Clinical effect of subgingival chlorhexidine i gation

on gingivitis in adolescent orthodontic patients

Dan Morrow, DMD, PhD," David P. Wood, DDS, MCID, b and Mark Speechley, PhD c
London, Ontario, Canada

Twenty-three adolescent orthodontic patients with gingivitis affecting all banded first molars
volunteered for the study. Three measures associated with gingivitis (papilla bleeding index, plaque
index, and probing depth) were recorded at four sites for all four molars. A single application of
subgingival irrigation with 0.12% chlorhexidine digluconate or isotonic saline was performed for 5
seconds at each site. As determined by coin toss, the first molars on the right or left side Of the
mouth received either chlorhexidine or saline irrigation. The papilla bleeding index, plaque index, and
probing depth were recorded before the treatment and subsequently at 2 weeks and then 4 weeks.
The gingival bleeding as determined by papilla bleeding index, was virtually eliminated in 4 weeks by
a single application of subgingival irrigation with either chlorhexidine or saline. However, there was
no significant reduction in pocket depth or plaque index. In addition, no significant difference
between the effect of chlorhexidine or saline was found for any of the outcome measures. (AM J
ORTHOD DENTOFACORTHOP 1992;101:408-13.)

G i n g i v i t i s is known to develop inadolescent fective plaque control is important in adolescent ortho-

patients during fixed orthodontic treatment with the re-
sponse characterized by gingival inflammation and lay-
perplasia. The sites reported to be the most severely
affected are the interproximal areas of the posterior
teeth, and the severity of the inflammation depends on
the level of oral hygiene. However, even orthodontic
patients with excellent oral hygiene have some inflam-
matory changes, i
Histologic evidence indicates that gingivitis in
orthodontic patients is related to dental plaque depos-
its. 2 It has also been shown that gingivitis develops in
the presence of dental plaque in nonorthodontic pa-
tients, and the condition can be reversed in nonortho-
dontic patients with plaque control. 3 Both supragingival
and subgingival plaque plays an important role in the
initiation of inflammation of the gingival tissues. 4'5
It has not been established that gingivitis in patients
with fixed orthodontic appliances results in periodontal
loss of attachment, 6 however, it is considered that in
some cases gingivitis can lead to periodontitis and the
associated periodontal attachment loss. 7 Therefore ef-
From The University of Western Ontario.
=Assistant Professor and Chairman, Division of Periodontics, Faculty of Den-
tistry.
*'Assistant Professor and Clinic Chairman, Graduate Orthodontics, Faculty of
Dentistry.
':Assistant Professor, Department of Epidemiology and Biostatistics, Faculty of
Medicine.
811128951
dontic patients for both the prevention and treatment of
gingivitis.
Thorough plaque control is very difficult in patients
with fixed orthodontic appliances, and the use of chem-
ical agents, such as chlorhexidine in the form of mouth
rinses, have been shown to be useful adjuncts in plaque
control for these patients, s Chlorhexidine is an effective
adjunct to periodontal therapy, but there are some pos-
sible side effects associated with its use. Staining of
the teeth, which may require professional removal, does
occur, and more uncommon, a dulling of taste and
epithelial desquamation is experienced. The latter two
effects resolve after discontinued use of chlorhexidine. 9
Subgingival irrigation with a solution of chlorhex-
idine, either by single or repeated applications over
varying time periods, has been reported to effectively
reduce inflammation in periodontal patients not under-
going active orthodontic treatment? ~ In addition, it
has recently been shown that subgingival irrigation with
either 0.1% chlorhexidine or saline at monthly intervals
over a 5-month period is effective in maintaining both
reduced bleeding on probing and reduced probing at-
tachment levels in patients with advanced periodontal
disease who were treated with scaling and root planing
procedures. ~6 Thus far, the effect of subgingival irri-
gation with chlorhexidine on gingivitis in adolescents
with fixed orthodontic appliances has not been reported.
The purpose of this study was to determine the
clinical effect of a single subgingival irrigation of chlor-

408
Volume 101
Number 5
Table I. Descriptive statistics for three outcome measures (papilla bleeding index, plaque index, and
probing depth) at three time points (n = 23)
M esur e I tim e
I X
Papilla bleeding index
Baseline 0.83
2 weeks 0.24
4 weeks 0.13
Plaque index
Baseline 0.83
2 weeks 0.80
4 weeks 0.96
Probing depth
Baseline 3.10
2 weeks 2.87
4 weeks 2.73
hexidine digluconate on gingivitis affecting orthodon-
tically banded first molars in adolescent orthodontic
patients.
MATERIALS AND METHODS
After the University of Western Ontario Review Board
for Health Sciences Research Involving ttuman Subjects ap-
proved the experimental protocol, eligible patients from ihe
University of Western Ontario Graduate Orthodontic Clinic
were invited to enter the study. Eligibility criteria were age
12 to 17 years, with orthodontically banded maxillary and
mandibular first molars, and existing gingivitis present. The
medical history of all the subjects was noncontributory.
Twenty-five subjects met the criteria and agreed to participate.
Marginal gingivitis, as determined clinically by observing the
redness of the gingiva and the bleeding on probing, affected
all of the banded first molars in all subjects. A pilot study of
I0 subjects revealed high reliability of measurement
(Chronbach's'7 alpha 0.81 to 0.91).
The treatment procedures consisted of isolating the four
first molars with cotton rolls, air drying the teeth, and then
irrigating subgingivally the mesiobuccal, distobuccal, me-
siolingual, and distolingual areas of the teeth with either a
solution of 0.12% chlorhexidine digluconate or sterile isotonic
saline. The subgingival irrigation was done at each of the
four sites for 5 seconds with a flow rate of 20 ml/min with
a commercially available ultrasonic dental instrument de-
signed for use in subgingival irrigation procedures, the Cavi-
Med 200 (Dentsply Canada Ltd., Downsview, Ontario, Can-
ada) with the CM-135 insert. No attempt at root-surface in-
strumentation was made. The Cavi-Med 200 had been pre-
viously calibrated and standardized in terms of flow rate of
the irrigating solutions.
The treatment condition (chlorhexidine versus saline) was
determined by coin toss and applied contralaterally (i.e., de-
termination of treatment condition to the side of mouth was
random and independent for each subject). The operator
(D.W.) was unaware of what solution was being applied.
Effect of subgingival irrigation on gingivitis in adolescents 409
SD
Coefficient o f
variation
0.255 0.307
0.153 0.637
0.100 0.798
0.173 0.215
0.121 0.151
0.130 0.136
0.279 0.090
0.249 0.087
0.197 0.072
Measures of plaque index, ts probing depth with a Mich-
igan 0 probe, and papilla bleeding index~9were taken at the
four interdental papilla sites on each first molar. These mea-
sur.es were taken at baseline and at 2 and 4 weeks after treat-
me nt. The treatments were applied immediately after the base-
line measures. All observations were made by the same ex-
aminer (D.M.), who was blinded as to the treatment condition
,and who did not review the data sheets from previous visits
when recording his measurements.
Patients had previously received oral hygiene instructions,
and they continued their usual oral hygiene procedures
throughout the study. No additional attempts to improve the
patients' oral hygiene were made.
Statistical analysis was by analysis of variance (ANOVA)
with repeated measures using BMDP2V. -'~Confidence inter-
vals about each mean were computed with the following
formula:
95% Confidence interval = X _ ~/2VMS error/n • t44
RESULTS
Of the 25 patients, 23 completed the study. One
patient was unable to attend all scheduled appointments
because of illness and the other because of inclement
weather.
Descriptive statistics for the three outcome mea-
sures are listed in Table 1. Analysis of variance
(ANOVA) was conducted separately on each measure.
In none of these statistical analyses was there a signif-
icant difference between chlorhexidine and saline (not
shown; available on request). Post hoc calculations of
statistical power indicate that we had at least an 80%
chance of finding differences as small as 20% in each
of the three outcome measures (a = 0.05, 2-tailed). 2~
This suggests that the lack of treatment effect is not
-due3_o low statistical power. All three measures (papilla
bleeding index, plaque index, and probing depth)
410 Morrow, Wood, and Speechley Am. J. Orthod. Dentofac. Orthop.
May 1992

CHLORHEXIDINE
. . . . SALINE

1.12

.79
.66 .63

I I I
Baseline 2 weeks 4 weeks

Fig. 1. Plaque index by treatmen t groups on orthodontically banded first permanent molars. Vertical
lines indicate 95% confidence intervals.

Table II. Results of repeated measures analysis of vari~ince across three time points for mean papilla
bleeding 9 Plaque index, and probing 9depth (n = 23)

O.tcome
variablelsource Sum of squares I DF I Mean square F I Probability

Papilla bleeding index

9Time effect 106. i 11 2 53.055 146.15 0.0001
Within subject error 15.973 44 0.363
Plaque index
Time effect 5.418 2 2.709 13.19 0.0001
Within subject error 9.040 44 0.205
Probing depth
Time effect 25.382 2 12.691 9 0.0001
Within subject error 24.326 44 0.553

showed significant differences over time; plaque indices DISCUSSION

increased from baseline to 4 weeks, whereas the other
two measures decreased. The results are summarized
in Table II. To assess the clinical significance Of the
changes, we calculated 95% confidence intervals for
eachmeasure at each time point (Figs. 1 to 3).In the
case of plaque index and probing depth, all differences
over time are within one unit of measurement (e.g.,
plaque increased on aver'age from 0.83 to 0.96 after 4
weeks; probing depth decrea'sed from 3.1 to 2.7 mm
over the same interval). These differences, while sta-
tistically significant, probably do not represent mean-
ingful clinical changes. The measure 0f papilla bleeding
index, however, decreased from near unity (0.83) to
near zero (0.13), a more meaningful clinical achieve-
ment than in the other two measures.
The results of this study show no difference in out-
come between the two solutions, chlorhexidine versus
saline. The repeated measures analysis, sensitive
enough to detect even relatively small differences over
time, consistently indicate an absence of difference be-
tween solutions.
Changes observed in the plaque indices after treat-
ment do not represent a clinically significant reduction
or increase in plaque levels. This could be because no
attempt was made to improve the patients' supragin-
gival plaque control throughout the study and because
the irrigation was restricted to the subgingivai area. Post
hoe power analysis reveals an 80% chance of finding
a difference as small as 14% between groups. The ex-
tremely small size of the differences actually observed
rob,me 101 Effect of subgingival irrigation on ghzgivitis in adolescents 411
Number 5

CHLORHEXIDINE
. . . . SALINE
3.41
~ 3 . 1 8 3 04

2.78
2.56 2.42

I I I
Baseline 2 weeks 4 weeks

Fig. 2. Probing depth by treatment groups on orthodontically banded first permanent molars. Vertical
lines indicate 95% confidence intervals.

CHLORHEXIDINE
. . . . SALINE

1.08
I
.58 " .49 .38

Baseline 2 weeks 4 weeks

Fig. 3. Papilla bleeding index by treatment groups on orthodontically banded first permanent molars.
Vertical lines indicate 95% confidence intervals.

between groups suggest the true absence of a mean-
ingful treatment effect. However, frequent supragin-
gival irrigations with chlorhexidine have been shown
to be effective for reducing plaque in patients with
gingivitis. 22 Studies involving patients with periodontal
pockets treated with more frequent irrigations of chlor-
hexidine solutions have also resulted in significant
plaque reductions. '~
The slight reduction in probing depths seen at 2 and
4 weeks could have resulted from variations in the prob-
ing technique and also from a reduction in gingival
inflammation. The initial shallow probing depths would
tend to limit the amount of probing depth reduction
expected to occur. However, in patients with deeper
periodontal pockets, frequent subgingival irrigations
with chlorhexidine have resulted in significant pocket
reductions. ~~ In addition, subgingival irrigation with
either chlorhexidine or saline in patients with peri-
412 Morrow, Wood, attd Speechley
odontitis has been shown to be effective in reducing
pockets, with the chlorhexidine solution being the more
effective."
The statistically significant reduction in this study
of the papilla bleeding index with either a solution of
0.12% chlorhexidine or isotonic saline has clinical sig-
nificance. The reductions occurred over a 4-week pe-
riod, and the bleeding index at 4 weeks approached
zero. A longer period of observation would allow a
better estimate of extinction of the effect. This would
also allow us to see how long it takes for the gingiva
to return to baseline condition and determine whether
there is a treatment effect after 4 weeks. The reduction
in papilla bleeding index after 4 weeks on patients with
gingivitis in this study with the single irrigation of saline
or chlorhexidine suggests that the effect could be a
result of the irrigation procedure on the subgingival
plaque and is not dependent on the solution used.
In a study involving patients with advanced peri-
odohtal defects, a single irrigation with a 0.2% solution
of chlorhexidine or saline has resulted in significant
reduction in bleeding sites. However, with saline the
bleeding had returned to baseline levels i n 5 weeks,
whereas the chlorhexidine resulted in maintenance-of
the reduction in bleeding sites for at least a 5-week
period. 13 However, patients with gingivitis who have
received repeated irrigations with either water or chlor-
hexidine have shown reduced bleeding on probing, and
the chlorhexidine irrigation was more effective. This
gingival irrigation with chlorhexidine was also more
effective than a chlorhexidine mouthrinse. 22
Subgingival access for irrigation is important, :3''-4
and oral irrigating devices have been shown to be useful
for the delivery of antimicrobial agents in effective
dosages. 25.26
The results of this study show that a single subgin-
gival irrigation of a 0.12% chlorhexidine digluconate
or a isotonic saline with the Cavi-Med 200 can effec-
tively reduce the inflammation of the interdental papilla
of orthodontically banded teeth in adolescent patients.
The effect of reduced inflammation is maintained over
a 4-week period, which frequently coincides with
scheduled orthodontic appointments during active treat-
ment. This would conveniently allow for repeated treat-
ments at specific interproximal sites that are difficult
for plaque control and are the most severely effected
by inflammation in orthodontic patients.
At this time an accurate and practical clinical
method of identifying periodontal sites that are actively
undergoing periodontal destruction or that are poten-
tially active does not exist; however, evidence "does
suggest that sites free of inflammation usually do not
loose periodontal attachment. 27
Am. J. Orthod. Dentofac. Orthop.
?.lab" 1992
It is possible that the mechanism for reduction of
the gingival inflammation associated with subgingival
irrigation may be due to the reduction of specific mi-
croorganisms or toxic products of plaque 22 or by a dis-
ruption of subgingival plaque rather than an instant
killing of microorganisms. 16
CONCLUSIONS
1. Subgingival irrigation of orthodontically banded
first molars with a solution of 0.12% chlorhexidine
digluconate or isotonic saline virtually eliminated gin-
gival papillary bleeding over a 4-week period. How-
ever, this does not insure that all of these sites are free
of periodontal disease activity or that they are immune
to future periodontal breakdown.
2. There is no difference between a single subgin-
gival irrigation with either the chlorhexidine or the sa-
line solution over a 4-week period.
3. Subgingival irrigation is an effective procedure
that could be performed during monthly visits on ad-
olescent orthodontic patients to reduce the gingival
bleeding associated with inflammation.
We wish to acl~nowledge Dentsply Canada Ltd. for pro-
viding financial support for this project. The support of Mrs.
Vicky Rhyno and Ms. Beverley Goldsmith for the typing of
the manuscript is gratefully acknowledged.
REFERENCES
I. Zachrisson S, Zachrisson BU. Gingival conditions associated
with orihodontic treatment. Angle Orthod 1972;42:26-34.
2. Zachrisson BU. Gingival condition associated with orthodontic
treatment II: histologic findings. Angle Orthod 1972;42:352-7.
3. Lre H, Theilade E, Jensen SB. Experimental gingivitis in man.
J Periodontol 1965;36:177-87.
4. Slots J. Subgingival microflora and periodontal disease. J Clin
Periodontol 1979;6:351-82.
5. Fillery ED, Pekovic DD. Identification of microorganisms in
immunopathologiealmechanismon humangingivitis. J Dent Res
1982;61:253.
6. Alstad S, Zachrisson BU. Longitudinalstudy of periodontal con-
dition associated with orthodontictreatment in adolescents. AM
J OR'ntOD1979;76:277-86.
7. Page RC. Gingivitis. J Clin Periodontol 1986;13:324-9.
8. Zachrisson BU. Cause and prevention of injuries to teeth and
supporting structures during orthodontictreatment. A.~IJ ORTHOD
1976;69:285-300.
9. Greenstein G, Berman C, Jaffin R. Chlorhexidine an adjunct to
periodontal therapy. J Periodontol 1986;57:370-7.
10. Soh LL, Newman HN, Strahan JD. Effects of subgingival chlor-
hexidine irrigation on periodontal inflammation. J Clin Peri-
odontol 1982;9:66-74.
I1. MacAlpine R, Magnusson I, Kiger R, Crigger M, Garret S,
Egelberg J. Antimicrobial irrigation of deep pockets to supple-
ment oral hygiene instruction and root debridement. J Clin Peri-
odontol 1985;12:568-77.
12. Wieder SG, Newman HN,' Strahan .ID. Stannous fluoride and
subgingival chlorhexidine irrigation in the control of plaque and
chronic periodontitis. J Clin Periodontol 1983;10:172-81.
Vo/ume 101 Effect of subgingival irrigation on gingivitis in adolescents 413
Number 5

13. Lander PE, Newcomb GM, Seymour JG, Powell RN. The an-
timicrobial and clinical effects of a single subgingival irrigation
of chlorhexidine in advanced periodontal lesions. J Clin Peri-
odontol 1986;13:74-80.
14. Watts EA, Newman HN. Clinical effects on chronic periodontitis
of a simplified system of oral hygiene including subgingival
pulsated jet irrigation with chlorhexidine. J Clin Periodontol
1986; 13:666-70.
15. Wennstrom JL, Heijl L, Dahlen G, Grondahl K. Periodic subgin-
gival antimicrobial irrigation of periodontal pockets. I. Clinical
Observations. J Clin Periodontol 1987;14:541-50.
16. Schlagenhauf U, Stellwag P, Fiedler A. Subgingival irrigation
in the maintenance phase of periodontal therapy. J Clin Peri-
odontol 1990;17:650-3.
17. Norusis JM. SPSS/PC+ Advanced Statistics VZ.0. Chicago:
SPSS Inc., 1988:B206-7.
18. Silness J, L~3e ti. Periodontal disease in pregnancy. II. Corre-
lation between oral hygiene and periodontal condition. Acta
Odontol Scand 1964;22:121-35.
19. Muhlmann HR. Psychological and chemical mediators of gin-
gival health. J Prev Dent 1977;4:6-17.
20. Jennrich R, Sampson P, Frane J. P2V analysis of variance and
covariance including repeated measures. In: Dixon WJ, ed.
BMDP Statistical Software. Berkeley: University of California
Press, 1983:359-87.
21. Cohen J. Statistical power analysis for the behavioral sciences.
L. Erlbaum. Hillsdale, NJ, 1988:19-74.
22. Flemmig TF, Newman MG, Doherty FM, Grossman E, Mechel
AH, Bakdash MB. Supragingival irrigation with 0.06% chlor-
hexidine in naturally occurring gingivitis. I. 6 month clinical
observations. J Periodontol 1990;61:112-7.
23. Pitcher OR, Newman HN, Strahen JD. Access to subgingival
plaque by disclosing agents using mouthrinses and direct irri-
gation. J Clin Periodontol 1980;7:300-8.
24. Eakle WS, Ford C, Boyd RL. Depth of penetration in peri-
odontitis pockets with oral irrigation. J Clin Periodontol
1986;13:39-44.
25. Lang NP, Raber K. Use of oral irrigators as a vehicle for the
application of antimicrobial agents in chemical plaque control.
J Clin Periodontol 1981;8:177-88.
26. Lang NP, Ramseier-Grossman K. Optimal dosage of chlorhex-
idine digluconate in chemical plaque control when applied by
the oral irrigator. J CIin Periodontol 1981;8:189-202.
27. Greenstein G, Caton J. Periodontal disease activity: a critical
assessment. J Periodontol 1990;61:543-52.
Reprint requests to"
Dr. D. Morrow
Chairman, Division of Periodontics
Faculty of Dentistry
The Uniyersity of Western Ontario
London, Ontario
NrA 5C!

BOUND VOLUMES AVAILABLE TO SUBSCRIBERS

Bound volumes of the AMERICAN JOURNAL OF ORTttODONTICS AND DENTO-
FACIAL ORTIIOPEDICS are available to subscribers (only) for the 1992 issues f r o m
the Publisher, at a cost o f $53.00 ($67.71 Canada and $64.00 international) for
Vol. 101 (January-June) and Vol. 102 ( J u l y - D e c e m b e r ) . Shipping charges are in-
cluded. Each b o u n d v o l u m e contains a subject and author index and all advertising
is r e m o v e d . C o p i e s are shipped within 60 days after publication o f the last issue
in the v o l u m e . T h e binding is durable b u c k r a m with the journal n a m e , v o l u m e
number, and y e a r stamped in g o l d on the spine. Paytnent must accompany all
orders. Contact M o s b y - Y e a r B o o k , Inc., Subscription S e r v i c e s , 11830 Westline
Industrial D r i v e , St. Louis, M O 63146-3318, U S A ; telephone (314)453-4351 or
(800)325-4177.
S u b s c r i p t i o n s m u s t be in f o r c e to q u a l i f y , . B o u n d v o l u m e s a r e n o t a v a i l a b l e
in p l a c e o f a r e g u l a r J o u r n a l s u b s c r i p t i o n .