Oral Mouthrinses and Periodontal Surgery In General
Microbial contamination and infection of postsurgical area inhibit normal tissue healing process. Minimizing the amount of postoperative dental plaque accumulation leads to more rapid and without complications wound healing. A negative correlation has been found between the amount of dental plaque at the postsurgical site and both gain in soft tissue attachment and osseous fill after periodontal surgical procedures. The first European Workshop in Periodontology (United Kingdom, 1994) concluded that meticulous postsurgical plaque control is an essential factor for a successful periodontal surgery outcome.
Self–performed mechanical plaque removal measures, using toothbrush and interdental brushes or dental floss, is essential for maintaining periodontal and dental health. However, mechanical removal of dental plaque in the early postoperative period (first 7-10 days) is almost not feasible because of sensitivity and pain released from the operated area and many times undesirable due to the risk of tissue irritation and traumatization. Therefore many different protocols have been proposed in order to control postsurgical microbial count.
Chemical supragingival plaque control appears to be an adjunct and not replacement for the mechanical methods, but it is a viable alternative when mechanical measures appear partially or totally ineffective alone or cannot be applied (for example during the immediate postoperative period). There is a plethora of commercially available mouthrinses containing various antimicrobial agents. Those containing digluconate chlorhexidine (CHX) are supposed to be the most effective in dental plaque reduction. Chlorhexidine is a potent antibacterial and antiplaque agent belonging to the bisbiguanide family. It is characterized by a broad antimicrobial spectrum against Gram positive / negative bacteria, yeasts and viruses (e.g. HSV1, HSV 2, Influenza A). CHX shows a persistent bacteriostatic action lasting in excess of 12 hours (supragingival substantivity). It cannot lead to development of resistant bacterial strains, even after prolonged use. On the other hand, as any antimicrobial / antiseptic agent, CHX has a number of local side effects. The most frequent one is brown discoloration of the teeth and some restorative materials and the dorsum of the tongue.
A common substance, present in the majority of CHX formulations, is ethanol. Ethanol has been associated with oral mucosa dryness, tissue irritation of postoperative areas, addiction symptoms in chronic alcoholic patients who have stopped drinking and increased risk for oral cancer. Even if no causal relationship between alcoholic mouthwashes and oral cancer has been proved, mainly due to existence of many confounding factors, formulations with ethanol display some disadvantages.
For that reason, chlorhexidine formulations lacking ethanol have been developed in the recent years. The efficacy of these formulations has been investigated in many studies and has been shown to be comparable to that of alcoholic ones. In the majority of those studies, the efficacy of alcoholic and non-alcoholic CHX formulations has been tested on periodontally healthy (or with gingivitis) patients, evaluating their ability to prevent dental plaque formation and inhibit gingival inflammation. The results indicate that there are no significant differences between the above mentioned formulations. However, there are no clinical studies evaluating the efficacy of CHX formulations with and without ethanol in the postsurgical control of microbial plaque and gingival healing response after periodontal surgical procedures.
Undoubtedly, CHX is the gold standard at a chemical level in the control of plaque and gingivitis. On the other hand, it displays side effects and in some cases its administration is contraindicated. In the literature there are few studies that have evaluated the efficacy of other antimicrobial agents (as for example hexitidine and amine / stannous fluoride), besides CHX, as a postoperative regime of plaque control after periodontal surgery. However, there is a plethora of antimicrobials / antiseptics widely available today, such as factor C31G (Therasol), that have not been evaluated at a periodontal postsurgical level.
“A randomized controlled clinical trial on the effectiveness of three
different mouthrinses (chlorhexidine with or without alcohol and C31G),
adjunct to periodontal surgery, in early wound healing.”
AM Gkatzonis et al. 2018
This is a controlled, randomized, double-blind clinical trial, which evaluated the effectiveness of three different oral mouthrinses in postsurgical dental plaque control and early wound healing adjunct to periodontal flap surgery. The trial was conducted at the Department of Periodontology, School of Dental Medicine, National and Kapodistrian University of Athens, Greece. The effectiveness of the tested mouthrinses was evaluated both clinically and microbiologically. The microbiological assessment was performed at the Laboratory of Cell and Matrix Pathobiology at the Institute of Biosciences and Applications, National Center for Scientific Research (N.C.S.R.) “DEMOKRITOS”, Athens, Greece. The results displayed that alcohol-based chlorhexidine (Plak out 0,12%) was superior compared to alcohol-free chlorhexidine (Chlorhexil 0,12%) and C31G (alkyl dimethyl glycine/alkyl dimethyl amine oxide, Therasol), regarding postsurgical plaque control. The results demonstrated that, regarding plaque control, the most effective mouthrinse was alcohol-based chlorhexidine. At the level of early wound healing improvement, C31G was as effective as alcohol-free chlorhexidine and these both mouthwashes were more effective than alcohol-free mouthrinse. Within the limitations of this study we can conclude that the presence of alcohol may increase the effectiveness of chlorhexidine in early wound healing response, as well as, that C31G might be prescribed alternatively to chlorhexidine formulations after periodontal flap surgery.