Does a final rinse with CHX influence perio? - Courtesy ROOTS
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photographs courtesy: Winfried Zeppenfeld
From: "Winfried Zeppenfeld"
Sent: Friday, March 04, 2005 3:22 AM
Subject: [roots] Does a final rinse with CHX influence perio?
A Tronstad paper states that the bugs in the pocket and the bugs in the canal are
very similar . Periodontal disease is caused by bacteria on the outside of the root
which may also penetrate the dentin and cause necrosis of the pulp in virgin teeth
that are periodontally compromised. The direction of the bacteria is outside in
whereas the direction of the disinfectant we use during cleaning and
shaping and as an intermediate dressing in inside>out. If bacteria can penetrate
the dentin from the outside, it's also imaginable that disinfectants penetrate the
dentin from the inside to its outer surface.
In case of CHX, this might have a positive effect on the progression of PERIODONTAL
disease if CHX from the root canal could penetrate dentin and influence bacteria on
the outside of the root, especially when higher concentrations of CHX are used. Does
this idea make any sense at all or am I just dreaming?
This idea came to my mind after I received a personal mail from Rüdiger Osswald
(remember: the CHKM/CMCP guy) asserting that CHKM does have
exactly this effect. Any lit on that topic? Opinions? Thanks for info! - Winfried
In the case of chlorhexidine, I would be concerned about cytotoxicity of chx in a
chronically eposed periodontium.
We are concerned about not only tissue shrinkage and resolution of abscesses at the
root/periodontium interface, but also with reattachment in this same microcosm.
I think I remember reading that chx, while useful against microbes, inhibits
attachment repair. Has anyone else heard this? - Wes
Hi Wes, I heard that as well!
On the other hand, there is the question if this effect or the
recolonization with bacteria if you don't use CHX is more important - Winfried
Winfried, Good point.
Of course, the best would be to find a topical that is antibacterial, yet
not cytotoxic - Wes
Yes, most of the species isolated from infected root canals can be find in the
periodontal pocket. But the root canal flora is not as complex as that of the
periodontal pocket and the number of anaerobic bacteria is higher in the root
canal compared to the periodontal pocket (different environments).
It seems that periodontal disease rarely cause alteration of the vital functions
of the pulp maybe because few open pathways exist in many peridontally involved
teeth. Many teeth with advanced periodontal disease maintain their vitality
until bacteria involves the apical foramina. Periodontal disease is better
treated from the outside the root, don't you think? If periodontal condition
has an endodontic origin, root canal treatment will solve the problem unless
chronic disease has been established. But in the case of pulpal disease secondary
to periodontal disease, root canal treatment won't solve the periodontal problem.
Don't you think? Or maybe I don't understand your question? - Carmen cohn
The question came up when I posted the attached case in a German mailing list
asking for treatment suggestions and opinions. (Pat. is 50 years old. , has a
big gummy smile, looks back at a long smoking career, has been nonsmoker for
3 months, left "her" dentist after 20 years because she felt something was
going wrong and went to see a colleague who does a lot of implants. He suggested
to take ALL teeth out and place implants and fixed crown and bridgework on top
which would cost her a double annual salary. She came to my practice to ask
for a second opinion). If you do perio treatment on such a patient, you get
quite a bit of esthetic problems, end up with a long epithelial attachment with no
cementum on the surface of the roots after perio.
I visited Rüdiger Osswald in his practice in Munic last fall and he showed me
quite a few similar cases and long term follow ups. In a case like that he would
splint the teeth with a horseshoe bridge in the maxilla and do perio on all
teeth that have a chance and probably endo too. You remember his way with the
CHKM. He says that this also has a positive effect on the perio problem because
it disinfects the tooth inside out giving the bacteria in the pocket less chance
to successfully attack. Of course this is no substutution for perio therapy, he
just claims an additional benefit. And in such difficult cases you are grateful
for anything that has a positive effect on the outcome. So my question was
if CHX as an endo rinse may have an addtional positive influence on the
perio problem - Winfried
Thanks for posting the case. Your patient has an important periodontal problem.
I don't think CHX endo rinse could have any benefit. As I know CHX significantly
reduced the bacterial counts only in the first 100 microns of dentinal tubules.
And cementum is an important factor that reduces the permeability of root dentin.
Even after removal of all of the cementum, the permeability remains low until
more than 200 microns of outer dentin is removed. So any disinfectant couldn't
reach the outer surface of the root such as to benefit the periodontal problem.
What is your treatment plan in this case? - Carmen Cohn