Introduction
Periodontitis is caused by microorganisms that results in breakdown of periodontium. It results from host response to bacterial challenge, and the disease is influenced by environmental, acquired risk factors and genetic susceptibility.1 Periodontal disease is initiated by gram-negative, anaerobic bacteria that colonize subgingival area.2
Successful periodontal therapy involves elimination of microorganisms found in dental plaque which is associated with tooth surface and present within niches in oral cavity. Scaling and root planing is indicated for efficient plaque control and for eliminating periodontal pathogens. Anti-infective therapy includes both mechanical and chemotherapeutic methods which aids in eliminating microorganism responsible for causing gingivitis and periodontitis. Mechanical therapy involves root debridement by use of scalers. It involves both supragingival and subgingival scaling.3
Scaling and root planing (SRP) is major treatment modality for periodontal disease, however, its efficacy to gain access into deep pockets, furcation or any other root morphologic alterations can leave some amount of plaque deposits in the pocket which can result in recolonization of the treated areas with pathogenic organisms. The use of adjunctive systemic and local anti-microbials in addition to SRP has been introduced for further reduction or elimination of microorganisms more specifically.4
Supragingival and subgingival irrigation has been used in order to minimize bacterial etiologic agents. The biologic rationale is to reduce microbial deposits that may cause periodontal diseases. The primary goal is to flush bacteria coronal to the gingival margin, so that to reduce gingival inflammation. Subgingival irrigation attempts to reduce pocket microorganisms to prevent periodontitis.5
Subgingival irrigation can effectively change both quality & quantity of subgingival plaque associated with periodontal disease. Most commonly used, medicament for subgingival irrigation is Chlorhexidine. It has a wide spectrum of antibacterial activity and therefore is used more frequently. Similarly, it has been observed that Povidine Iodine has enhanced healing property and can suppress periodontal pathogens. Povidine Iodine has adjunctive benefits when used as pocket irrigation.6
Recently, Ozone has been introduced as an adjunctive treatment for chronic periodontitis. Ozone is a potent oxidant with high antimicrobial activity and also has host immunomodulation property. Molecular oxygen, hyperbaric oxygen and hydrogen peroxide have been used for irrigation. Ozone can be used in various forms such as gaseous, aqueous and oil forms.7
The aim of this study was to compare clinical parameters after using ozonated water, 0.2% Chlorhexidine and 5% Povidine Iodine for management of chronic periodontitis.
Materials and Methods
This study was designed as a randomized controlled clinical trial. A total of 45 patients within the age group of 18 to 55 years of both sexes reporting to the Department of Periodontology were selected based on inclusion and exclusion criteria. Out of these, 45 patients having at least 2 sites with PPD of 5mm or more with CAL of 3-4 mm or >5mm or more were included in the study. Patients who had received any antibiotic therapy, chemotherapeutic mouth rinses and oral irrigation during the past 6 months or pregnant and lactating women, patients who had undergone any surgical or non-surgical periodontal therapy in the past 6 months, patients with less than 20 natural teeth, smokers and tobacco chewers were excluded from the study. The purpose of the study was explained to the patients and a written consent was taken. Prior to the study, ethical approval was also taken form ethical committee. Subjects were divided into three groups, the ozone group (Group A), Chlorhexidine group (Group B), Povidone- Iodine group (Group C) received scaling and root planing followed by subgingival irrigation. Ozone group (Group A) received subgingival irrigation with Ozone Dental jet EDS-1601(Figure 1). Group B and C received irrigation with help of WaterPik (WP-70EC) (Figure 2). All patients were instructed to brush and use tooth paste in a similar manner and were called for further follow-up after 1 month and 3 months for evaluation of clinical parameters.
Clinical parameters assessed
Indices:
Gingival index (GI) (Silness P, Loe H, 1963) at baseline, 1st month and 3rd month.
Plaque index (PI) (Silness P, Loe H, 1964) at baseline, 1st month and 3rd month.
Modified sulcus bleeding index (Mombelli et al., 1987) at baseline, 1 st month and 3rd month.
Probing depth at baseline, 1st month and 3rd month.
Clinical attachment level at baseline, 1st month and 3rd month.
Statistical analysis
All the clinical parameters values thus obtained at baseline, 1 month and after 3 months were then statistically analysed. Data comparison was done by applying specific statistical tests to find out the statistical significance of the comparisons. Kolmogorov –Smirnov and Shapiro Wilk tests were performed to determine the normality of the data for gingival and periodontal parameters for subgingival irrigant.
Results
In this study, a total of 45 chronic periodontits patients with mean age of 42.66±0.87 were selected for SRP and subgingival irrigation with ozonated water, chlorhexidine and povidone iodine. All the selected sites were subjected to assessment of the clinical parameters like plaque index, gingival index, probing pocket depth, clinical attachment level and modified sulcus bleeding index at baseline, 1 month and after 3 months. All the clinical parameters values thus obtained at baseline, 1 month and after 3 months were then statistically analysed. The overall mean age was 42.66±0.87 with 62.2% males and 37.8% females. But the gender distribution was similar in all three groups with no statistical significance at p=0.516.
Pairwise comparison shows that the greatest mean difference was noted in the Chlorhexidine versus Povidine Iodine group at -.23600 at p=0.000. The difference in the plaque scores between Ozone versus Chlorhexidine was not significant at p=0.944. The difference between ozone versus Povidone Iodine was found to be significant at p =.001 as seen in Table 3. None of pairs showed significant mean difference for gingival index as seen in Table 6. The mean difference between ozone versus chlorhexidine was found to be .00290 with p =0.976. Similarly, mean difference between ozone versus povidone iodine was found to be .01067 with p=.717 which was found to be non-significant and difference between chlorhexidine versus povidone iodine was also found to be non-significant with p=.596 as seen in Table 4. Pairwise comparison showed no significant difference between groups. Mean difference between ozone versus chlorhexidine was found to be 0.01267 and .01867 difference between ozone versus Povidone Iodine. Similarly, mean difference between chlorhexidine versus Povidone Iodine was found to be 0.00600 which was non-significant as seen in Table 5. On pairwise intergroup comparison none of the pairs showed significant difference. Pairwise Intergroup comparison demonstrated that there was no significant difference when ozone was compared to Chlorhexidine and Povidone Iodine. A post hoc pairwise comparison using the Bonferroni correction showed a decreased Gingival Index score between baseline and follow-up assessment one month later which was statistically significant (p = .0.005).
Significant findings were also noted when comparing the initial assessment to a second follow-up assessment done 3 months later after the original assessment (p = .001). Therefore, we can conclude that the results for the ANOVA indicate a significant time effect for Gingival Index as measured in the Ozone treated group. Repeated- measures ANOVA test determined that mean Sulcus bleeding index scores differed significantly across three time points (F = 4.633, p = .015). A post hoc pairwise comparison using the Bonferroni correction showed an decreased Sulcus bleeding index score between baseline assessment and follow-up assessment one month later which was statistically significant (p = .0.047). Significant findings were also noted when comparing the initial assessment to a second follow-up assessment done 3 months later after the original assessment (p = .019). Therefore, we can conclude that the results for the ANOVA indicate a significant time effect for Sulcus bleeding index as measured in the Ozone treated group.
Repeated-measures ANOVA test determined that mean Probing Pocket depth scores did not differ significantly across three time points (F = 0.536, p = .589). Probing Pocket depth was not significantly different between any intervals as measured in the Ozone treated group. Repeated-measures ANOVA test determined that mean Clinical attachment loss was not significant across three time points (F = 0.513, p = .0.602). A post hoc pairwise comparison using the Bonferroni correction showed an decreased Clinical attachment loss between baseline assessment and follow-up assessment one month later which was not statistically significant (p = .0.787). CAL was not significant across intervals for Ozone group.
Repeated-measures ANOVA test showed that the mean Plaque Index scores in Chlorhexidine group differed significantly across three time points (F = 6.411, p = .004).() A post hoc pairwise comparison using the Bonferroni correction showed an decreased Plaque Index score between baseline assessment and follow-up assessment one month later which was statistically significant (p = .0.018). Significant findings were also noted when comparing the initial assessment to a second follow-up assessment done 3 months later after the original assessment (p = .005). No significant difference was noted between 1st and 3rd month. Therefore, we can conclude that the results for the ANOVA indicate a significant time effect for Plaque Index as measured in the Chlorhexidine treated group.
A post hoc pairwise comparison using the Bonferroni correction showed a decreased Clinical attachment loss between baseline assessment and follow-up assessment one month later which was not statistically significant (p = .0.860). CAL was not significant across intervals for chlorhexidine group.
A post hoc pairwise comparison using the Bonferroni correction showed a decreased Plaque Index score between baseline assessment and follow-up assessment one month later which was statistically significant (p = .0.029). Significant findings were also noted when comparing the initial assessment to a second follow-up assessment done 3 months later after the original assessment (p = .000). Therefore, we can conclude that the results for the ANOVA indicate a significant time effect for Plaque Index as measured in the Povidine Iodine treated group. Between 1 month to 3 months, the difference was not significant.
A post hoc pairwise comparison using the Bonferroni correction showed a decreased Plaque Index score between baseline assessment and follow-up assessment one month later which was statistically significant (p = .0.000). Significant findings were also noted when comparing the initial assessment to a second follow-up assessment done 3 months later after the original assessment (p = .000). Therefore, we can conclude that the results for the ANOVA indicate a significant time effect for gingival Index as measured in the Povidine Iodine treated group.
A post hoc pairwise comparison using the Bonferroni correction showed a decreased Sulcus bleeding index score between baseline assessment and follow-up assessment one month later which was statistically significant (p = .0.002). Significant findings were also noted when comparing the initial assessment to a second follow-up assessment done 3 months later after the original assessment (p = 0.000). Therefore, we can conclude that the results for the ANOVA indicate a significant time effect for Sulcus bleeding Index as measured in the Povidine Iodine treated group.
Table 1
Intergroup comparison of mean plaque index score
Table 2
Intergroup comparison of mean gingival index score
Table 3
Intergroup comparison of sulcus bleeding index
Table 4
Intergroup comparison of pocket depth
Table 5
Intergroup comparison of mean clinical attachment level
Table 6
Intragroup comparison of clinical parameters at baseline, 1 month & 3 months for all groups
Discussion
Periodontal diseases are characterized by a local hypoxia of tissues & also by various micro-organisms. Progression of periodontal disease may be attributed to bacterial accumulation in subgingival pockets.8 The supragingival cleaning aids are not sufficient to remove periodontal inflammation.9
Ozone is a potent oxidant with marked antimicrobial activity and the potential to act as a metabolic and host immune modulator. Ozone has been used in the treatment of early carious lesions; for the sterilization of cavities, root canals and periodontal pockets; to enhance epithelial wound healing, such as that caused by ulceration and herpetic lesions; as a rinse for avulsed teeth; and as a denture cleaner. The routes of ozone administration are topical and regional for both gaseous and aqueous forms.10
Chlorhexidine digluconate mouth rinses at concentrations of 0.1–0.2% have a long history of use in controlling supragingival plaque and gingivitis. Chlorhexidine digluconate at low concentrations may require controlled release delivery to exert effective killing of subgingival microorganisms and tends to be more bactericidal for gram-positive organisms than for gram-negative species.11
Povidone-Iodine has also been used as an adjunct to treat chronic periodontitis with promising results.12
The role of subgingival irrigating solutions i.e., ozonated water, 0.2% chlorhexidine and 5% Povidine Iodine in nonsurgical periodontal treatment for the management of chronic periodontitis was evaluated in the present study.
In the present study Ozone treated group had the lowest plaque index score, followed by Chlorhexidine and Povidone Iodine. This was in accordance with a study conducted by Dodwad V et al.13 They reported significant reduction in plaque index with ozonated water irrigation followed by chlorhexidine and Povidone Iodine.
Pairwise comparison shows that the greatest mean difference was noted in the Chlorhexidine versus Povidine Iodine group. On the other hand, the difference in the plaque scores between Ozone versus Chlorhexidine was not significant at p=0.944.
The possible mechanism for the reduction in Plaque Index with ozone irrigation may be the antibacterial effect on the plaque microorganisms or may be by disruption of subgingival plaque rather than instant killing of microorganisms.
In the present study, when the comparison was made between all the three groups ozonated water showed slightly better improvement than chlorhexidine and povidone iodine. However, a statistically significant improvement was seen only with Plaque score. Ramzy et al.14 found a significant improvement in Plaque score treated by SRP alone along with ozone application. The ozonated water had strong bactericidal activity in a biofilm and also inhibited the accumulation of plaque in vitro.
In our study at 3 months there was no statistical difference found between groups. All three groups i.e., ozone treated group, chlorhexidine and povidone iodine group ranked similar. This was in accordance with Kaur A et al.15 where inter group comparison of mean gingival score was statistically nonsignificant at baseline, 4 weeks and 3 months. Irrigation of the gingival tissue results in an alteration in the composition of plaque thereby resulting in reduced inflammation as well as resulting in healthier gingival tissue.
This was also in accordance with Lander et al.16 who has determined the effect of single subgingival irrigation of 0.2% CHX at baseline and at weeks 1,2,3,4,5,7 and 10, and has shown reduction in the gingival index from baseline to 1 week.
In this study Sulcus bleeding Index scores at the end of 3 months showed no significant difference at the end of 3 months with p value as 0.578. Pairwise comparison also showed no statistical difference.17
This may be attributed to the fact that both chlorhexidine and ozone mechanize by disrupting the cell wall, thereby damaging the cellular components. However, the use of ozone is justified as a new option of irrigating agent with antimicrobial action without developing resistance which results from oxidation of microbial cellular components.
Our study showed that at the end of 3 months none of the pairs showed significant difference. However, there can be difference observed between all the three groups but it was not statistically significant.
The result is in accordance with Hirshi TS et al.18 where on intergroup comparison they did not observe any significant change in terms of pocket depth.
In our study percentage reduction in PPD was slightly better in ozone as compared to chlorhexidine and povidone iodine. Though, on intergroup comparison the results were non- significant.
This can be attributed to better antimicrobial action against P.gingivalis, Parvimonas Micra, Tannerella forsythia on irrigation with ozone compared to chlorhexidine as observed by Huth et al.19
This study demonstrated that mean CAL gain was statistically significant in all groups after 3 months and Intergroup comparison showed that difference between the groups was not significant.
The result is in accordance with Kaur A et al.20 where they evaluated efficacy of ozonated water and 0.2% chlorhexidine gluconate as adjunct to SRP in the management of chronic periodontitis. They demonstrated significant results in both the groups with regard to improvement in clinical parameters. However, on intergroup comparison of the mean CAL gain was statistically non-significant.
Conclusion
Within the limits of the study, it can be concluded that adjunctive role of subgingival irrigating solutions i.e., ozonated water, 0.2% chlorhexidine and 5% Povidine Iodine in nonsurgical periodontal treatment for chronic periodontits patients, have effective role in reduction of all the clinical parameters.
In our study, ozone group was found to be superior than chlorhexidine followed by povidone Iodine in terms of reduction of Plaque Index. However, intergroup comparison for other parameters did showed difference but it was not statistically significant.
It can be concluded that use of ozone can serve as beneficial irrigating solution to treat chronic periodontitis for home care and professional practice. More studies with a larger sample size may be used to evaluate the potential of these irrigating agents.
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