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ORIGINAL ARTICLE
Year : 2012  |  Volume : 1  |  Issue : 1  |  Page : 38-45

Clinical effects of professional antimicrobial subgingival pulsated jet irrigation [WaterPik®] in patients with chronic periodontitis: A comparative study


1 Department of Periodontics, CKS Teja Institute of Dental Sciences, Tirupati, India
2 Department of Periodontics, Govt. Dental College, RIMS, Kadapa, India
3 Department of Periodontics, Sri Rama Dental College, Kanpur, India
4 Department of Periodontics, Triveni Dental College, Bilaspur, Chhatishgarh, India

Date of Web Publication21-Mar-2012

Correspondence Address:
N Ravindrareddy
Department of Periodontics, CKS Teja Institute of Dental Sciences, Tirupati, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-8632.94174

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  Abstract 

Background and Objectives : Gingivitis and periodontitis are primarily bacterial infections caused by diverse groups of microorganisms. The prevalence and severity of these diseases can be reduced by mechanical plaque removal or a variety of systemic and topically applied antimicrobial agents, aimed at selectively removing or inhibiting pathogenic bacteria. Hence, the present study is designed to evaluate the role of professional subgingival irrigation in chronic generalized periodontitis patients.
Materials and Methods: Eight subjects were randomly selected between age groups 25 and 55 years, with a total of 160 active sites with chronic periodontitis. Each quadrant was required to have at least one site with a probing depth of ≥5 mm to ≤9 mm, with radiographic evidence of bone loss. For every patient, the first quadrant received no treatment, the second quadrant received scaling and root planning (SRP) only, the third quadrant received SRP plus professional subgingival 0.12% chlorhexidine gluconate irrigation with WaterPik; device, and the fourth quadrant received treatment with WaterPik; device only. Treatment sites were irrigated on 0, 7 th , and 15 th days. Plaque index, bleeding index, gingival index, and clinical attachment levels were measured and recorded at 0, 15 th , 30 th , and 45 th days.
Results: With subgingival irrigation with 0.12% chlorhexidine gluconate, there was significant reduction in all clinical parameters: plaque index, bleeding index, and gingival index in all the groups.
Interpretation and Conclusion: Subgingival irrigation with 0.12% chlorhexidine gluconate along with scaling and root planing appeared to be effective in gaining clinical attachment levels and other parameters than scaling and root planing alone or subgingival irrigation with 0.12% chlorhexidine gluconate alone in the treatment of chronic adult periodontitis.

Keywords: Subgingival irrigation, 0.12% chlorhexidine gluconate, chemotherapeutic agents


How to cite this article:
Ravindrareddy N, Madhubabu D S, Mahendraraju C, Himasilpa C, Kiran K. Clinical effects of professional antimicrobial subgingival pulsated jet irrigation [WaterPik®] in patients with chronic periodontitis: A comparative study. J NTR Univ Health Sci 2012;1:38-45

How to cite this URL:
Ravindrareddy N, Madhubabu D S, Mahendraraju C, Himasilpa C, Kiran K. Clinical effects of professional antimicrobial subgingival pulsated jet irrigation [WaterPik®] in patients with chronic periodontitis: A comparative study. J NTR Univ Health Sci [serial online] 2012 [cited 2019 Nov 18];1:38-45. Available from: http://www.jdrntruhs.org/text.asp?2012/1/1/38/94174


  Introduction Top


Periodontal diseases are bacterial infections characterized by inflammation and destruction of the attachment apparatus, often leading to tooth loss. It is generally accepted that bacteria play a significant role in the pathogenesis of human periodontal diseases. [1] Almost all of the putative periodontal pathogens can be diagnosed and treated as anaerobic infections. From the early 1970s, the bacterial specificity in periodontal disease has become the prominent area of investigation. [2] Periodontal therapy aims at arresting further loss of periodontal attachment and to ensure an aesthetic outcome. Periodontal disease can be treated by either surgical or non-surgical therapy. Non-surgical therapy, i.e., scaling and root planning (SRP) may not always result in the complete elimination of the disease, because of poor access to the base of the deep periodontal pockets. However, scaling and root planing was found to be of limited efficacy, especially in deep pockets or furcations, because accretions can be easily left behind. Therefore, treatment strategies using antimicrobials in conjunction with SRP have been evolved, assuming that chemical aides would compensate for technical shortcomings, and furthermore prevent early microbial re-colonization to ultimately ensure the best chance for clinical improvements.

Elimination or adequate suppression of putative periodontopathic microorganisms in the subgingival microbiota is essential for periodontal healing. Antimicrobial treatments in periodontics range from mechanical debridement of tooth surfaces and home plaque removal to local and systemic delivery of chemical antimicrobial agents. The increased emphasis on the role of bacteria in the initiation and progression of periodontal disease has led to great interest in the use of antibiotics and antimicrobials in periodontal therapy.

Periodontal diseases are induced by a variety of organisms that colonize and proliferate supragingivally and subgingivally in susceptible individuals. Conceptually, supragingival and subgingival irrigation have the potential to be used by therapists and patients to help in suppressing bacterial etiologic agents. The biologic rationale for performing supragingival and subgingival irrigation is to nonspecifically reduce microbial deposits that may induce periodontal diseases. Subgingival irrigation attempts to directly reduce the pocket microflora to prevent initiation of periodontal diseases or to facilitate their reduction.

Oral irrigation was occasionally suggested as an alternative for those who don't floss, but now it should be considered a regular part of oral hygiene for everyone. Supragingival lavage with water or a placebo was employed in conjunction with tooth brushing, with mixed results regarding its ability to provide additional reduction of gingival inflammation beyond that attained with tooth brushing. [3]

Crumley and Sumner [4] showed that the use of an oral irrigator supragingivally in patients with deep periodontal pockets produced a slight decrease in gingival swelling and bleeding but had no effect on the deeper tissues. There has been little study of the subgingival effect of oral irrigators, expect for that of Selting et al., [5] who devised a model system with 7-mm pockets containing artificial debris. The value of the water-irrigating device as an oral hygiene aid and its role in reduction of gingival inflammation was reported by Lobene. [6] The WaterPik® was first introduced in 1966 as a plaque and debris removal device.

The purpose of this study was to assess the effect of professional subgingival irrigation with 0.12% chlorhexidine gluconate irrigation, combined with scaling and root planing, on clinical parameters of plaque index (PI), bleeding index (BI), gingival index (GI), and clinical attachment levels (CAL) as compared with a non-treatment control, SRP alone, and 0.12% chlorhexidine gluconate irrigation alone, over a period of 45 days, to evaluate positive clinical benefits of professional subgingival antimicrobial irrigation with WaterPik® device using 0.12% chlorhexidine gluconate antimicrobial solution, and to evaluate the additive effect of scaling, root planning, and antimicrobial professional subgingival irrigation with WaterPik® device.


  Materials and Methods Top


The patients for this study were selected from the outpatient section, Department of Periodontics, C.K.S Teja Institute of Dental Sciences and Research, Tirupathi. Eight periodontitis subjects between 25 and 55 years of age, based on presence of probing pocket depth of >5 mm on clinical examination and radiographic evidence of bone loss were selected randomly, and included into study after obtaining verbal and written informed consent from all subjects. This study was reviewed and approved by the board of ethical committee of the Dental College. Patients who were diagnosed as suffering from chronic generalized periodontitis, free from any acute or chronic systemic diseases, who had not received any surgical or non-surgical periodontal therapy for the past 6 months, were included, and patients with the history of taking anti-inflammatory, antibiotics, or immunosuppressive drugs in the last 6 months, with habit of smoking, and female patients who were pregnant or receiving oral contraceptives were excluded from the study.

Eight subjects were selected randomly and categorized into four groups, and all the eight patients received treatment according to a predetermined four-quadrant design. A total number of 160 sites from eight patients, i.e., four sites from each quadrant were selected and divided into the following groups:

  • Control Group: These were sites from the first quadrant in each patient, which included all the surfaces of the periodontally involved tooth with attachment loss, where no treatment was planned.
  • Experimental Group-A: These were the sites from the second quadrant in every patient who were treated by scaling and root planning (SRP).
  • Experimental Group-B: These were the sites from the third quadrant in every patient who received both SRP and professional antimicrobial irrigation using 0.12% chlorhexidine gluconate solution with WaterPik® device.
  • Experimental Group-C: These were the sites from the fourth quadrant who received only professional subgingival antimicrobial irrigation using 0.12% chlorhexidine gluconate solution with WaterPik® device.
Clinical parameters, i.e., PI, BI, GI, and CAL, were recorded for all the patients The relative CAL was measured using UNC-15 (Hu-freidy, USA) periodontal probe, graduated in 1-mm increments. Probing measurements was done at selected sites. The reading was recorded to the nearest millimeter.

Customized occlusal stents were fabricated from the patient models using bio-cryl sheets. The stent was made to cover the occlusal as well as the middle third of buccal and lingual surfaces of the teeth. Vertical grooves were made to guide the probe penetration vertically in the same plane every time it was inserted for recording the measurements. The lower/apical limit of the vertical groove was used as the fixed reference point for the clinical attachment level. Later the stents were preserved for the follow-up measurement. 0.12% chlorhexidine gluconate solution with WaterPik® irrigator was used in irrigating the periodontal pockets. Irrigation was done in experimental sites in group C and group D. The recordings of all the clinical parameters was done on "0" day, 15 th day, 30 th and 45 th day, except probing pocket depth, which was recorded on "0" day and 45 th day. Finally, the complete data was statistically analyzed.

Statistical analysis

For each of the clinical parameters, post-treatment changes at different time intervals compared with baseline were analyzed by paired t-test. Post-treatment significance of difference observed between different groups was ascertained by one-way ANOVA F test followed by Mann-Whitney test for pair-wise comparisons.


  Results Top


The mean PI, BI, and GI scores and the mean CAL at 0, 15 th , 30 th and 45 th day has been shown in [Table 1].
Table 1: Descriptive statistics of baseline parameters in the study population (mean ± SD)

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When mean plaque scores within each group at different intervals were compared, in the control group the mean difference of plaque scores between 0 and 45 th days was statistically non-significant (P = 0.06), and percentage reduction was 15.9%. In experimental group A, the mean difference of PI between 0 and 45 th day was statistically significant (P = 0.03), and percentage reduction was 18.0%. In experimental group B, between 0 and 45 th day, the mean difference was statistically highly significant (P = 0.001), and the percentage of reduction was 22.2%. In experimental group C, the mean difference of plaque scores between 0 and 45 th day was statistically significant (P = 0.05) and the percentage reduction was 13.0%.

When mean BI within each group at different time intervals was compared in control group, the mean difference of BI between 0 and 45 th days was statistically significant (P = 0.05), and percentage reduction was 20.6%. In experimental group A, the mean difference of plaque index between 0 and 45 th day was statistically highly significant (P < 0.001), and percentage reduction was 64.6%. In experimental group B, between 0 and 45 th day was statistically highly significant (P < 0.001), and the percentage of reduction was 75.8%. In experimental group C, the mean difference of plaque scores between 0 and 45 th day was statistically highly significant (P < 0.001), and the percentage reduction was 61.3%.

When mean GI within each group at different time intervals, in control group, the mean difference of GI score between 0 and 45 th day was statistically highly significant (P < 0.001), and percentage reduction was 34.2%. In experimental group A, the mean difference of GI between 0 and 45 th day was statistically highly significant (P < 0.001) and percentage reduction was 20.3%. In experimental group B, between 0 and 45 th day, the mean difference was statistically highly significant (P < 0.001) and the percentage of reduction was 33.8%. In experimental group C, the mean difference of GI scores between 0 and 45 th day was statistically highly significant (P < 0.001), and the percentage reduction was 25.0%.

When CAL within each group at different time intervals, in control group , the mean difference of CAL between 0 and 45 th days was statistically non-significant (P = 1.00), and percentage reduction was 0%. In experimental group A, the mean difference of CAL between 0 and 45 th day was statistically highly significant (P < 0.001), and percentage reduction was 4.9%. In experimental group B, between 0 and 45 th day, the mean difference was statistically highly significant (P < 0.001), and the percentage of reduction was 5.1%. In experimental group C, the mean difference of CAL between 0 and 45 th day was statistically significant (P = 0.03), and the percentage reduction was 2.4% [Table 2] and [Table 3].
Table 2: Comparison of various clinical parameters within each group at different time intervals ("0" to "45 th" day, paired t-test)

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Table 3: Comparison of various clinical parameters within each group at different time intervals ("0" to "45 th" day, paired t-test)

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In the present study, when the clinical parameters were compared between different groups, the mean difference of PI from 0 to 45 th day was 0.25 ± 0.54 (15.9%) for the control group, 0.28 ± 0.55(18.0%) for experimental group A, 0.30 ± 0.51 (22.2%) for experimental group B, and 0.17 ± 0.54 (13.0%) for experimental group C [Table 4]. On comparison of reduction of plaque score, between control group and experimental groups A, B and C, between experimental group A and B, between experimental group A and C, and between experimental group B and C, were not statistically significant from baseline to 45 th day.
Table 4: Comparison of various clinical parameters between different groups at different time periods (one-way anova F-test)

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The mean difference of BI scores from 0 to 45 th day was 0.18 ± 0.55 (20.6%) for the control group, 0.52 ± 0.64 (64.6%) for experimental group A, 0.62 ± 0.49 (75.8%) for experimental group B, and 0.47 ± 0.59 (61.3%) for experimental group C. On comparison of reduction of bleeding scores between control group and experimental group A, B and C, the difference was statistically significant (P = 0.02, P < 0.001, P = 0.03, respectively) and between experimental group A and B, between experimental group A and C, and between experimental group B and C, were not statistically significant from baseline to 45 th day.

The mean reduction of GI from 0 to 45 th day was 0.65 ± 0.53 (34.2%) for the control group, 0.32 ± 0.57 (20.3%) for experimental group A, 0.57 ± 0.55 (33.8%)for experimental group B, and 0.42 ± 0.69 (25.0%) for experimental group C. On comparison of reduction of GI scores between control group and experimental group A and C, the difference was statistically significant (P < 0.01, P < 0.05, respectively) and between control group and experimental group B, between experimental group A and B, between experimental group A and C, and between experimental group B and C, were not statistically significant from baseline to 45 th day.

The mean difference of CAL from 0 to 45 th day was 0 (0%) for the control group, 0.42 ± 0.55 (4.9%) for experimental group A, 0.42 ± 0.50 (5.1%) for experimental group B, and 0.20 ± 0.40 (2.4%) for experimental group C. On comparison of reduction of CAL between control group and experimental group A, B and C, and between experimental group A and C, the difference was statistically significant (P < 0.001, P < 0.001, P = .0033, P = 0.01, respectively) and between experimental group A and B, and between experimental group B and C, were not statistically significant from baseline to 45 th day [Table 5].
Table 5: Mann-Whitney U test for pair-wise comparison of different clinical parameters

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All the clinical parameters, i.e., PI, BI, GI, and CAL showed significant reduction on all days from the baseline.


  Discussion Top


New knowledge about the microbial etiology of periodontal disease emerged between 1970 to 1980 and led to widespread interest in the use of antimicrobial agents to treat periodontitis. With the increasing awareness of bacterial etiology of the periodontal disease (Socransky and Haffejee [1] and Loesche et al.[2] ), a more direct approach using antimicrobial agents has been an integral part of the therapeutic armamentarium.

In the present study, an attempt was made to evaluate effectiveness of professional subgingival irrigation with 0.12% chlorhexidine gluconate in the treatment of periodontal pockets, with or without scaling and root planing in periodontitis patients. The clinical parameters such as PI, BI, GI, and CAL were compared between baseline and 45 th day. CAL measurement on each site selected for treatment was made from an acrylic stent (fixed reference point) to the base of the periodontal pocket (Van Steenberg et al.). [7]

In the present study, the mean reduction of plaque score from "0" to 45 th day was 15.9% in control group, which was statistically non-significant. This was consistent with the findings of Eros S. Chaves et al.[8] This improvement observed from "0" to 45 th day may be due to adequate maintenance of oral hygiene, which was instructed to each patient. In experimental group A, the mean reduction in plaque score from "0" to 45 th day was 18.0%, which was significant (P = 0.03). This finding was similar to that of Badersten et al., [9] Hill et al., [10] Lindhe et al., [11] Lisgarten et al., [12] and Tseng PW et al.[13] In experimental group B, the mean reduction in plaque score from baseline to 45 th day was 22.2%, which was highly significant (P < 0.001); this finding is similar to that of observation made by Robert MacAlpine et al., [14] Steven R. Southard et al., [15] and Thomas F. Flemmig et al.[16] In experimental group C , the mean reduction in plaque score from baseline to 45 th day was 13.0%, which was significant (P = 0.05); this finding similar to that of observation made by Lisgarten et al.[12]

Mean reduction in plaque scores between control group and experimental group A, B, and C, between experimental group A and B, between experimental group A and C, and between experimental group B and C were not statistically significant from baseline to 45 th day. These observations were supported by Krust et al., [17] and Shiloah et al.[18]

When BI was compared, the mean reduction in gingival score from "0" to 45 th day was 20.6% for control group. The reduction in gingival scores was significant (P = 0.05) in control group, maybe due to adequate maintenance of oral hygiene, which was instructed to each patient. The mean reduction in gingival score from "0" to 45 th day was 64.6% for experimental group A. This was consistent with the studies by Badersten et al., [9] Hill et al., [10] Lindhe et al., [11] and Lisgarten et al.[12] The mean reduction in gingival score from "0" to 45 th day was 75.8% for experimental group B, which was in accordance with the studies by David L. Jolkovsky et al., [16] Robert MacAlpine et al., [14] Steven R. Southard et al., [15] and Flemmig et al.[19] The mean reduction in gingival score from "0" to 45 th day was 61.3% for experimental group C, which was consistent with the findings of Lander PE et al.[20] and Soh et al.[21]

On comparison of reduction of bleeding scores, the difference between control group and experimental group A, B, and C were significant. These findings were similar to those of David L. Jolkovsky et al.[16] and Lander PE et al.[20]

For GI, the mean reduction in gingival score from "0" to 45 th day was 34.2% for control group and 20.3% for experimental group A. The reduction in gingival scores was highly significant (P < 0.001) in all the groups, which was consistent with the findings of Steven R. Southard et al.[15] The mean reduction in gingival score from "0" to 45 th day was 33.8% in experimental group B, which was significant and was in accordance with the findings of David L. Jolkovsky et al.[16] and Steven R. Southard et al.[15] The mean reduction in gingival score from "0" to 45 th day was 25.0% in experimental group C, which was significant and was in accordance with the studies by Lisgarten et al.[12] and Steven R. Southard et al.[15]

On comparison between groups, the reduction of the gingival scores was significant (P < 0.01) and (P < 0.05) between control group and experimental group A and C, but the reduction of gingival score was not significant between control and experimental group B.

When CAL was compared, the mean gain in probing attachment levels from "0" to 45 th day was 0% for control group and 4.9% for experimental group A, which is in accordance with the studies done by Badersten et al., [9] Hill et al., [10] Lindhe et al., [11] and Lisgarten et al.[12] The mean gain in CAL from "0" to 45 th day was 5.1% for experimental group B, which was statistically significant (P < 0.001) and is similar to the findings of Robert MacAlpine et al.[14] and Steven R. Southard et al.[15] Mean gain in CAL from baseline to 45 th day was 2.4% in experimental Group C, which was significant (P = 0.03) and the findings were similar to Mazza et al., [22] Soh et al., [21] and Steven R. Southard et al.[15] The mean gain in CAL between experimental group B and C was not significant. However, between control group and experimental group A, B and C and between experimental group A and C, the mean gain in attachment level was significant. These findings strongly support that of Mazza et al., [22] Steven R. Southard et al., [15] and Soh et al.[21]

No adverse reaction was observed with administration of 0.12% chlorhexidine gluconate through professional subgingival irrigation. In another study, investigators reported that a single subgingival irrigation with 0.12% chlorhexidine gluconate or sterile water can result in incidence of bacteremia as with other dental manipulations. [23]

Subgingival irrigation with 0.12% chlorhexidine gluconate along with scaling and root planing appeared to be effective in gaining clinical attachment levels than scaling and root planing alone or subgingival irrigation with 0.12% chlorhexidine gluconate alone in the treatment of chronic adult periodontitis. This finding supports the observations made by Jolkovsky et al.[16]

In the present study, taking into consideration parameters describing clinical features of periodontitis, the results suggest that scaling and root planing in conjunction with subgingival irrigation with 0.12% chlorhexidine gluconate provided a more favorable approach in the treatment of chronic periodontitis patients. This finding was similar to the observation made by Steven R. Southard et al.[15]


  Conclusion Top


With subgingival irrigation with 0.12% chlorhexidine gluconate, there was significant reduction in all clinical parameters, i.e., PI, BI, and GI, in all the groups. When compared between the groups, there was no significant reduction in PI, although SRP, SRP with subgingival irrigation, and subgingival irrigation only groups showed the maximum reduction in plaque index at the end of the study. BI and GI showed significant reduction in SRP and SRP with subgingival irrigation and subgingival irrigation only groups. There was significant gain in CAL in SRP, SRP with subgingival irrigation, and subgingival irrigation only groups.

This study has demonstrated that subgingival irrigation with 0.12% chlorhexidine gluconate in its specially designed formulation can be well tolerated by patients, safe, easy to deliver, and effective in reducing the clinical signs of periodontitis, along with scaling and root planing. However, further studies should be directed towards microbiologic evaluation and determination of long-term efficacy of subgingival irrigation with 0.12% chlorhexidine gluconate on clinical parameters with a lager sample.

 
  References Top

1.Socransky SS, Haffajee AD. The Bacterial Etiology of Destructive Periodontal Disease: Current Concepts. J Periodontol 1992;63:322-31.  Back to cited text no. 1
    
2.Loesche WJ, Syed SA, Schmidt E, Morrison EC. Bacterial Profiles of Subgingival Plaques in Periodontics. J Periodontol 1985;56:447-56.  Back to cited text no. 2
    
3.Newman MG, Cattabriga M, Etienne D, Flemmig T, Sanz M, Kornman KS, et al. Effectiveness of adjunctive irrigation in early periodontitis. Multi-centre evaluation. J Periodontol 1994;65:224-9.  Back to cited text no. 3
    
4.Crumley PJ, Sumner CF. Effectiveness of a water pressure cleaning device. Periodontics 1965;3:193-5.  Back to cited text no. 4
    
5.Selting WJ, Bhaskar SN, Mueller RP. Water jet direction and periodontal pocket debridement. J Periodontol 1972;43:569-72.  Back to cited text no. 5
    
6.Lobene RR. The effect of a pulsed water pressure device on oral health. J Periodontol 1969;40:667-70.  Back to cited text no. 6
    
7.Van Steenberg D, Rosling B, Soder PO, Landry RG, Vander Velden U, Timmermen MF, et al. A 15- month evaluation of the effects of repeated subgingival minocycline in chronic adult periodontitis. J Periodontol 1999;70:657-67.  Back to cited text no. 7
    
8.Chaves ES, Kornman KS, Manwell MA, Jones AA, Newbold DA, Wood RC. Mechanism of irrigation effects on gingivitis. J Periodontol 1994;65:1016-21.  Back to cited text no. 8
    
9.Badersten A, Nilveus R, Egelberg J. Effect of nonsurgical periodontal therapy. I. Moderately advanced periodontitis. J Clin Periodontol 1981;8:57-2.  Back to cited text no. 9
    
10.Hill RW, Ramfjord SP, Morrison EC, Appleberry EA, Caffesse RG, Kerry GN, et al. Four types of periodontal treatment compared over two years. J Periodontol 1981;52:655-62.  Back to cited text no. 10
    
11.Lindhe J, Westfelt E, Nyman S, Socransky SS, Heijl L, Bratthall G. Healing following surgical/nonsurgical treatment of periodontal disease. J Clin Periodontol 1982;9:115-28.  Back to cited text no. 11
    
12.Lisgarten MA, Lindhe J, Hellden L. Effect of Tetracycline and/or Scaling On Human Periodontal Disease. Clinical, Microbiological, and Histological Observations. J Clin Periodontol 1978;5:246-71.  Back to cited text no. 12
    
13.Tseng PW, Newcomb GM. The effect of a single episode of chlorhexidine irrigation on the gingival response to scaling and root planing. J Clin Dent 1991;2:83-6.  Back to cited text no. 13
    
14.Macalpine R, Magnusson I, Kiger R, Crigger M, Garrett S, Egelberg J. Antimicrobial irrigation of deep pocket to supplement oral hygiene instruction and root debridement, I. Bi-weekly irrigation. J Clin Periodontol 1985;12:568-77.  Back to cited text no. 14
    
15.Southard SR, Drisko CL. Killoy WJ, Cobb CM, Tira DE. The effect of 2% chlorhexidine digluconate irrigation on clinical parameters and the level of bacteroides gingivalis in periodontal pockets. J Clin Periodontol 1989;60:302-9.   Back to cited text no. 15
    
16. Jolkovsky DL, Waki MY, Newman MG, Otomo-Corgel J, Madison M, Fleming TF, et al. Clinical and microbiological effects of subgingival and gingival marginal irrigation with chlorhexidine gluconate. J Periodontol 1990;61:663-9.  Back to cited text no. 16
    
17.Krust KS, Drisko CL, Gross K, Overman P, Tira DE. The effects of subgingival irrigation with chlorhexidine and stannous fluoride. A preliminary investigation. J Dent Hyg 1991;65:289-95.  Back to cited text no. 17
    
18.Shiloah J, Patters MR. DNA probe analyses of the survival of selected periodontal pathogens following scaling, root planing, and intra-pocket irrigation. J Periodontol 1994;65:568-75.  Back to cited text no. 18
    
19.Flemmig TF, Newman MG, Doherty FM, Grossman E, Meckel AH, Bakdash MB. Supragingival irrigation with 0.06% chlorhexidine in naturally occurring gingivitis i.6 months clinical observations. J Periodontol 1990;61:112-7.  Back to cited text no. 19
    
20.Lander PE, Newcomb GM, Seymour GJ, Powell RN. The antimicrobial and clinical effects of a single subgingival irrigation of chlorhexidine in advanced periodontal lesions. J Clin Periodontol 1986;13:74-80.  Back to cited text no. 20
    
21.Soh LL, Newman HN, Strahan JD. Effects of subgingival chlorhexidine irrigation on periodontal inflammation. J Clin Periodontol 1982;9:66-74.  Back to cited text no. 21
    
22.Mazza JE, Newman MG, Sims TN. Clinical and antimicrobial effect of stannous fluoride on periodontitis. J Clin Periodontol 1981;8:203-12.  Back to cited text no. 22
    
23.Lofthus JE, Waki MY, Jolkovsky DL, Otomo-Corgel J, Newman MG, Flemmig T, et al. Bacteremia Following Subgingival Irrigation and Scaling and Root Planing. J Periodontol 1991;62:602-7.  Back to cited text no. 23
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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