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Effect of 0.25% sodium hypochlorite oral rinse and subgingival irrigation on periodontal clinical parameters

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Effect of 0.25% sodium hypochlorite oral rinse and subgingival irrigation on periodontal clinical parameters

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Content !
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EFFECT OF 0.25% SODIUM HYPOCHLORITE ORAL RINSE AND SUBGINGIVAL
IRRIGATION ON PERIODONTAL CLINICAL PARAMETERS

By

María Galván

____________________________________________________

A Thesis Presentation to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF SCIENCE
(CRANIOFACIAL BIOLOGY)

December 2013

Copyright 2013 María Galván

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Dedication

This thesis is dedicated to my parents and my sister who have always supported
me through the good times and the bad. Thank you for encouraging and motivating me
to always move forward. Special thanks to my mother and father, who have sacrificed
very much for me. Your unconditional love will be always remembered.

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Acknowledgements

Though only my name appears on the cover of this thesis, a great many people
have contributed to its production. I owe my gratitude to all those people who have made
this thesis possible and because of whom my graduate experience has been one that I will
cherish forever. My deepest gratitude is to my advisor, Dr. Jorgen Slots, for allowing me
to participate in his research study.
Thank you Dr. Jorgen Slots for your mentorship, your guidance and your help in
executing the clinical components of the project. His patience, crucial thoughts and
feedback helped me overcome many crisis situations and finish this thesis. I am grateful
to him for holding me to a high research standard and enforcing strict validations for each
research result, and thus teaching me how to do research.
Thank you Dr. Sandra Rich for your hard work, dedication, patience and words of
encouragement. I am also thankful to her for emphasizing the use of correct grammar
and consistent notation in my writings and for carefully reading and commenting on
countless revisions of this manuscript.
Thank you Dr. Faisal Alonaizan for your help with the data interpretation and the
statistical analysis.
I would also like to thank Dr. Stephanie Gonzalez and Dr. Chloe Cohen for their
collaboration in this study, their friendship and support will always be remembered.
Finally I would like to thank you, Dr. Homa Zadeh, Dr. Kian Kar and Dr. Alon
Frydman, for their support, thoughts and words of encouragement.
! "#!
Table of Contents
Dedication ii
Acknowledgements iii
List of Tables and Figures v
Abstract viii
Chapter 1: Introduction and Background 1
Chapter 2: Materials and Methods 13
Chapter 3: Results 22

Chapter 4: Discussion 46
Chapter 5: Conclusion 53
References 54

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List of Table and Figures
Figure A: Drop out patients.
Figure B: Questionnaire of compliance.
Table 1: Test group (Facial surface): number of surfaces with absence of plaque, number
of surfaces with presence of plaque at visit 1 and visit 2. Difference in absence of plaque
between visit 1 and visit 2.

Table 2: Test group (Lingual surface): number of surfaces with absence of plaque,
number of surfaces with presence of plaque at visit 1 and visit 2. Difference in absence
of plaque between visit 1 and visit 2.

Table 3: Control group (Facial surface): number of surfaces with absence of plaque,
number of surfaces with presence of plaque at visit 1 and visit 2. Difference in absence of
plaque between visit 1 and visit 2.

Table 4: Control group (Lingual surface): number of surfaces with absence of plaque,
number of surfaces with presence of plaque at visit 1 and visit 2. Difference in absence of
plaque between visit 1 and visit 2.

Table 5: Test group (BOP): number of teeth with absence of BOP, number of teeth with
presence of BOP and difference in number of teeth with BOP between visit 1 and visit 2.
!
Table 6: Control group (BOP): number of teeth with absence of BOP, number of teeth
with presence of BOP and difference in number of teeth with BOP between visit 1 and
visit 2.
!
Table 7: Test group (Facial surface): % of surfaces with absence of plaque and % of
overall improvement.

Table 8: Test group (Lingual surface): % of surfaces with absence of plaque and % of
overall improvement.

Table 9: Control group (Facial surface): % of surfaces with absence of plaque and % of
overall improvement.

Table 10: Control group (Lingual surface): % of surfaces with absence of plaque and %
of overall improvement.
! #"!

Table 11: Test group (BOP): % of teeth with absence of BOP and % over all
improvement.

Table 12: Control group (BOP): % of teeth with absence of BOP and % over all
improvement.

Table 13: % of plaque-free surfaces and bleeding free teeth and % of overall
improvement for test and control group at visit 1 (baseline) and visit 2 (2 weeks).

Table 14: % of plaque-free surfaces and bleeding free teeth for test and control group at
visit 1 (baseline) and visit 2 (2 weeks). (Blue = visit 1, Red = visit2)

Table 15: % of overall improvement of plaque-free surfaces and bleeding free teeth for
test and control group at visit 1 (baseline) and visit 2 (2 weeks). (Blue = Test group, Red
= Control group)

Table 16: Test group (Facial surface): number of surfaces with absence of plaque,
number of surfaces with presence of plaque at visit 1, visit 2 and visit 3. Difference in
absence of plaque between visit 1 and visit 3.

Table 17: Test group (Lingual surface): number of surfaces with absence of plaque,
number of surfaces with presence of plaque at visit 1, visit 2 and visit 3. Difference in
absence of plaque between visit 1 and visit 3.

Table 18: Control group (Facial surface): number of surfaces with absence of plaque,
number of surfaces with presence of plaque at visit 1, visit 2 and visit 3. Difference in
absence of plaque between visit 1 and visit 3.

Table 19: Control group (Lingual surface): number of surfaces with absence of plaque,
number of surfaces with presence of plaque at visit 1, visit 2 and visit 3. Difference in
absence of plaque between visit 1 and visit 3.

Table 20: Test group (BOP): number of teeth with absence of BOP, number of teeth with
presence of BOP and difference in number of teeth with BOP between visit 1 and visit 3.

Table 21: Test group (BOP): number of teeth with absence of BOP, number of teeth with
presence of BOP and difference in number of teeth with BOP between visit 1 and visit 3.

Table 22: Test group (Facial surface): % of surfaces with absence of plaque and % of
overall improvement.

Table 23: Test group (Lingual surface): % of surfaces with absence of plaque and % of
overall improvement.
! #""!

Table 24: Control group (Facial surface): % of surfaces with absence of plaque and % of
overall improvement.

Table 25: Control group (Lingual surface): % of surfaces with absence of plaque and %
of overall improvement.

Table 26: Test group (BOP): % of teeth with absence of BOP and % over all
improvement.

Table 27: Control group (BOP): % of teeth with absence of BOP and % over all
improvement.

Table 28: % of plaque-free surfaces and bleeding free teeth and % of overall
improvement for test and control group at visit 1 (baseline) and visit 3 (3 months).

Table 29: % of plaque-free surfaces and bleeding free teeth for test and control group at
visit 1 (baseline) and visit 3 (3 months). (Blue = visit 1, Red = visit2)

Table 30: % of overall improvement of plaque-free surfaces and bleeding free teeth for
test and control group at visit 1 (baseline) and visit 3 (3 months). (Blue = Test group, Red
= Control group)

Table 31: Wilcoxon Signed Ranks test, comparison within groups between visit1 and
visit 2. Wilcoxon-Mann Whitney test, comparison between test group and control group.
*Statistically significant difference.

Table 32: Anova Repeat Measure Analysis. Improvement over 3 visits of test group and
control group. *Statistically significant difference.

Table 33: Anova Repeat Measure analysis, improvement of plaque-free facial surfaces.
(Blue = Control group, Red = Test group)

Table 34: Anova Repeat Measure analysis, improvement of plaque-free lingual surfaces.
(Blue = Control group, Red = Test group)

Table 35: Anova Repeat Measure analysis, improvement of BOP-free teeth. (Blue =
Control group, Red = Test group)

!#"""!

Abstract
!
Background: Conventional periodontal therapy includes an anti-infective phase and, if
necessary, may be followed by a surgical phase. Once the end-point of active therapy has
been reached, a maintenance phase is instituted. Anti-infective therapy includes
mechanical removal of biofilm. An array of adjunctive antimicrobial therapies have been
proposed for the therapy with varying results. The application of diluted sodium
hypochlorite has been examined in previous studies and there is significant data in favor
of this agent. The purpose of the present study is to determine the initial and 3 months
clinical effects of two rinses (0.25% sodium hypochlorite and water), performed twice a
week, in the treatment of periodontitis. Our research hypothesis is that 2 weeks post-
baseline and 3 months post-baseline, those participants who rinse with diluted bleach
solutions will exhibit improved periodontal health vs. those participants who rinse with
water alone.
Methods: Thirty otherwise healthy adults, diagnosed with periodontitis, were included in
the study. The following clinical variables were evaluated at baseline (visit 1), two weeks
post-baseline (visit2) and 3 months post-baseline (visit 3): medical history, dental
radiographs, number of teeth, presence or absence of plaque, presence or absence of
bleeding on probing, pocket depth and gingival recession. Participants randomly received
professional subgingival irrigation with either sodium hypochlorite 0.25% (test) or water
(control) at visit 1 and visit 2 and rinsed at home twice a week with either sodium
! "$!
hypochlorite 0.25% (test) or water (control) throughout the course of the study. At the
end of the study participants were given a questionnaire to evaluate compliance with the
regimen and perceived adverse effects of the rinse. Normality of the underlying
distribution was assumed based on visual assessment and tested using Shapiro–Wilk
Normality test. Wilcoxon-Mann-Whitney test was used to compare improvement
between the two groups. Wilcoxon Signed Rank test was used to test the difference
within the groups. Spearman Correlation (non parametric) test was used to determine the
correlation coefficient between the difference in absence of plaque from visit 1 to visit 3
and difference in absence of bleeding on probing (BOP) from visit 1 to visit 3. ANOVA
Repeated Measures was used to evaluate the difference in improvement over the 3
visits. The significance level was set at ! = 0.05. Statistical analysis was performed using
STATA statistical software version 12 (StataCorp, Texas, USA)
Results: The results indicate that for those participants that completed visit 1 and visit 2,
the difference of plaque-free facial surfaces within the test group was statistically
significant (p= 0.009*). The control group showed no statistically significant difference.
For those patients that completed visit 1 to visit 3, the test group showed a statistically
significant improvement of, 0.009* plaque-free facial surfaces, 0.006* plaque-free
lingual surfaces and 0.006* BOP-free teeth. However, the control group showed no
statistically significant difference. The comparison at visit 3 of test group versus control
group showed statistically significant difference for plaque-free facial surfaces (0.0042*),
plaque-free lingual surfaces (0.042*) and BOP-free teeth (0.012*). The correlation
between the difference in absence of plaque from visit 1 to visit 3 and difference in
! $!
absence of BOP from visit 1 to visit 3, was evaluated using Spearman Correlation test
(non parametric). The correlation coefficient was 0.62 (p=0.03*)
Conclusions: Within the limitations of this study, it can be concluded that mouthrinsing
with 0.25% sodium hypochlorite is highly safe, minimally invasive, extremely
inexpensive and may be efficacious to reduce the presence of plaque and bleeding on
probing, and therefore possibly prevent the risk of future attachment loss.

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Chapter 1: Introduction and Background

A survey of the periodontal status of the US population derived from data from
Phase 1 of the Third National Health and Nutrition Examination Survey conducted by the
National Institute of Dental Research from 1988-1991, showed that over 90% of persons
13 years of age or older had experienced some clinical loss of attachment (LA) and 15%
exhibited more severe destruction (LA > or = 5 mm) (Brown et al., 1996). Other studies
reported that thirty-five million adults in the United States are affected by destructive
periodontal disease (Albandar 2002) and the total expense for periodontal treatment and
prevention was approximately $14.3 billion in 1999 (Johns & Wall 2002).
Of those patients that recognize the importance of daily plaque removal as
measured by compliance of oral hygiene instructions, only 50% or less are involved in
regular, supportive periodontal therapy (Wilson 1996). Some may be uninvolved due to
lack of education on the importance of oral health, while for others, there may be
economical limitations.
Periodontal disease is triggered by the presence of microbial biofilms that colonize
the sulcular region between the tooth surface and the gingival margin. The following
periodontal pathogens have been described in the literature as contributing to periodontal
disease; Aggregatibacter (Actinobacillus) actinomycetemcomitans, Porphyromonas
gingivalis, Prevotella intermedia, Tannerella Forsythia, Peptostreptococcus micros,
Campylobacter rectus, Eikenella corrodens, Fusobacterium nucleatum, Eubacterium spp,
! &!
Treponema denticola, Selenomonas spp, betahemolytic streptococci, a variety of enteric
rods and pseudomonads, enterococci, staphylococci and possibly yeasts ('()*!+!Ebersole
2005; Baelum & Lopez 2013). Treating periodontal disease as an infectious disorder
requires the suppression or elimination of the above mention periodontal pathogens. The
scope of treatment of periodontal disease ranges from: 1) mechanical debridement alone,
to combinations of mechanical debridement with 2) antiseptics, 3) systemic antibiotics
and/or local antibiotics, or 4) local antiseptics or surgical therapy. The therapeutic options
for the treatment of periodontal disease are chosen according to the extent of the disease,
benefits of the treatment and economical circumstances of the patient (Slots 2012).
Dental plaque is a type of biofilm, defined as a sessile community of interdependent
microorganisms organized within an exopolymer that is attached to solid surfaces or
associated with interfaces (Davey & O’Toole 2000). Patient home care routine is usually
limited to tooth brushing and flossing. However, sonic or mechanical toothbrushes only
cause disruption of microbes up to 1 mm subgingivally (Williams et al., 2001). In
addition, among university students, Rimondini et al. (2001) found 92% of their sample
brushed at least twice a day, whereas only 15% flossed their teeth daily.
The use of mechanical debridement alone, performed by a dental professional, may
not be sufficient to suppress or eliminate periodontal pathogens and presents some
limitations such as, plaque bacteria recolonization, limited effect over specific pathogens
and oral niches, inability to access deep pockets (furcation areas, torturous pockets) and
the occurrence of secondary effects (loss of tooth surface, gingival recession, dentin
hypersensitivity) (Rateitschak-Plüss et al., 1992). As shown in many studies, non-surgical
! ,!
scaling and root planing cannot ensure complete removal of subgingival plaque in sites
with probing depths exceeding 5mm (Lindhe et al., 1982). Supragingival plaque control
may reduce the quantity of subgingival pathogens in mild to moderate forms of
periodontitis, but achieves little change in patients with advanced periodontitis (Dahle "n
et al., 1992). After mechanical debridement, supragingival plaque microorganism
recolonization can occur within hours or days. Subgingival plaque microorganism
recolonization may take as long as several months for those patients who have good oral
hygiene. But for those patients with poor oral hygiene, recolonization can be re-
established within 42-60 days (Magnusson I et al., 1984).
Periodontal pockets are not the only reservoir for periodontal pathogens. The
tongue, tonsilar and buccal mucosal areas harbor many of the above mention periodontal
pathogens (Asikainen & Chen 1999). In addition, some periodontal species have the
ability to penetrate into the gingival epithelial cells and subepithelial connective tissue
and have high affinity for the crevicular epithelium and dentinal tubules. These
periodontal pathogens are A. actinornycetemcomitans, P. gingivalis, P. intermedia, T.
forsythia, P. micros, enteric rods (Rams & Slots 1996).
Since the use of mechanical debridement alone is not sufficient to eliminate
periodontal pathogens, there may be a benefit in using chemical antimicrobial agents,
such as systemic antibiotics, local antibiotics or local antiseptics. A systemic
antimicrobial agent reaches the periodontal pockets from its presence in gingival
crevicular fluid and saliva, after passing from the blood stream into the oral tissues. (Slots
2002). The use of systemic antibiotics as an adjunct for non-surgical periodontal therapy
! -!
for the treatment of chronic and aggressive periodontitis, significantly improved clinical
outcomes (Cionca et al., 2009; Casarin et al., 2012). Commonly used antibiotics in
periodontal treatment are penicillin, metronidazole, tetracycline, macrolides. Penicillin,
tetracycline and erythromycin are broad spectrum antibiotics, effective against gram-
positive and gram-negative microorganisims. Metronizadole requires metabolic
activation by strict anaerobe microorganisms (Soares et al., 2012). The use of systemic
antibiotics presents some possible adverse effects, such as chance of developing bacterial
resistance, and is subject to lack of patient compliance (Slots & Jorgensen 2002).
Bacterial resistance to penicillin can occur due to production of #-lactamases,
permeability alteration of the bacteria cell to the antibiotic and alteration of the penicillin-
binding proteins. Bacterial resistance to metronidazole differs among organisms, but the
primary basis for resistance is decrease uptake of the drug. Bacteria resistance to
tetracyclines or macrolides can occur due to alteration of ribosome in order to prevent
effective binding of the drug or by production of tetracycline/macrolide-inactivating
enzymes.
In addition, several topical antibiotics are available in the market, such as
tetracycline-HCL, minocycline, metronidazole or ofloxacin. In patients diagnosed with
chronic periodontitis, application of tetracycline fibers showed pocket depth reduction of
0.727 mm, followed by doxycycline (0.573 mm) and minocycline (0.472 mm)
(Matesanz-Pérez et al., 2013). These findings are in agreement with other systematic
reviews. Bonito et al. (2005) reported significant efficacy for minocycline,
metronidazole, chlorhexidine and local tetracycline and Hanes & Purvis (2003) reported
! .!
the best results for minocycline. On the other hand, the use of such topical antibiotics can
cause problems with selectivity of antimicrobial action, possible development of bacteria
resistance and adverse host reaction (Slots & Jorgensen 2002). The majority of these
local and systemic antibiotics have a high acquisition cost and some are only available in
a few countries (Slots 2012).
In comparison to the systemic antibiotics, there are many benefits of local antiseptic
agents: 1) local drug delivery can achieve a higher concentration in subgingival sites
compared with a systemic drug regimen, 2) local pocket delivery allows the use of such
broad-spectrum antiseptic solutions which will not be possible with systemic antibiotics,
3) they have less problems with patient compliance, and 4) they reduce the risk of
developing drug-resistant microbial populations (Slots & Jorgensen 2002).
However, local antimicrobials agents present other difficulties, such as the small
entrance and the outflow of crevicular fluid in a periodontal pocket. The entrance of a
4mm periodontal pocket is 150 um and the outflow of crevicular fluid in a periodontal
pocket is 20 ml/h, (pocket fluid replacement rate of 40 times per hour) (Matesanz-Pérez
et al., 2013). In order for the pharmaceutical effect to occur, the local antimicrobial agent
should reach the deepest area of the pocket and should be maintained long enough and at
a sufficient concentration (MacNeill et al., 1998). Therefore, out of the possible local
application, only subgingival irrigation can penetrate into the entire pocket (Daneshmand
et al., 2002).
Finally, the local delivery of antimicrobial agents can be divided into categories of
personally-applied (in-patient, home self-care) and professionally-applied (in dental
! /!
office). The personally-applied agents can be subdivided into non-sustained, subgingival
drug delivery (home oral irrigation) and sustained, subgingival drug delivery (none
developed to date). The professionally-applied agents can be subdivided into sustained-
release devices (drug delivery for less than 24 hours) and controlled-delivery devices
(drug release exceeding 1 day) (Slots 2012).

Local antiseptics
Chlorhexidine:
Chlorhexidine is a diphenyl compound. The cationic chlorhexidine molecule is
attracted by the negatively charged bacterial surface. Once chlorhexidine has been
absorbed by the bacteria, the integrity of the bacteria cell membrane is modified which
results in severe damage or a reversible leakage of bacterial low molecular weight
components (Gagari & Kabani 1995). Although chlorhexidine rinsing may not prevent all
plaque and gingivitis formation, the ADA, in the Council on Dental Therapeutics, states
in its “Acceptance Guidelines for Chemotherapeutic Products for Control of Gingivitis”
(American Dental Association 1997, 2008) that in terms of efficacy, the estimated
proportional reduction of dental plaque must be no less than 15%. However, only minor
microbiological changes have been observed, when using 0.2% Chlorhexidine because of
its reduced bactericidal activity against enteric gram-negative rods (Slots et al., 1991) and
its high affinity for salivary or serum proteins and blood which can explain the rapid
decrease in concentration in the subgingival area (Wade & Addy 1989). However,
chlorhexidine can bind to soft and hard tissue which will prolong supragingival
! 0!
sustantivity (Wade & Addy 1989). The effect of chlorhexidine varies depending on its
formulation or vehicle.
The greatest effect was shown by chlorhexidine gel, followed by chlorhexidine
chips and then by chlorhexidine varnish (Soskolne et al. 1998, Paolantonioet al. 2009).
Bonito et al. 2005, reported significant efficacy for minocycline, metronidazole,
chlorhexidine and local tetracycline in combination with mechanical debridement in
comparison to mechanical debridement alone. Conversely, Daneshmand et al. (2002),
show no adjunctive microbial benefit for the use of chlorhexidine chip. In addition, Von
Ohle et al. (1998), reported that povidone-iodine at 0.05% as a subgingival irrigation
agent will cause more changes in the subgingival microbiota flora than a 0.2% solution of
Chlorhexidine.
Other disadvantages of Chlorhexidine are: 1) propensity to stain teeth and
restorations, and 2) a toxicity for gingival fibroblasts, which can impair periodontal
healing (Von Ohle et al., 1998).
Povidone Iodine
Povidone-iodine is microbicidal for gram-positive and gram-negative bacteria,
fungi, mycobacteria, viruses and protozoans. Povidone iodine is composed of a loose
complex of elemental iodine and the surfactant povidone (polyvinylpyrrolidone), which
improves the wetting properties and, therefore, enhances the solubility of the iodine
solution while providing a sustained release reservoir of the element. Iodine is able to
penetrate the cell walls of the microorganisms quickly, and the bactericidal effects result
from a disruption of protein and nuclei acid structures and synthesis (Slots & Jorgensen
! 1!
2002). Povidone-iodine has been used since 1960s, and is the most popular antiseptic
used in hospitals for skin and mucous membrane disinfection (Slots & Jorgensen 2002).
Iodophors have also shown promise in preventing dental caries (Caufield & Gibbons
1979). Povidone iodine in 5-10% solutions has an inhibitory effect of the serum and can
kill bacteria of experimental biofilm, (Kunisada et al., 1997) but is not able to do so for
all naturally formed biofilm (Anderson et al., 1990).
Povidone iodine, in comparison to chlorhexidine is water soluble, does not dark
stain teeth and restorations and does not cause toxicity for gingival fibroblasts, which
could impair periodontal healing (Von Ohle et al.,1998). In addition, subgingival
irrigation with 0.05% povidone iodine will cause more changes in the subgingival
microbiota flora than 0.2% of chlorhexidine (Von Ohle et al.,1998).
The contraindications of povidone iodine include patients with iodine
hypersensitivity, thyroid pathosis, nursing and pregnant women. Nevertheless, studies
report that patients with pre-existing thyroid gland diseases, who performed oral rinsing
four times daily with povidone iodine over a period of 6 weeks, experienced little or no
disturbances in thyroid function (Rahn et al., 1997).
Hydrogen peroxide:
Hydrogen peroxide is a strong oxidizer, a compound with an oxygen-oxygen single
bond. The use of 3% subgingival irrigation with hydrogen peroxide has failed to
demonstrate microbial shifts compared with saline irrigation when used in combination
with mechanical debridement (Slots & Jorgensen 2002). However, biweekly professional
irrigation of deep pockets after root planing, demonstrated temporary depression of A.
! 2!
actinomycetemcomitans (Wikesjo et al., et al 1989).
Fluoride
The ability of fluoride compounds to affect dental plaque is limited. But
periodontal treatment will shift the oral microbiota to an increase of gram-positive
formation, which will therefore increase cariogenic bacteria. It is recommended to use
0.05% sodium fluoride rinses, or 1.1% sodium fluoride or 0.4% stannous fluoride gels
after periodontal therapy to reduce the likelihood of dental caries (Paine et al., 1998).
Sodium hypochlorite:
The American Dental Association Council on Dental Therapeutics has designated
0.1% sodium hypochlorite a ‘mild antiseptic mouth rinse’ and suggested its use for direct
application to mucous membranes (American Dental Association. Accepted Dental
Therapeutics. Chicago, IL: ADA; 1984).
Sodium hypochlorite solution was first in the marketed 200 year ago, under the
name, “Eau de Javel”. Initially it was only used for bleaching clothes, but after Pasteur
discovered that living organisms cause infectious disease, Labarraque (1825) and
Semmelweis (1846) found that sodium hypochlorite was effective in controlling wound
infections (Lobene et al.,1972). Sodium hypochlorite has been used for more than one
century as a root canal irrigant at a concentration ranging from 1.0 % to 5.25% 3Slots &
Jorgensen 2000).
Lobene et at. (1972), evaluated the effect of antiseptic agents on plaque pH, plaque
mass and gingivitis using a pulsating irrigant device as a delivery system, in college
students who were required to abstain from oral hygiene. The therapeutic agents
! %4!
investigated were a 1% hydrogen peroxide solution prepared daily by diluting a stock
solution of 3% hydrogen peroxide and 0.5% sodium hypochlorite solution prepared daily
from a stock solution of 5% sodium hypochlorite ( Labarraque´s Solution). According to
this study, flushing tooth surfaces at safe levels of pressure with therapeutic agents has a
strong effect on dental plaque. The use of these antiseptics agents has the ability to reduce
the capacity of plaque to produce an acidic environment, and repeated daily flushing
reduced the ability of dental plaque to maintain an acidic environment. The toxic
products of dental plaque, which will cause gingivitis, may have been altered or diluted in
that they no longer possess the capacity to produce gingivitis. It is also possible that the
use of oxidizing agents changes the flora from an anaerobic type to an aerobic type,
which is not as pathogenic. These findings are especially relevant for interproximal
dental plaque, since plaque in these areas is difficult to remove by brushing or mouth
rinsing alone. The sodium hypochlorite effect on plaque pH persisted for 24 hours after
the last treatment. In conclusion, Lobene et al. (1972) showed that subgingival irrigation
with 0.5% sodium hypochlorite (Dakin’s solution) caused significantly greater and longer
lasting reduction in plaque and gingivitis than irrigation with water.
De Nardo et al. (2012) evaluated the clinical effect of 0.05% sodium hypochlorite
mouth rinse on supragingival biofilm and gingival inflammation in a study with 40 prison
inmates. Prior to entering the study, participants received supragingival and subgingival
scaling and root planning. The study reported that the use of 0.05% sodium hypochlorite
solution daily for 21 days in absence of oral hygiene, in comparison with water
demonstrated reduction of 48.2% in scores on the QHPI (Quigley–Hein Plaque Index),
! %%!
52.4% in scores on the L&SGI (Loe and Silness Gingival Index) and 39.1% in the
percentage of sites that bled on probing.
Sodium hypochlorite in comparison to chlorhexidine, does not cause toxicity for
gingival fibroblasts, which could impair periodontal healing (Von Ohle et al., 1998). In
addition, the highest in vitro bactericidal effect for endodontic/periodontal pathogens was
obtained with 2.25% sodium hypochlorite and 10% povidone-iodine followed by 0.2%
chlorhexidine 3Slots & Jorgensen 2000).
Therefore, the advantages of sodium hypochlorite as a local antiseptics agent are: 1)
ability to eliminate most viruses, fungi and bacteria, 2) a broad antimicrobial activity, 3)
rapid bactericidal action, 4) no staining and 5) non-toxicity at recommended
concentrations, 6) and extremely inexpensive.

! %&!
Purpose of the study:

Aim: The purpose of the present study is to determine the initial and 3 month clinical
effects of two rinses (0.25% sodium hypochlorite and water), performed twice weekly, in
the treatment of periodontitis.

Research questions: Will there be statistically significant differences for the presence or
absence of plaque and bleeding on probing between those participants who rinse with
0.25% sodium hypochlorite and those who rinse with water alone?

Our research hypothesis is that after 2 weeks and 3 months post-baseline, those
participants who rinse with diluted bleach solutions will exhibit improved levels of
absence of plaque and absence of bleeding on probing. !

! %,!
!
Chapter 2: Materials and Methods

This study was performed as a randomized, controlled, single-blinded, clinical
trial in parallel groups according to the CONSORT criteria. (Schulz et al., 2001; Altman
et al., 2010) This research project was approved by the University of Southern California
Health Sciences Campus Institutional Review Board (HSCIRB) (#HS-10-00509). All
patients reviewed and signed informed consent and HIPAA documents prior to enrolling
in the study.
!
Study participants: The study included 30 otherwise healthy adults with periodontitis,
who were scheduled for periodontal therapy at the Herman Ostrow School of Dentistry of
USC (SODUSC) A total of 36 patients were enrolled in the study. Six participants were
lost to attrition. (Figure A: List of patient attrition and reasons for individual loss.)

Participant selection
Inclusion criteria:
Participants of either sex and of any race, 18 years of age or older were included, in the
study.
Inclusion criteria were:
1. Diagnosed with periodontitis,
2. Current full mouth radiographs on record
! %-!
3. At least 4 teeth with periodontal pockets of 6mm or more

Exclusion criteria were:
1. Medically compromised and unable to comply with protocol
2. Smoking habit of >10 cigarettes/day
3. Emergency dental care indicated for dental caries or periodontitis
4. Periodontal abscesses and/or acute periodontitis
5. At least 3 months since last periodontal treatment was performed (prophylaxis, scaling
and root planing, subgingival irrigation with antimicrobials, local antibiotics, pocket
reduction surgery)
6. At least 3 months since patient took systemic antibiotics.

Study Design: The clinical parts of the study were performed at the dental clinics at
University Park Campus USC. Each visit took one hour or less. Participants were
randomly assigned to control group or test group. The study was performed blindly, i.e.
one investigator treated the participants and another investigator performed the clinical
recordings. The periodontal treatment and the clinical parameters are outlined below.

! %.!

Clinical procedures:
The following clinical variables were completed/assessed in each participant, according
to the standard treatment of periodontitis patients included administering a medical/dental
questionnaire and general oral examination and evaluation of existing full-mouth dental
Patient recruitment:
(1) Recruitment of 30
Participants
(2) Obtaining patient consent
Baseline (Visit 1)

(1) Clinical assessment
(2) Subgingival irrigation (0.25%
sodium (test group) or water [control
group]
(3) Participant instruction in home
care
!
!
!!
3.5!67*"89*!"9:*;<=*"(9!"9!>(?8!=7;8!
Every Wednesday and Sunday

(1) Participants will mouth rinse at
home for 30 seconds with
0.25% sodium hypochlorite (test)
or water (control)
!!
Day 14 (Visit 2)

(1) Clinical assessment
(2) Subgingival irrigation (0.25%
sodium (test group) or water [control
group]
(3) Participant instruction in home care
!
3 months from baseline (Visit 3)

(1) Clinical assessment
(2) Participant instruction in home
care
(3) Scaling and root planing
!
Every Wednesday and Sunday

(1) Participants will mouth rinse at
home for 30 seconds with
0.25% sodium hypochlorite (test)
or water (control)
!!
! %/!
radiographs. Notation was made of 1) number of teeth present, (2) presence or absence of
plaque, (3) bleeding on probing, (4) periodontal pocket depths in mm (Marquis CP 12
probe), and (5) gingival recession in mm. Periodontal pocket depth, gingival recession
and bleeding on probing were assessed for each tooth on the facial, lingual, mesiofacial,
distofacial, mesiolingual and distolingual surface. The previous clinical variables listed
above (1) - (5) were assessed at Baseline (Visit 1), at Day 14 (Visit 2) and 3 months from
baseline (Visit 3).
Supragingival plaque was evaluated by visual tooth inspection. No plaque-
disclosing solution was used. For each tooth, visual presence or absence of plaque was
determined for facial and lingual surface separately. A value of “0” was assigned to those
surfaces with absence of plaque and a value of “1” was assigned to those surfaces with
any presence of plaque. Bleeding was monitored to the bottom of the pocket and was
recorded upon completion of the facial or lingual probing of each quadrant.
Approximately bleeding of probing was recorded 30 seconds after probing to the
bottom of the pocket was performed. The absence or presence of bleeding on probing to
the bottom of the pocket was evaluated on six sites per tooth (facial, lingual, mesiofacial,
distofacial, mesiolingual and distolingual). A value of “0” was assigned for the absence
of bleeding on probing on all the six sites evaluated per tooth. A value of “1” was
assigned for the presence of bleeding on probing on any of the six sites evaluated per
tooth
On the first visit, the previous clinical variables listed above (1)-(5) were
assessed. The participants received (1) professional subgingival irrigation with either
! %0!
0.25% sodium hypochlorite (test group) or water (control), and (2) the participants were
asked to rinse the mouth every Wednesday and Sunday for 30 seconds with either 0.25%
sodium hypochlorite (test group) or water (control). Test group mixed the 0.25% sodium
hypochlorite bleach at home as per our study directions. Instructions in oral hygiene
home care were given to the participants at the end of the visit.
Subgingival irrigation was performed with a 3cc Monoject
!
Endodontic Syringe
with 23-gauge cannula (metal w. side port). The syringe was placed at the bottom of the
pockets of all teeth in the dentition, and 0.25% sodium hypochlorite (test group) or water
(control) was applied for a total of 5 minutes.
The mouth rinse for home use was made up as follows. Participants (test group)
were provided with Clorox bleach (6%). The control group was instructed to use a water
rinse. The procedure for rinsing was explained and practiced under supervision of the
investigator. Participants were also given written instructions to take home. Directions
for the mixing for test group: 5 ml (one teaspoonful) of 6.0 % Clorox bleach should be
placed in 120 ml (one half-glass) of water. Control group: Water rinse was used. The
participants were asked to rinse with 5 ml of the study solutions for 30 seconds and then
spit out. Test groups were ask to abstain from subsequent rinsing with water for at least
10 minutes after rinsing.
Instructions to participants for home care included tooth brushing twice a day and
flossing once per day. Bass tooth brushing technique was emphasized. Participants were
provided with a new manual Oral B tooth brush and dental floss samples.
On the second visit the previous clinical variables listed above (1)-(5) were
! %1!
assessed. The participants received professional subgingival irrigation with either 0.25%
sodium hypochlorite (test group) or water (control), and (2) the participants were asked to
rinse the mouth every Wednesday and Sunday for 30 seconds with either 0.25% sodium
hypochlorite (test group) or water (control). Test group mixed the 0.25% sodium
hypochlorite bleach at home as per our study directions. Instructions in oral hygiene
home care were reviewed with the participants at the end of the visit.
On the visit 3, the previously mentioned clinical variables were
completed/assessed in each participant, according to the standard treatment of
periodontitis patients. Each participant received the standard periodontal therapy for
periodontitis, including (1) explanation of the cause of the disease, (2) instruction in oral
hygiene, (3) regularly scheduled scaling and root planing, and (4) supragingival
polishing, (Scaling and root planing and supragingival polishing were performed after
completion of visit 3) and (5) recall schedule to prevent recurrence of the disease.
At recall visit, a decision was determined whether additional periodontal therapy,
such as surgery, was indicated by the standard criteria of the Advanced Periodontics
Program at the OSDUSC.
Once the study was completed, participants were asked to complete a survey
about the study and return it within three days. For patient ease, a stamped envelope with
return address was included with the survey. Those patients who did not reply where
contacted by telephone. Participants were asked to answer the questionnaire honestly, so
that a realistic evaluation of study compliance and possible side effects could be
determined. Patients were reassured that their answers to the questions would not in any
! %2!
way affect their future dental care at OSDUSC or their relationships with their doctors.
(Figure B)

Statistical Analysis
Normality of the underlying distribution was assumed based on visual assessment
and tested using Shapiro–Wilk Normality test. Wilcoxon-Mann-Whitney test was
used to compare improvement between the two groups. Wilcoxon Signed Rank
test to test the difference with in the groups. Spearman Correlation test was used to
determine the correlation coefficient between the difference in absence of plaque
from visit 1 to visit 3 and difference in absence of BOP from visit 1 to visit 3. ANOVA
Repeated Measures was used to evaluate the difference in improvement over the 3
visits. The significance level was set at ! = 0.05. Statistical analysis was
performed using STATA statistical software version 12 (StataCorp, Texas, USA)
! &4!

Patient Drop out
#1 Drop: study protocol was not followed by examiner
#2 Drop: no contact (patient did not complete study)
#3
#4
#5
#6
#7 Drop: abscess developed from recruitment date to visit 1
#8
#9
#10
#11
#12
#13 Drop: abscess developed from recruitment date to visit 1
#14 Drop: patient could not tolerate solution taste
#15
#16
#17
#18
#19
#20
#21
#22
#23
#24
#25
#26
#27
#28
#29
#30
#31 Equal to patient #1
#32 Equal to patient #2
#33 Equal to patient #7
#34 Equal to patient #13
#35 Equal to patient #14
#36 Equal to patient #21

Figure A: Drop out patients.

! &%!
Questionnaire of compliance:

- Did you understand the instructions to mix the rinsing solution at home?

- Did you rinse twice a week (Wednesday and Sunday) for 2 weeks?

o If you did not rinse twice a week (Wednesday and Sunday) for 2 weeks,
which dates did you miss?

o If you missed any rinsing dates, what is the reason?

- Did you swallow the solution?

o If you did swallow the solution, did you experience any reactions?

- Did you abstain for rinsing your mouth with water 10 min after using the rinsing
solution?

- Did you have a bad taste due to the rinsing solution?

o If you had a bad taste, how long did it last?

- Did you experience any abrasion of the mucosa after using the mouthwash?

o If you experience abrasion/burn of the mucosa, where was it located?
o If you experience abrasion/burn of the mucosa, how long did it last?

- Did you experience tingling sensation in your tongue?

o If you experience tingling sensation in your tongue, how long did it last?

- Do you feel that after using the rinsing solution your oral hygiene improved?

- Do you feel that after using the rinsing solution your gums bleed less and were
less inflamed?

- Did you experience staining of teeth or coloring of your restorations?

- Did you experience whitening of your teeth?

Figure B: Questionnaire of compliance.
! &&!

Chapter 3: Results

A total of 36 participants were enrolled in the study. Six participants were lost to
attrition (Figure B). Fifteen patients were included in experimental group and 15 patients
were included in control group. The proportion of male to female study participants was
17:13 and the mean age was 41.2 years.
Evaluation of questionnaire of compliance revealed that 83.33% (25/30) the
participants fully understood the instructions for mixing the rinsing solution and
complied completely with the study guidelines of rinsing twice a week on Wednesday
and Sunday for two weeks. Only five patients did not complete the rinsing protocol.
Three patients forgot to rinse at least once (2 of them were control group and 1
was test group) and two patients did not rinse the second week due to bad taste (both of
them were test group). Two out of 30 patients swallowed part of the solution but did not
experience any adverse effects, one patient was control group and one patient was test
group. Seventeen out of 30 patients abstained for rinsing with water 10 min after using
the rinsing solution, 9 were control group and 8 were test group. Thirteen out of 30
patients had a bad taste after using the solution and it lasted from 5 min to 1 hour, all of
these patients were in test group. None of the participants experienced abrasion of the
mucosa or tingling sensation of the tongue. Twelve out of 30 patients perceived
improvement of their overall oral hygiene, less inflammation and less bleeding, 2 were in
! &,!
control group and 10 were in test group. None of the study patients experienced staining
or coloring of the restorations but 11 out of 30 patients perceived whitening of their teeth,
all of these patients were in test group.
A total of 30 participants completed visit 1 and visit 2 and a subset of 12
participants completed visit 3. Due to time limitations, the rest of the participants have
not yet completed the study.
For those patients that completed visit 1 and visit 2, a total of 394 teeth were
evaluated in test group and a total of 404 teeth were evaluated in the control group.
In the test group, at baseline (visit 1), 131 (33%) facial surfaces, 70 (19%) lingual
surfaces were plaque free and 125 (32%) teeth had absence of bleeding on probing. After
2 weeks (visit 2), 210 (52%) facial surfaces, 115 (52.63%) lingual surfaces were plaque
free and 141 (36.67%) teeth had absence of bleeding on probing. At visit 2, the test group
showed an overall improvement of surfaces with absence of plaque of 57.57% for the
facial surfaces and 52.63% for the lingual surfaces, and an overall improvement of teeth
with absence of bleeding on probing of 14.87%.
In the control group, at baseline (visit 1), 158 (40%) facial surfaces, 90 (21%)
lingual surfaces were plaque free and 172 (42%) teeth had absence of bleeding on
probing. After 2 weeks (visit 2), 191 (47%) facial surfaces, 101 (23%) lingual surfaces
were plaque free and 188 (46%) teeth had absence of bleeding of probing. At visit 2, the
control group showed an overall improvement of surfaces with absence of plaque of
17.50% for the facial surfaces and 9.52% for the lingual surfaces, and an overall
! &-!
improvement of teeth with absence of bleeding on probing of 9.52%. (Table 1 to Table
15)
Twelve out of 30 participants completed visit 3 (3 months after baseline). Seven
of these participants were in the test group and five of these participants were in control
group.
Descriptive statistics showed that after 3 months the overall improvement of the
test group (7 participants) was: 87.75% of improvement of plaque free facial surfaces,
196.64% of improvement of plaque free lingual surfaces and 405.45 % of improvement
of bleeding free teeth. In comparison the overall improvement of the control group (5
participants) after 3 months was: 23.94% of improvement of plaque free facial surfaces,
2.95% of decrease of plaque free lingual surfaces and 59.67 % of improvement of
bleeding free teeth. (Table 16 to Table 30)
Wilcoxon Signed Rank test was used to determine the difference within test group
and within control between visit 1 and visit 2. Within the test group between visit 1 and
visit 2 there was statistically significant difference for the plaque-free facial surfaces
(p=0.009*), although plaque-free lingual surfaces and BOP-free teeth showed no
statistically significant difference. Within the control group between visit 1 and visit 2
none of the studied variables showed statistically significant difference. (Table 31)
Wilcoxon-Mann Whitney test was used to evaluate the difference between test and
control group. The difference of plaque-free facial surfaces, plaque-free lingual surfaces
and BOP-free teeth from visit 1 to visit 2 between test and control showed no statistically
significant difference. However, there was statistically significant difference for plaque-
! &.!
free facial surfaces (p=0.042*), plaque-free lingual surfaces (p=0.042*) and BOP-free
teeth (p=0.012*) from visit 1 to visit 3 between test and control. (Table 31)
The correlation between the difference in absence of plaque from visit 1 to visit 3
and difference in absence of BOP from visit 1 to visit 3, was evaluated using Spearman
Correlation test (non parametric). The correlation coefficient was 0.62 (p=0.03*)
Anova Repeated Measure test was used to evaluate the improvement of the studied
variables from visit1, to visit 2 and visit 3. For the test group, the improvement from visit
1, to visit 2 and visit 3 for plaque-free facial surfaces (p=0.005*), plaque-free lingual
surfaces (p=0.006*) and BOP-free teeth (p=0.0002*) were statistically significant.
However, the control group showed no statistically significant differences.
Analysis of the pocket depth and gingival recession at visit 2 and visit 3, showed
no statistically significant differences within control group and test group or in between
control group and test group.

! &/!
!
Table 1: Test group (Facial surface): number of surfaces with absence of plaque, number
of surfaces with presence of plaque at visit 1 and visit 2. Difference in absence of plaque
between visit 1 and visit 2.
!
! !
Table 2: Test group (Lingual surface): number of surfaces with absence of plaque,
number of surfaces with presence of plaque at visit 1 and visit 2. Difference in absence of
plaque between visit 1 and visit 2. !
!!
! &0!

Table 3: Control group (Facial surface): number of surfaces with absence of plaque,
number of surfaces with presence of plaque at visit 1 and visit 2. Difference in absence of
plaque between visit 1 and visit 2.
!
!
Table 4: Control group (Lingual surface): number of surfaces with absence of plaque,
number of surfaces with presence of plaque at visit 1 and visit 2. Difference in absence of
plaque between visit 1 and visit 2.
!
! &1!
! !
Table 5: Test group (BOP): number of teeth with absence of BOP, number of teeth with
presence of BOP and difference in number of teeth with BOP between visit 1 and visit 2.!
!
!
!
Table 6: Control group (BOP): number of teeth with absence of BOP, number of teeth
with presence of BOP and difference in number of teeth with BOP between visit 1 and
visit 2.!
! &2!
!
!
!
Table 7: Test group (Facial surface): % of surfaces with absence of plaque and % of
overall improvement.
!
!
!
Table 8: Test group (Lingual surface): % of surfaces with absence of plaque and % of
overall improvement.
! ,4!

Table 9: Control group (Facial surface): % of surfaces with absence of plaque and % of
overall improvement.

Table 10: Control group (Lingual surface): % of surfaces with absence of plaque and %
of overall improvement.
!
! ,%!
! !!
Table 11: Test group (BOP): % of teeth with absence of BOP and % over all
improvement.!
@! !
Table 12: Control group (BOP): % of teeth with absence of BOP and % over all
improvement.

! ,&!

Table 13: % of plaque-free surfaces and bleeding free teeth and % of overall
improvement for test and control group at visit 1 (baseline) and visit 2 (2 weeks).
*Table 9,10,11,12,13: results for patients that completed visit 1 and visit 2.

! ,,!

Table 14: % of plaque-free surfaces and bleeding free teeth for test and control group at
visit 1 (baseline) and visit 2 (2 weeks). (Blue = visit 1, Red = visit2)

Table 15: % of overall improvement of plaque-free surfaces and bleeding free teeth for
test and control group at visit 1 (baseline) and visit 2 (2 weeks). (Blue = Test group, Red
= Control group)

! ,-!

Table 16: Test group (Facial surface): number of surfaces with absence of plaque,
number of surfaces with presence of plaque at visit 1, visit 2 and visit 3. Difference in
absence of plaque between visit 1 and visit 3.

Table 17: Test group (Lingual surface): number of surfaces with absence of plaque,
number of surfaces with presence of plaque at visit 1, visit 2 and visit 3. Difference in
absence of plaque between visit 1 and visit 3.

! ,.!

Table 18: Control group (Facial surface): number of surfaces with absence of plaque,
number of surfaces with presence of plaque at visit 1, visit 2 and visit 3. Difference in
absence of plaque between visit 1 and visit 3.

Table 19: Control group (Lingual surface): number of surfaces with absence of plaque,
number of surfaces with presence of plaque at visit 1, visit 2 and visit 3. Difference in
absence of plaque between visit 1 and visit 3.

! ,/!

Table 20: Test group (BOP): number of teeth with absence of BOP, number of teeth with
presence of BOP and difference in number of teeth with BOP between visit 1 and visit 3.
!

Table 21: Test group (BOP): number of teeth with absence of BOP, number of teeth with
presence of BOP and difference in number of teeth with BOP between visit 1 and visit 3.

! ,0!

Table 22: Test group (Facial surface): % of surfaces with absence of plaque and % of
overall improvement.

Table 23: Test group (Lingual surface): % of surfaces with absence of plaque and % of
overall improvement.
! ,1!

Table 24: Control group (Facial surface): % of surfaces with absence of plaque and % of
overall improvement.

Table 25: Control group (Lingual surface): % of surfaces with absence of plaque and %
of overall improvement.
! ,2!

Table 26: Test group (BOP): % of teeth with absence of BOP and % over all
improvement.

Table 27: Control group (BOP): % of teeth with absence of BOP and % over all
improvement.

! -4!
!
!
Table 28: % of plaque-free surfaces and bleeding free teeth and % of overall
improvement for test and control group at visit 1 (baseline) and visit 3 (3 months).
*Table 22,2,3,2,4,25,26,27: results for patients that completed visit 1 and visit 3.

!

!

! -%!

!

Table 29: % of plaque-free surfaces and bleeding free teeth for test and control group at
visit 1 (baseline) and visit 3 (3 months). (Blue = visit 1, Red = visit2)
!
!
!
!
Table 30: % of overall improvement of plaque-free surfaces and bleeding free teeth for
test and control group at visit 1 (baseline) and visit 3 (3 months). (Blue = Test group, Red
= Control group)

!
! -&!
!
!

Table 31: Wilcoxon Signed Ranks test, comparison within groups between visit1 and
visit 2. Wilcoxon-Mann Whitney test, comparison between test group and control group.
*statistically significant difference.

Table 32: Anova Repeat Measure Analysis. Improvement over 3 visits of test group and
control group.
*statistically significant difference.

! -,!

Table 33: Anova Repeat Measure analysis, improvement of plaque-free facial surfaces.
Test p= 0.005* and Control p= 0.47. (Blue = Control group, Red = Test group)
(*Statistically significant)

! --!

Table 34: Anova Repeat Measure analysis, improvement of plaque-free lingual surfaces.
Test p= 0.006* and Control p= 0.69. (Blue = Control group, Red = Test group)
(*Statistically significant)
! -.!

Table 35: Anova Repeat Measure analysis, improvement of BOP-free teeth.
Test p= 0.002* and Control p= 0.47. (Blue = Control group, Red = Test group)
(*Statistically significant)

! -/!

Chapter 4: Discussion

This study was performed with participants who were diagnosed with periodontal
disease and had not undergone basic periodontal therapy prior to entering the treatment
protocol. Findings show that professionally applied subgingival irrigation and mouth
rinsing at home with 0.25% sodium hypochlorite significantly reduces the presence of
plaque and the number of teeth with bleeding on probing. In addition the present study
shows high correlation between the absence of plaque and the absence of bleeding of
probing (correlation coefficient 0.62). These finding support the use of sodium
hypochlorite to not only reduce the levels of plaque but also to reduce the presence of
bleeding on probing, which are both considered risk factors for the progression of
periodontal disease (Claffey et al.,1990; Badersten et al., 1990).
Periodontal disease is caused by pathogenic bacterial species located subgingivally.
This biofilm evolves and overcomes the natural antibactericidal defense mechanism
(Socransky & Haffajee. 2002). In addition the etiological role of viruses in periodontal
disease has several lines of evidence of support. Epstein–Barr virus-1, human
cytomegalovirus and herpes simplex virus have been detected at high frequency and
levels in localized and generalized aggressive periodontitis, chronic periodontitis and
acute necrotizing ulcerative gingivitis (Slots 2010).
Plaque control alone is known to have a minimal effect on clinical parameters
associated with periodontitis including probing depth and attachment level and does not
! -0!
predictably alter microbial composition in deeper pockets (Jorgensen et al., 2005).
Supragingival plaque removal performed meticulously by a professional may
interfere with the quantity and quality of subgingival microbiota and clinical symptoms
of periodontal disease such as inflammation and bleeding on probing. (Lovdal et al.,
1961; Suomi et al., 1971; Smulow et al., 1983; Axelsson & Lindhe 1981; Dahlen et al.,
1992; McNabb et al., 1992; Hellstrom et al., 1996). However, for those patients with
advanced periodontal disease professional supragingival plaque removal has failed in
preventing further periodontal tissue destruction (Westfelt et al., 1998). In addition, it is
known that sites with previous gingival inflammation accumulate more plaque that sites
with previously absent inflammation (Ramberg et al., 1996). Therefore, oral hygiene care
is best combined with subgingival instrumentation to achieve oral health (Kaldahi et al.,
1993). For some patients, subgingival instrumentation may not be sufficient and there
may be a necessity for anti-inflammatory medication (Salvi & Lang 2005), systemic
antibiotics or antiviral medication (Teles et al., 2013; Sunde et al., 2008).
Even though plaque control alone has a limited effect on periodontal disease, the
presence of dental plaque is considered a risk predictor for future attachment loss. The
diagnostic predictability improves with increase in length of time for recording scores.
In a 3$ -year observational study following initial periodontal therapy, results indicate
that accumulated plaque scores demonstrate low predictability for future attachment loss
whereas bleeding on probing demonstrated modest predictive values. Probing depth
showed modest predictability after 12 months, but increasing accuracy in revealing
attachment loss after three and a half years (Claffey et al.,1990).
! -1!

In a five-year observational study following initial periodontal therapy, the results
indicated that plaque and bleeding scores’ relationship with attachment loss was limited.
Plaque frequency of >75% reached diagnostic predictability of 28% at 36 months. This
means that 28% of sites with supragingival plaque present at 75% or more of the
examinations between 6-36 months had undergone probing attachment loss during 0-60
months. Thirty percent (30%) of the surfaces with plaque at 75% or more of
examinations eventually lost probing attachment (Badersten et al., 1990).
Therefore mouth rinses with 0.25% sodium hypochlorite may be effective in reducing the
presence of plaque and bleeding on probing, and in preventing risk of future attachment
loss; but, in order to achieve periodontal health, the use of sodium hypochlorite may be
combined with supra and subgingival debridement.
The limitations of the present study may be associated with: 1) gingival status and
levels of plaque at baseline, 2) control of patient compliance, 3) concentration of the
rinsing solution, 4) frequency of rinsing solution, 5) duration of the study, 6) use pressure
cleansing devices, 7) level of oral hygiene care at home.
Previous studies have evaluated the effect of sodium hypochlorite as a mouthwash
to reduce dental plaque and gingival inflammation. De Nardo et al. (2012) showed
statistically significant reductions for plaque, gingival, and bleeding indices for those
patients rinsing with sodium hypochlorite in comparison to water solution.
Participants of the present study required no professional care, or increase in
personal care, before the onset of the study treatment and did not receive any periodontal
! -2!
therapy prior to entering the study. Although subgingival irrigation was performed at visit
1 and visit 2 to disrupt periodontal biofilm. In comparison, participants of the De Nardo
et al. (2012) study received supra- and subgingival scaling, polishing with a rubber cup,
and were asked to do daily brushing and interproximal cleaning using dental floss every 2
days at home. Then, 40 subjects were able to participate in the study only if < 75% of all
tooth sites showed absence of bleeding on probing.
Consequently, the present study evaluated the ability of usual plaque control at
home, subgingival irrigation and mouth rinsing with sodium hypochlorite to wash out
previously established dental plaque and to reduce formation on new deposits. De Nardo
et al. (2012), however, evaluated the ability of mouth rinsing with sodium hypochlorite in
absence of usual plaque control at home, to reduce de novo plaque formation on teeth
surfaces.
The level of plaque was evaluated by visualization of presence or absence of
plaque on the facial or lingual surface. In order to limit the study to what it is
reproducible no plaque index was utilized. In addition, no plaque disclosing solution was
used in any of the visits. The use of plaque disclosing solution to evaluate the presence of
plaque, requires professional plaque debridement to eliminate the discoloration. It is the
aim of this study, to evaluate the ability of sodium hypochlorite to reduce the presence of
plaque in absence of supragingival or subgingival debridement, therefore no plaque
disclosing solution with potential bacterial inhibiting effect was used. However,
evaluation of dental plaque without a plaque disclosing agent may underestimate the level
of plaque.
! .4!
Patient compliance can also be considered a limiting factor in the present study.
Although the questionnaire of compliance revealed that, 83.33% (25/30) of the patients
understood the instructions to mix the rinsing solution, we have no way of confirming
that participants mixed the solution appropriately at home. De Nardo et al. (2012) had the
advantage of performing their study with a confined population. Although prisoners are
considered a “vulnerable” population as per human subject ethics, if treated with fairness
as per Institutional Review Board guidelines, they can be ideal participants for
investigations of investigator-administered medications. Even though we may never be
able to fully control patient compliance at home similar to a confined population, it may
be beneficial to provide patients with a premixed solution, which yet is unavailable from
the manufacturer. Most likely, a premixed solution will improve patient compliance as it
may make it easier for patients to follow a rinsing regimen and, thus, improve overall oral
health results.
Frequency, rinsing seconds and duration of the study may also be variables that
influenced our study results. Our participants rinsed with 0.25% sodium hypochlorite for
30 seconds, twice weekly; whereas De Nardo et al. (2012) participants rinsed with a
lower concentration (0,05% sodium hypochlorite), but for 60 seconds daily. The present
study intended to improve patients’ compliance by reducing the frequency of mouth
rinsing per week while increasing the concentration to achieve similar effects.
Nevertheless, further studies are needed in order to determine if lower frequency,
but higher concentration, is more beneficial than lower concentration but higher
frequency. In addition, the present study shows that the use of sodium hypochlorite long-
! .%!
term is safe and the overall improvement of plaque free surfaces and bleeding free teeth
is greater in comparison to short-term. These findings have to be analyzed with
precaution due to the limited number of patients that have already completed 3
rd
visit.
Clinical studies have demonstrated that the daily use of pressure cleaning devices at safe
pressure reduces gingivitis and the rate of calculus formation. The recommended pressure
is 2100 pulses per minute which produces an average force of 8.8 grams at the point of
impact (Lobene et al.,1969). Lobene et al. (1972) reported that flushing tooth surfaces at
safe levels of pressure with sodium hypochlorite has a strong effect on dental plaque.
Although professional subgingival irrigation with a Monojet® syringe was performed at
visit 1 and visit 2, the present study did not require home use of pressure cleansing
devices to deliver sodium hypochlorite, which may have improved clinical results.
None of the patients in the present study reported staining or discoloration of their
restorations in comparison to the De Nardo et al study in 2012 which reported that all
subjects receiving sodium hypochlorite rinse demonstrated a brownish stain at the end of
the study. However, 35.0% of subjects in the water rinse group of the De Nardo’s study
also exhibited brown tooth staining, although of a lower magnitude. Again, this
difference in findings may be explained due to the differences in rinsing time frequencies.
In contrast, in the present study, according to patients’ observations, 11 out of 30 patients
perceived whitening of their teeth (all of these patients were in test group).
The rate of periodontal disease is higher for those individuals living in low income
areas. The total expense for periodontal treatment and prevention in the United States was
approximately $14.3 billion in 1999 (Johns & Wall., 2002). Therefore there is need to
! .&!
enforce a low cost and efficacious periodontal health care especially in low income area.
We suggest that the use of sodium hypochlorite may serve for the prevention and
care of most types of periodontal disease.

! .,!

Chapter 5: Conclusion

Professionally applied subgingival irrigation and mouth rinsing at home with
0.25% sodium hypochlorite significantly reduced the presence of plaque and the number
of teeth with bleeding on probing. In addition the present study showed high correlation
between the absence of plaque and the absence of bleeding of probing. These finding
support the use of sodium hypochlorite not only to reduce the levels of plaque but also to
reduce the presence of bleeding on probing, which are consider risk factors for the
progression of periodontal disease.
Within the limitations of this study, it can be concluded that mouthrinsing with
0.25% sodium hypochlorite is highly safe, minimally invasive, extremely inexpensive
and may be efficacious in reducing the presence of plaque and bleeding on probing, and
therefore possibly prevent the risk of future attachment loss.

.-!
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Abstract (if available)

Abstract Background: Conventional periodontal therapy includes an anti-infective phase and, if necessary, may be followed by a surgical phase. Once the end-point of active therapy has been reached, a maintenance phase is instituted. Anti-infective therapy includes mechanical removal of biofilm. An array of adjunctive antimicrobial therapies have been proposed for the therapy with varying results. The application of diluted sodium hypochlorite has been examined in previous studies and there is significant data in favor of this agent. The purpose of the present study is to determine the initial and 3 months clinical effects of two rinses (0.25% sodium hypochlorite and water), performed twice a week, in the treatment of periodontitis. Our research hypothesis is that 2 weeks post-baseline and 3 months post-baseline, those participants who rinse with diluted bleach solutions will exhibit improved periodontal health vs. those participants who rinse with water alone. ❧ Methods: Thirty otherwise healthy adults, diagnosed with periodontitis, were included in the study. The following clinical variables were evaluated at baseline (visit 1), two weeks post-baseline (visit 2) and 3 months post-baseline (visit 3): medical history, dental radiographs, number of teeth, presence or absence of plaque, presence or absence of bleeding on probing, pocket depth and gingival recession. Participants randomly received professional subgingival irrigation with either sodium hypochlorite 0.25% (test) or water (control) at visit 1 and visit 2 and rinsed at home twice a week with either sodium hypochlorite 0.25% (test) or water (control) throughout the course of the study. At the end of the study participants were given a questionnaire to evaluate compliance with the regimen and perceived adverse effects of the rinse. Normality of the underlying distribution was assumed based on visual assessment and tested using Shapiro–Wilk Normality test. Wilcoxon-Mann-Whitney test was used to compare improvement between the two groups. Wilcoxon Signed Rank test was used to test the difference within the groups. Spearman Correlation (non parametric) test was used to determine the correlation coefficient between the difference in absence of plaque from visit 1 to visit 3 and difference in absence of bleeding on probing (BOP) from visit 1 to visit 3. ANOVA Repeated Measures was used to evaluate the difference in improvement over the 3 visits. The significance level was set at α = 0.05. Statistical analysis was performed using STATA statistical software version 12 (StataCorp, Texas, USA). ❧ Results: The results indicate that for those participants that completed visit 1 and visit 2, the difference of plaque-free facial surfaces within the test group was statistically significant (p= 0.009*). The control group showed no statistically significant difference. For those patients that completed visit 1 to visit 3, the test group showed a statistically significant improvement of, 0.009* plaque-free facial surfaces, 0.006* plaque-free lingual surfaces and 0.006* BOP-free teeth. However, the control group showed no statistically significant difference. The comparison at visit 3 of test group versus control group showed statistically significant difference for plaque-free facial surfaces (0.0042*), plaque-free lingual surfaces (0.042*) and BOP-free teeth (0.012*). The correlation between the difference in absence of plaque from visit 1 to visit 3 and difference in absence of BOP from visit 1 to visit 3, was evaluated using Spearman Correlation test (non parametric). The correlation coefficient was 0.62 (p=0.03*). ❧ Conclusions: Within the limitations of this study, it can be concluded that mouthrinsing with 0.25% sodium hypochlorite is highly safe, minimally invasive, extremely inexpensive and may be efficacious to reduce the presence of plaque and bleeding on probing, and therefore possibly prevent the risk of future attachment loss.

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Asset Metadata

Creator Galván, María (author)

Core Title Effect of 0.25% sodium hypochlorite oral rinse and subgingival irrigation on periodontal clinical parameters

School School of Dentistry

Degree Master of Science

Degree Program Craniofacial Biology

Publication Date 09/16/2013

Defense Date 05/30/2013

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag infection control,local antiseptics,OAI-PMH Harvest,periodontal disease,sodium hypochlorite

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Slots, Jorgen (committee chair), Rich, Sandra (committee member), Zadeh, Homayoun H. (committee member)

Creator Email mgalvancordero@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c3-328024

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