From: "Winfried Zeppenfeld" 
To: "ROOTS" 
Sent: Friday, March 04, 2005 3:22 AM
Subject: [roots] Does a final rinse with CHX influence perio?

Dear Rooters,

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