Modified Widman flap and non-surgical therapy using chlorhexidine chip in the treatment of moderate to deep periodontal pockets: A comparative study.

INTRODUCTION: It is a well established fact that periodontitis is caused by a group of highly specific microorganisms, organized as a bio-film on the tooth surface. Hence, therapeutic modalities are directed against elimination or adequate suppression of these organisms. Thorough debridement of these sites is possible mainly by scaling and root planing (SRP) and open- flap debridement in deeper sites. Open- flap debridement includes conventional surgical procedures such as the modified Widman flap procedure. Surgical procedures, however, have a number of disadvantages and hence efforts have been on at improving various non-surgical approaches, which are directed more specifically at the microbial nature of periodontal disease. Use of local drug-delivery devices is one such approach. The combined therapy of SRP and local drug delivery has been showing promising results in improving all the parameters in periodontal disease.
MATERIALS AND METHODS: This study compares the clinical, as well as, microbiological results of a split-mouth trial using modified Widman flap and non-surgical therapy of SRP and the use of a controlled release drug-delivery device (Chlorhexidine chip), in the management of moderate to deep pockets. RESULTS AND
CONCLUSION: The results showed that the non-surgical most sites subjected to the non-surgical treatment were found to be maintainable without further deterioration, during the study period.

INTRODUCTION

Over the years there is a significant improvement in the understanding of the etiopathogenesis of periodontal disease. Consequently, therapeutic modalities have been modified to suit the changing trends of time, for the successful clinical management of these diseases.

Today, there is abundant scientific evidence to suggest that periodontitis is caused by a group of specific microorganisms with pathogenic potential. Elevated proportions of highly organized putative pathogenic species, in the subgingival environment and in close proximity to the advancing front of the pocket, are believed to be associated with the destruction of the periodontal tissues. The conceptual basis, at present, for the treatment of periodontitis is the elimination or adequate suppression of putative organisms in the subgingival microbiota.[1]

The only effective and reliable method for the elimination of these microbes is the mechanical debridement of the subgingival sites.[1] Hence, the traditional therapies for periodontal disease were dependent upon scaling and root planing (SRP), or an open-flap approach to achieve this objective.[23] However, surgical procedures have inherent disadvantages such as causing changes in hard and soft-tissue topography in the form of gingival recession, interproximal soft-tissue cratering and crestal bone resorption.[4]

Hence, new non-surgical techniques (cause-related approaches to treat the microbial nature of periodontal disease) were developed to overcome the above. In recent years, there are reports which suggest that mechanical debridement with locally delivered adjunctive antimicrobial therapy are quite effective in the management of periodontal diseases and could hence reduce the need for surgical therapy.[256]

This study is an attempt to compare the time-tested surgical approach, the modified Widman flap, with the new technique of combined therapy consisting of SRP and chlorhexidine-controlled release drug-delivery system.

Aims and objectives

To compare the results of SRP with chlorhexidine-controlled release drug delivery system and modified Widman flap in the management of moderate to deep periodontal pockets, both clinically and microbiologically.

To evaluate the effects of either procedure on clinical parameters like bleeding on probing, probing pocket depth and clinical attachment level.

To study the changes in pocket microbiota brought about by either procedure, using dark-field microscopy.

MATERIALS AND METHODS

Seventeen patients, comprising of eleven females and six males, attending the Department of Periodontology, M.R. Ambedkar Dental College and Hospital, Bangalore, diagnosed as having moderate to severe periodontitis were included in the study. The age of the participants was between 30 and 60 years. Two female patients dropped out of the study and only fifteen completed the study period.

Inclusion criteria

Subjects with moderate to severe periodontitis as defined by atleast one contralateral defect (pocket depth ≥5mm) and demonstrating bleeding on probing.

Presence of a minimum of 15 natural teeth (minimum of atleast four teeth per quadrant).

Subjects in good general health.

Exclusion criteria

Subjects with a known history of systemic diseases, allergies or drug usage that would alter the healing response of the oral tissues.

Subjects who had undergone periodontal treatment within six months prior to the study.

Subjects who would require antibiotic therapy during the course of the treatment.

Subjects with a history of allergy to chlorhexidine.

Clinical procedure and study design

After a comprehensive phase-I therapy, the patients were recalled after 3-4 weeks for revaluation. Two contralateral sites of similar probing depths (≥5mm) were selected and by coin flip [Figure 1], one site underwent modified Widman flap procedure (control site) and the other underwent non-surgical therapy of SRP with placement of the chlorhexidine chip (experimental site) [Figure 2].

Figure 1

Experimental site and control site at baseline

Figure 2

SRP and chlorhexidine chip placed at experimental site and modified widman flap procedure done in control site

The selected sites were standardized for reproducibility, by the use of custom-made acrylic stents featuring a groove to facilitate the same point and angle of insertion of the probe.

Clinical parameters of plaque index,[7] calculus index,[8] bleeding on probing,[9] probing pocket depth and clinical attachment level were recorded at baseline, at the end of 3, 6 and 9 months; at the experimental and control sites [Figures 1 and 3].

Figure 3

Experimental site and control site at the end of 9 months

Microbiological analysis was done in seven patients at baseline, at the end of 3, 6 and 9 months. Supragingival plaque, if present, was removed before sampling. Subgingival plaque samples at the experimental and control sites were collected using sterile after five curettes, with the curette inserted to the apical limit of the pocket and drawn coronally, while maintaining contact with the root surface. The collected samples were dispersed and suspended in 0.2 ml of 0.9% sodium chloride solution, by vigorously agitating the tip of the curette in the sample. The third drop of sample expelled through a sterile micropipette was placed on a microscopic slide and covered by a glass cover slip.

The slide was examined using dark-field microscopy of ×400 and this examination was completed within 1 hour of the sample collection. For each sample, 200 bacteria from fields selected at random were counted and classified into spirochetes, motile and non-motile bacilli, cocci, fusiforms and filaments, as described by Listgarten and Hellden (1978)[10] [Figures 4,5 and 6].

Figure 4

Microbiological profile assessed under dark-field microscopy (×400) at the experimental and control sites; at baseline

Figure 5

Microbiological profile assessed under dark-field microscopy (×400) at the experimental and control sites; at the end of 3 months

Figure 6

Microbiological profile assessed under dark-field microscopy (×400) at the experimental and control sites; at the end of 9 months

The sum total of motile and non-motile organisms; at the experimental and control sites were calculated, and subjected to statistical analysis.

RESULTS

Students’t’ test was used with appropriate degrees of freedom and P-values were obtained with appropriate levels of significance. Whenever means of more than two groups were to be compared, ANOVA was used to test statistic F- value.

Both the control and experimental site showed improvements in bleeding on probing, probing pocket depth and clinical attachment level from baseline to 9 months [Table 1].

Table 1

Mean values with standard deviation for different clinical variables

At the control site bleeding on probing improved from 0.933±0.258 to 0.400±0.507, probing pocket depth from 7.533±0.743 to 2.467±1.457 and clinical attachment level from 8.00±1.069 to 4.467±1.642,from baseline to 9 months [Table 1].

At the experimental site, bleeding on probing improved from 1.00 to 0.467±0.516, probing pocket depth from 7.267±1.280 to 3.200±1.512 and clinical attachment level from 8.200±1.740 to 3.867±1,767, from baseline to 9 months [Table 1]

The amount of improvement in the above mentioned parameters was better in the control site but the improvement in the experimental site was adequate to be maintained without further deterioration.

Both the experimental and control groups showed a comparable improvement in the microbiological parameters in terms of decrease in total motile organisms and a corresponding increase in non-motile organisms, from baseline to 9 months [Table 2, Figures 7 and 8].

Table 2

Mean values with standard deviation for different microbiological variables (×400 magnification) at the experimental and control sites; at the end of 9

Figure 7

Depicting total motile organisms in experimental and control groups

Figure 8

Depicting total non-motile organisms in experimental and control groups

DISCUSSION

The role of bacteria in the etiology of periodontal diseases has been established. Conventional periodontal treatment consists of mechanical debridement to eliminate the subgingival microbiota and infected tissue in the inflamed pocket, usually performed by SRP. However, achieving consistent success is demanding for both the patient and therapist. Deep periodontal pockets, especially with root concavities or furcation involvement prevent the effectiveness of SRP.[11]

In the above-mentioned situations, it is necessary to perform a flap operation, in order to obtain access and visibility, to the underlying root surface and bone. One of the commonly performed procedures for this purpose is the modified Widman flap.[12] This procedure has shown to reduce pocket depths and promote attachment gain. However, it is associated with certain disadvantages such as greater patient morbidity; marginal bone resorption and compromised post-surgical aesthetics, in the form of gingival recession and interproximal soft-tissue cratering.[4] There are certain individuals in whom surgery is contraindicated such as medically compromised patients, uncooperative individuals, elderly patients and persons with physical or mental handicaps. There are also patients who show sites refractory to conventional therapy. Such patients may benefit tremendously if there are better non-surgical methods of managing periodontal disease.

Hence in the past decade, a greater emphasis was laid on the microbiological etiology of periodontal diseases and various new chemotherapeutic approaches were developed to manage the same. Various systemic and locally administered antimicrobials have been used and it has been observed that the duration to which the microflora is exposed to the antimicrobial agent is the most critical factor to determine the efficacy of a locally delivered antimicrobial. This saw the introduction of local drug-delivery devices in the form of sustained and controlled delivery devices.[2]

The preceding discussion brings to the forefront two approaches in the management of chronic periodontitis. One is the time-tested surgical approach and the other is the recent non-surgical approach using SRP and local drug delivery.

The results of this study show that on the experimental site, the treatment of periodontal pockets with chlorhexidine chip as an adjunct to SRP provides a significant improvement in bleeding on probing, probing pocket depth and clinical attachment level.

At the experimental site, the mean improvement in probing depth (4 mm, from baseline to 9 months) and that of clinical attachment level (4.3 mm) was compliant with studies conducted by Jeffcoat et al., Staboltz et al. and Grisi et al.,[13-16] and at the control site, improvements in probing pocket depth (5.1 mm) and in clinical attachment level (3.5 mm) were in keeping with studies conducted by Pihlstrom et al., Kaldahl et al. and Ramfjord et al.[17-19] All surgical sites showed a 1-2 mm recession.

The amount of pocket reduction on the experimental site was mainly attributed to pocket reduction, due to soft-tissue shrinkage following SRP, as well as resolution of gingival inflammation due to action of the antimicrobial agent (Chlorhexidine chip).

On the control site, the amount of pocket reduction could be attributed to shrinkage of the gingiva following removal of the pocket lining, resolution of gingival inflammation, as well as some amount of new attachment.

Results of the microbiological evaluation (dark-field microscopy) in the two individual groups showed a significant increase in the total number of non-motile organisms and a decrease in total number of motile organisms at the end of 9 months. There was no statistically significant difference between the experimental and control groups. These findings were compliant with improvement in periodontal health and indicate that the non-surgical treatment modality used is just as effective as that as that of the surgical treatment in suppressing the pathogenic microflora and favoring the growth of organisms associated with periodontal health.

The changing concepts in pocket management have shown that periodontal pockets with probing depth ≤5mm can be well maintained, without requiring a surgical intervention. Although, the control site showed better improvement in probing pocket depth, the amount of pocket reduction achieved in the experimental site was sufficient to be maintained adequately during the maintenance phase, without further deterioration.

A surgical approach is, however, deemed necessary in certain clinical settings, such as difficult to access sites, anatomical aberrations such as furcation areas, root concavities, grooves, ridges, etc. It should be borne in mind that non-surgical approaches are not substitutes for surgery.

These results when translated into specific clinical settings could bear a lot of relevance. It could reduce the need for surgeries in patients having a contraindication for it as well as reduce patient morbidity and could be useful in uncooperative patients or those afraid of surgery.

The cost-effectiveness of a procedure has to be borne in mind. The use of a local delivery device may be effective only when used in an isolated area or a few localized areas. A surgical approach may be more cost effective in generalized areas of periodontal disease.

SUMMARY AND CONCLUSIONS

With the changing concepts of disease etiopathogenesis, a more cause-related approach to disease management is necessary. While time-tested surgical procedures are still very much essential, their indications are limited to very definite clinical situations. The results of this study bring to the forefront that most periodontal cases can be managed non-surgically with both improved instruments for access, as well as the use of antimicrobial agents. Very few sites are actually non-responsive to such treatment and may have to be managed surgically.

Non-surgical intervention is not a substitute for surgery as surgery has definite indications in specific clinical settings such as furcationally involved teeth, roots with ridges, grooves, concavities, etc, where thorough SRP by means of a closed approach is difficult.

It is suggested that all measures of non-surgical therapy first be advocated, results evaluated after an adequate revaluation interval and then a surgical option planned in case of non-responsive cases.

The clinician while debating on a treatment option should hence follow an integrated approach of taking all the above-mentioned criteria into consideration and thereby providing each individual patient with the best possible option.