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35]

Original Article

Effectiveness of a controlled release

chlorhexidine chip (PerioColTM‑CG)
as an adjunctive to scaling and root
planing when compared to scaling
and root planing alone in the
treatment of chronic periodontitis:
A comparative study
Kameswari Kondreddy, N. Ambalavanan, T. Ramakrishna, R. Saravana Kumar

Department of Abstract:
Periodontology and Aims and objectives: The aim of this study is to evaluate the effectiveness of a controlled‑release
Imlantology, Meenakshi chlorhexidine chip as an adjunctive therapy to scaling and root planing when compared with scaling and
Ammal Dental College, root planing alone in the treatment of chronic periodontitis. Materials and Methods: 20 patients with a total
Maduravoyal, Chennai, number of 40 posterior sites were selected. These sites were divided into two groups in a split mouth design,:
India Group A (control site) had 20 sites treated with scaling and root planing alone and Group B (test site) had
20 sites treated with scaling and root planing and PerioColTM-CG. The clinical parameters (Plaque index,
bleeding on probing, probing pocket depth, clinical attachment level) were recorded at baseline, 90th and
180th day for both the groups. Results: When both groups were compared the change in Plaque index was
significantly higher in Group B when compared to Group A on the 90th day and 180th day. However, there was
no statistically significant difference in the mean percentage of gingival bleeding sites between the two groups
Access this article online on the 90th day, though Group B showed a statistically higher reduction in the mean percentage of gingival
Website: bleeding sites at the end of 180th day. There was no statistically significant difference in probing pocket depth
www.jisponline.com between the two groups on both 90th and 180th day. Gain in clinical attachment level was significantly higher
DOI:
in Group B when compared to Group A on the 90th and 180th day. Conclusion: From the results observed
10.4103/0972-124X.106909 in this study, it can be concluded that the adjunctive use of PerioColTM‑CG was safe and provided significant
improvement in both Plaque index and gingival bleeding index. It was also more favorable than scaling and
Quick Response Code: root planing alone for gain in clinical attachment level.
Key words:
Chronic periodontitis, chlorhexidine, scaling and root planing, probing pocket depth and clinical attachment level

INTRODUCTION Adjunctive administration of systemic

antimicrobials has been useful in treating

T he main therapeutic approach for the

management of periodontal disease includes
mechanical scaling and root planing, thereby
periodontal pockets. However, the dose necessary
to achieve sufficient local concentrations of
antimicrobials in the periodontal environment
Address for
correspondence: removing the bacterial deposits from tooth might be associated with undesirable side
Dr. K Kameswari surface. Because of the complex anatomy of the effects. Local administration therefore may be
Kondreddy, Department roots and contours of the lesion, mechanical considered as an alternative to overcome these
of Periodontology and
periodontal treatment alone may not be effective, problems. The local delivery device consists of
Imlantology, Meenakshi
Ammal Dental College, and sufficient in the reduction of the bacterial load a drug reservoir and a limiting element that
Alapkkam Main Road, to make the tooth surface biologi cally acceptable. controls the rate of the medicament release.
Maduravoyal, Moreover, the success of mechanical periodontal The goal is to maintain effective concentrations
Chennai ‑ 600 95, India. treatment is closely related to the patient’s oral of chemotherapeutic agents at the site of action
Email: hygiene performance. Recurrent periodontal for longer periods.[1]
drkameswarikondreddy@
tissue destruction is almost inevitable in patients
yahoo.co.in
who fail to achieve an acceptable plaque control Local delivery devices can be divided into
Submission: 14-12-2010 during treatment or maintenance phase of two classes according to the duration of the
Accepted: 05-01-2012 periodontal therapy.[1] medicament release:

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Kondreddy, et al.: PerioColTM‑CG as an adjunctive to SRP in the treatment of chronic periodontitis
• sustained release devices
• controlled delivery devices
Sustained release formulations are designed to provide drug
delivery for less than 24 h. On the other hand, controlled
delivery systems should have duration of drug release that
exceeds 1 day.[2,3]
Chlorhexidine has long been used as an effective antimicrobial
agent. Its mechanism of action relates to reduction in pellicle
formation, alteration of bacterial adherence to teeth and an
alteration of bacterial cell wall causing lysis. Chlorhexidine is
effective against subgingival plaque bacteria when delivered
via a sustained‑release device for 9 days. The antimicrobial
effects were evident up to 11 weeks after treatment, and clinical
efficacy in terms of reduced probing depth, clinical attachment
levels, and reduction of bleeding on probing was evident.
A biodegradable chip for sustained and direct delivery of
chlorhexidine to the periodontal pocket has been developed.[4]
The aim of this study is to evaluate the effectiveness of a
controlled‑release chlorhexidine chip (PerioColTM‑CG) as an
adjunct to scaling and root planing when compared with
scaling and root planing alone in the treatment of chronic
periodontitis.
PerioColTM-CG is manufactured by Eucare pharmaceuticals
(P) Ltd. PerioColTM‑CG is a small, orange‑ brown rectangular
chip. It is rounded at one end for easy insertion into periodontal
pockets. Each PerioColTM‑CG contains approximately 2.5 mg of
chlorhexidine gluconate in a biodegradeable matrix of Type 1
collagen derived from fish sources. PerioColTM‑CG releases
chlorhexidine in vitro with a release profile of approximately
40‑45% within 24h and afterward in linear fashion for 7‑8 days.
The release profile may be explained by initial burst effect due
to diffusion of the drug from the chip followed by release of
the drug due to enzymatic degradation.
MATERIALS AND METHODS
Twenty patients, aged 35‑55 years, diagnosed with generalized
chronic periodontitis, having probing pocket depth ≥5mm
were selected from the Department of Periodontology and
Implantology, Meenakshi Ammal Dental College, Chennai, for
this study which was approved by Ethical Committee.
A total number of 40 posterior sites were selected. These sites
were divided into two groups in a split mouth design.
Group‑A (control site) had 20 sites treated with scaling and
root planing alone.
Group‑B (test site) had 20 sites treated with scaling and root
planing and PerioColTM‑CG.
Exclusion criteria included allergy to chlorhexidine, presence of
overhanging restoration, smoking, pregnant women, those who
have received antibiotics or any form of periodontal treatment
in the previous 6 months.
Study design
After selection of patients, a full mouth supragingival scaling
554
was done with ultrasonic scalers and oral hygiene instructions
were given. Impressions were taken and an acrylic stent was
made for standardized measurements of probing pocket depth
and clinical attachment level [Figure 1a, c-e].
The clinical parameters (Plaque index, bleeding on probing,
probing pocket depth, clinical attachment level) were recorded
at baseline, 90th, and 180th day.
Baseline (0 day): After recording the clinical parameters, scaling
and root planing was performed using ultrasonic scalers
and Gracey curettes in control sites [Figure 2] and test sites
[Figure 3a]. It was followed by the placement of PerioColTM‑CG
at the (test sites) Group‑B [Figure 3b].
Placement of Periocol‑CG: After scaling and root planing, the
test sites were dried with cotton pellets. The PerioColTM‑CG
was taken with a sharp tweezer tip from an individual foil
packet. PerioColTM‑CG was moistened with normal saline.
It was grasped at the flat end, and the curved end was first
inserted into the periodontal pocket. It was gently pressed
apically to the base of the pocket without any folds [Figure 3b].
After placement into the test sites, patients were instructed
not to use interdental cleansers such as dental floss or tooth
pick for the next 10 days to avoid displacement, or any kind of
chemotherapeutic mouth rinses or oral irrigation device. The
patients were recalled on the third and seventh day to assess
the position of PerioColTM‑CG.
On 90th day: The clinical parameters were recorded in both
Groups A and B [Figures 2 and 3a]. Supragingival scaling was
performed in both Groups A and B. PerioCol‑CGTM was again
placed into Group B.
On 180th day: The clinical parameters were recorded in both
Groups A and B.
Statistical analysis
The mean and standard deviation were compared by using
Student’s paired t‑test, Wilcoxon’s signed rank test, and
McNemar’s test.
RESULTS
Overall, 40 sites were treated, 20 with SRP and 20 with SRP
plus CHX chip.
Table 1 shows the comparison of mean, standard deviation, and
test of significance for the Plaque index score between Groups
A and B at different time points.
At baseline, there was no statistically significant difference in
the Plaque index score between the SRP alone and the CHX plus
Table 1: Comparison of mean, standard deviation, and
test of significance for the Plaque index score between
Groups A and B at different time points
Treatment Baseline 90th day 180th day
Group A 1.5(0.3) 1.1(0.3) 0.9(0.3)
Group B 1.5(0.3) 0.9(0.3) 0.7(0.2)
P value 0.32 0.001 <0.0001
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Kondreddy, et al.: PerioColTM‑CG as an adjunctive to SRP in the treatment of chronic periodontitis

a b

c d e
Figure 1: (a) Armamentarium; (b) PerioCol-CG; (c) Chronic periodontitis; (d) Assessment of bleeding on probing; (e) After scaling and root planing

a
Figure 2: Group A - Measurement of probing pocket depth and clinical attachment
level using acrylic stent

SRP group. Both groups had a significant change in the Plaque

index score at 90 and 180 days. At the 90th day, the plaque index
score was reduced to 1.1 in the SRP alone group and 0.9 in the
SRP plus CHX chip group. Further improvements occurred in
the Plaque index score at 180th day, 0.9 in SRP alone, and 0.7 in
the SRP plus CHX chip group, respectively.

Table 2 shows the percentage of gingival bleeding sites in

Group A and Group B at different time points.

The positivity of gingival bleeding sites was 100% at baseline b

in both Group A and Group B. On the 90th day, there was
25% reduction in gingival bleeding sites in Group A and 45%
reduction in Group B. On 180th day, there was 40% reduction
in gingival bleeding sites in Group A and 85% reduction in
Group B.
Table 3 shows the comparison of mean, standard deviation,and
test of significance for probing pocket depth between
Figure 3: (a) Group B-Measurement of probing pocket depth and clinical attachment
level using acrylic stent; (b) Placing of PerioCol-CG
Group A and B at different time points. At baseline, there was
no statistically significant difference in probing depth between
the SRP alone and CHX plus SRP group. At 90th day, PD was
reduced to 6.2 mm in the SRP alone group and 5.8 mm in the

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Kondreddy, et al.: PerioColTM‑CG as an adjunctive to SRP in the treatment of chronic periodontitis

SRP plus CHX chip group compared to baseline. At 180th day Table 2: Percentage of gingival bleeding sites in Group
PD was further reduced to 4.8mm in SRP alone group and A and B at different time points
4.2 mm in the SRP plus CHX chip group, respectively. Time point Gingival Group A Group B P value
bleeding index (n=20) (n=20)
Table 4 shows the comparison of mean change in probing No. % No. %
pocket depth between Group A and B from baseline. Mean Day 0 + 20 100 20 100 −
reduction in probing pocket depth between 0 and 90th day in − 0 0 0 0
Group A was 1.4±0.5 mm and in Group B it was found to be Day 90 + 15 75 11 55 0.12(NS)
1.6±0.5 mm. Mean reduction in probing pocket depth between − 5 25 9 45
180th day in Group A was 2.8±1.0 mm and in Group B it was Day 180 + 12 60 3 15 0.004(Sig.)
found to be 3.2±0.6 mm. − 8 40 17 85
+ : Presence / postivity for bleeding; − : Absence / negativity for bleeding
Table 5 shows the comparison of mean change in clinical
attachment level between Group A and B from baseline. The Table 3: Comparison of mean, standard deviation, and
mean gain in clinical attachment level from Day 0 to 90 in test of significance for probing pocket depth between
Group A was 1.3±0.5 mm and in Group B it was 1.8±0.6 mm. Group A and B at different time points
The mean gain in clinical attachement level from Day 0 to 180 Treatment Baseline 90th day 180th day
in Group A was 2.7±1.0 mm and in Group B it was 3.2±0.9 mm.
Group A 7.6 mm (1.0) 6.2 mm (1.2) 4.8 mm (1.4)
Group B showed a significant gain in the clinical attachment Group B 7.4 mm (1.0) 5.8 mm (1.1) 4.2 mm (1.3)
level as compared to Group A from baseline to 90th day and P value 0.27 0.03 0.04
180th day, respectively.

DISCUSSION Table 4: Comparison of mean change in probing pocket

In clinical trials by Soskolne[5] and Jeffcoat,[6] Periochip was used
as an adjunctive to scaling and root planing in the treatment of
chronic periodontitis. Both studies showed that the adjunctive
use of Periochip was effective in reducing Plaque index scores,
bleeding on probing, probing pocket depth, and gain in clinical
attachment level when compared to scaling and root planing
alone.
In the present study, supragingival plaque decreased
significantly from baseline in both the groups as a result
of full mouth supragingival and subgingival scaling. In
Group A, the mean reduction in the Plaque index score was in
accordance to studies done by Mc Nabb et al.,[7] Dahlen et al.,[8]
and Ximmenez‑Fyvie et al.[9] who demonstrated that repeated
professional supragingival plaque control reduced both supra
and sub‑gingival plaque. The reduction was higher in Group B
because of application of PerioColTM-CG This result was similar
to the study done by Mizrak et al.[10] The plaque scores were
maintained at a low level throughout the study, indicating good
oral hygiene performance of all the patients and successful
re‑motivation and instruction in supportive periodontal care.
Both the treatment groups presented marked reduction in
the percentage of bleeding sites. On comparing both these
parameters between the groups, the reduction was more
significant in Group B compared to Group A. The results in
Group A were similar with the results of Mc Nabb et al.,[7]
Dahlen et al.,[8] and Ximmenez‑Fyvie et al.[9] who demonstrated
that repeated professional supragingival plaque control
reduced counts of both supra‑ and sub‑gingival plaque and may
have altered the inflammatory state of the periodontal tissues.
In Group B, apart from supragingival scaling, the adjunctive
placement of PerioCol‑CG would have released chlorhexidine
with drug concentration greater than 125 µg/ml into the
periodontal pocket for 7‑10 days. This concentration has been
reported to be above the minimum inhibitory concentration for
more than 99% of subgingival microorganisms. This change
in microflora would have further reduced the inflammatory
depth between Group A and B from baseline
Treatment Day 0 to 90 Day 0 to 180
Group A 1.4 mm (0.5) 2.8 mm (1.0)
Group B 1.6 mm (0.5) 3.2 mm (0.6)
P value 0.10 0.07
Table 5: Comparison of mean change in clinical
attachment level between Group A and B from baseline
Treatment Day 0 to 90 Day 0 to 180
Group A 1.3 mm (0.5) 2.7 mm (1.0)
Group B 1.8 mm (0.6) 3.2 mm (0.9)
P value 0.004 0.05
state of periodontal tissues, thus bringing about reduction
in the bleeding on probing. The results in Group B were in
accordance with the results of the study done by Killoy et al.[4]
In the present study, the mean reduction in probing pocket
depth in Group A was similar to the studies done by Hill,[11]
Pihlstorm,[12] and Cugini.[13] The mean reduction in probing
pocket depth in Group B was similar to studies done by
Soskolne,[14] Jeffcoat,[15] Azmak,[16] and Paolantonio.[17]
On comparison of the mean probing pocket depth between
Group A and B, there was no statistically significant difference
observed from the baseline to 90 th day and baseline to
180th day. On clinical examination, Group B demonstrated a
higher reduction in probing pocket depth when compared to
Group A. In Group A, the probing pocket depth would have
reduced because of the beneficial effects of scaling and root
planing which occurred within the first 3 months followed by
a period of stability aided by maintenance scaling. In Group B,
the probing pocket depths reduced because of the placement
of PerioColTM‑CG. This indicates that there was an additional
beneficial effect of chlorhexidine apart from scaling and root
planing alone. The continuing efficacy of chlorhexidine was
due to the fact that the periodontal pockets received a second
application of chlorhexidine at 3 months with supragingival

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Kondreddy, et al.: PerioColTM‑CG as an adjunctive to SRP in the treatment of chronic periodontitis
scaling while the control group received supragingival scaling
only.
The mean gain in the clinical attachment level from baseline to
90th day, and baseline to 180th day was statistically significant in
Group A and Group B. On comparing the mean gain in clinical
attachment level between Group A and B, the gain was higher
in Group B. In Group A, the improvement in clinical attachment
level was due to deeper baseline probing depth in the present
study. According to Kaldahl,[18] there was greater gain in clinical
attachment level after scaling and root planing with PPD of
>4 mm. In Group B, the sites were treated by SRP followed by
treatment of periodontal pockets with PerioColTM‑CG. With
the additional placement of chlorhexidine chip, there was
sustained exposure of chlorhexidine in pocket environment
for 6‑9 days which gave long‑lasting effects on microbiota.
This would have brought about additional gain in the clinical
attachment level in Group B. These findings were similar to
studies by Soskolne[14] and Jeffcoat[15] who also demonstrated
gain in the clinical attachment level in test sites which received
the chlorhexidine chip.
Studies done by Mizrak[10] and Azmak[16] demonstrated that
after placement of Periochip there was reduction in GCF PGE2
and GCF MMP‑8 levels. In this present study, the adjunctive use
of chlorhexidine along with SRP resulted in a beneficial effect
in both clinical and microbiological parameters which could
have been due to reduction in GCF PGE2 levels and reduction
in GCF MMP‑8 levels. The microbiological analysis and GCF
analysis after placement of the chlorhexidine chip was not
performed as it was not within the scope of this study.
However, long‑term studies are required with larger sample
size and longer time period with microbiological analysis to
evaluate the effectiveness of PerioColTM‑CG.
CONCLUSION
From the results observed in this study, it can be concluded
that the adjunctive use of PerioColTM‑CG was safe and provided
significant improvement in the Plaque index and gingival
bleeding index. It was more favorable than scaling and root
planing alone in the reduction of probing pocket depth and
gain in the clinical attachment level.
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How to cite this article: Kondreddy K, Ambalavanan N,
Ramakrishna T, Kumar RS. Effectiveness of a controlled release
chlorhexidine chip (PerioColTM‑CG) as an adjunctive to scaling and
root planing when compared to scaling and root planing alone in
the treatment of chronic periodontitis: A comparative study. J Indian
Soc Periodontol 2012;16:553-7.
Source of Support: Nil, Conflict of Interest: None declared.
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