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From: "Winfried Zeppenfeld" To: "ROOTS" 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 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 Dear Carmen, 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 theeth 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
Dear 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
