Hygiene. January 2022; 20(1)47.

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