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Endo tips    Better Endo    Endo abstracts    Endo discussions

The opinions within this web page are not ours. Authors have been credited
for the individual posts where they are. photographs courtesy: Winfried Zeppenfeld
Does a final rinse with CHX influence perio? - Courtesy ROOTS

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

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 
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

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

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