Volume 5, Issue 6, June – 2020 International Journal of Innovative Science and Research Technology

ISSN No:-2456-2165

Clinical and Microbial Comparative Evaluation of

0.1% Chlorine Dioxide Mouthwash Versus 0.2%
Chlorhexidine Mouthwash after Periodontal
Surgery: A Randomized Clinical Trial
Kale AM Sethi KS
Department of Periodontics, Department of Periodontics,
K.B.H. Dental College & Hospital K.B.H. Dental College & Hospital
Nashik, India Nashik, India

Mahale SA Karde PA
Department of Periodontics, Department of Periodontics,
K.B.H. Dental College & Hospital K.B.H. Dental College & Hospital
Nashik, India Nashik, India

Abstract:- Postsurgical mouthwash is routinely used in I. INTRODUCTION

daily clinical practice. Chlorhexidine gluconate (CHX)
is considered gold standard for chemical plaque control Various surgical procedures are performed in
regime. Extensively studied Chlorine dioxide (ClO2) Periodontics to treat periodontal pockets, correct
formulation has shown to have antiplaque, antibacterial mucogingival deformities or replacement of missing teeth
effect and effective against oral malodor. Unlike CHX it by placement of implants. The success and the favorable
does not cause teeth staining. Chlorine dioxide could be clinical outcomes of all this procedures depend on how
the possible alternative to CHX. The aim of the study is meticulously the bacterial contamination is avoided at these
to clinical and microbial comparative evaluation of operated sites to ensure uneventful healing.[1] Immediately
0.1% chlorine dioxide mouthwash versus 0.2% post operatively, these operated sites are predominated with
Chlorhexidine mouthwash after periodontal surgery. inflammatory phase of healing that harbors biofilm
Forty-five patients scheduled for periodontal flap formation and accumulation.[2] It has been observed that
surgery were randomly assigned in three groups good plaque control at these operated sites could fasten
depending on the post-surgical mouthwash. Patients healing, while in absence of good maintenance, chances
belonging to Group A and Group B were asked to rinse and risk of secondary infection and delayed wound healing
with 0.2% CHX mouthwash and 0.1% Chlorine dioxide are high.[3]
respectively, twice a day for 2 weeks after periodontal
surgery while patients belonging to Group C were asked Maintaining plaque free zone post-operatively is sine
to rinse with saline solution. On 7th and 14th day, quo non and this is been extensively documented gold
Plaque index (PI), Gingival index (GI), halitosis and standard in re-establishment of periodontal and peri-
early wound healing index were recorded. Microbial implant health.[4,5,6,7,8]. Despite of the extremely convincing
analysis was performed by determining colony forming evidence that support the positive effects of patient-
unit on blood agar plates cultured using plaque samples performed plaque control post-surgically, the studies
from the site. The data obtained from these were evaluating the effect of plaque control is sparse. [9]
statistically analysed. Both the test groups demonstrated
statistically significant reduction in colony forming unit, The post-operative chemical plaque measures are
PI, GI, and halitosis from baseline while Saline group suitable and complaint for patients. Among the various
showed non-significant reduction in colony forming chemical plaque control measures that are available,
unit, PI, GI, and halitosis from baseline. The result of chlorine dioxide mouthwash is one of the suitable
the present study supports alternate use of chlorine alternatives that have been reported to reduce oral malodor.
dioxide mouthwash to promote early wound healing The chlorite anion in the mouthwash induces oxidative
after periodontal surgery. consumption of precursors of VSCs - Volatile sulphur
compounds. [10] In this way, the post-operative use of
Keywords:- Chlorine dioxide, Chlorhexidine, Halitosis, chlorine dioxoide mouthwash, a strong oxidizing agent,
Perio-mouthwash, Post-surgical mouth rinses. reduces oral malodor by reduction of cysteine and
methionine like VSCs amino acids. The activity of Chlorine
dioxide is easily lost. “Stabilization” process improves its
stability by converting it to molecular chlorine dioxide at a
low pH of 7.[11,12] However, its clinical trial are poorly
documented.

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Volume 5, Issue 6, June – 2020 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
Chlorhexidine (CHX) is the most studied C. Post-operative maintenance
antimicrobial chemical plaque control agent. Results from Patients in the Group A, B and C were instructed to
two case series type of study evaluating halitosis patients rinse with15 ml CHX 0.2 % mouth rinse , 0.1% Chlorine
suggested a significant effect of 0.20% or 0.12% CHX dioxide mouthwash and normal saline respectively for 30 s
rinsing.[14,15] Though the gold standard and most suitable, twice daily. They advised to refrain from gargling, eat, or
there are various side effects on its prolonged prescription drink anything for subsequent hour. Oral hygiene
to patients such as as staining, altered taste and reduced reinforcement for non-operative sites were encouraged
taste sensation [16,17] which included brushing twice daily from days 3 to 14 to
ensure efficient plaque control and uneventful healing. 7
Considering the well documented CHX and poorly days post-operatively, sutures were removed.
documented chlorine dioxide, the two most potent chemical
plaque control agent, the clinical and microbial D. Clinical assessment
comparative evaluation of 0.1% chlorine dioxide The clinical parameters were recorded at baseline, 1
mouthwash versus 0.2% chlorhexidine mouthwash was week and at 2 weeks after surgery by the single calibrated
evaluated post-operatively in this study. examiner (K.S). Plaque index (PI),[18] Gingival index
(GI),[19] halitosis using halimeter and early wound healing
II. MATERIALS & METHOD index were recorded. Halitosis was evaluated using HC-
212SF Breath Checker. The HC-212SF uses a Semi-
Forty-five patients scheduled for flap surgery were Conductor gas sensor to measures the amount of volatile
selected for this randomised controlled clinical trial. Every sulfur compounds (VSCs) given off by bacteria. Plaque
subject received verbal and written information about the samples were collected and Microbial Analysis was
study and the signed consent was obtained from each of performed using Blood agar as culture media. Post-
them. The study protocol was approved by the Committee operative healing was assessed by the early wound healing
of Ethics Affairs of dental college and was conducted index (EHI)[20] differentiating between the following 5
according to the principles outlined in the Declaration of degrees:
Helsinki for experiments involving human subjects.  Complete flap closure–no fibrin line in interproximal
area
The selected patients were systemically healthy, non-  Complete flap closure–fibrin line in interproximal area
smokers and with no history of systemic antibiotics up to 6  Complete flap closure–fibrin clot in the interproximal
months prior to enrolment. Female subjects with pregnancy area
and breastfeeding history were excluded. Subjects requiring  Incomplete flap closure–partial necrosis of
reconstructive periodontal surgery as treatment were interproximal tissue
excluded from the study. All the patients diagnosed with  Incomplete flap closure–complete necrosis of the
chronic periodontitis were treated with initial periodontal interproximal tissue
therapy for 1 month prior to enrolment. Patients with an
indication for periodontal surgery in at least one sextant E. Evaluation of patient acceptance
exhibiting residual probing depths (PD) of ≥ 6 mm at the Patient acceptance was determined by the use of
end of 1 month following nonsurgical therapy were only visual analogue scale (VAS) questionnaires. Post-operative
selected for the study. pain, irritation of taste and dentine hypersensitivity have
been assessed using a scale of 10 cm. Additionally, patients
A total of 45 subjects were randomly assigned in three have been asked to mark subjectively how much teeth have
groups (15 patients in each group). Group A was asked to been stained using VAS with 0 cm representing none and
rinse with0.2% Chlorhexidine mouthwash*, Group B with 10 cm all teeth, respectively
0.1% chlorine dioxide mouthwash † and Group C with
normal saline twice a day for 30 seconds for 2 weeks after F. Statistical Analysis
periodontal surgery. For all tests, P < 0.05 was considered statistically
significant. Statistical analysis was performed using
A. Clinical procedures “INSTATS” software version 3.06.
Subjects satisfying the periodontal re-evaluation
criteria continued for this trial. Open-flap debridement III. RESULT
procedure were performed with root surface debridement
with either hand or ultrasonic instruments. Reflected flaps The use of chlorine dioxide was observed and
were repositioned by direct loop interrupted sutures. reported to be safe among Group B subjects with no
adverse tissue reaction and good patient compliance. The
B. Experimental design subjects were regularly evaluated for clinical parameters to
With the help of computer generated randomization assess healing and improvement in the condition (Fig 1).
table, the subjected were allotted to the groups. Subjects
were encouraged to strictly follow the post-surgical The Clinical Parameters like Halitosis, Plaque index
maintenance regime advised to them. and Gingival Index were evaluated at baseline, 7 days and
on 14 days (Table1). The Halitosis result of Group A i.e.
Chlorhexidine group showed statistical significant result

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Volume 5, Issue 6, June – 2020 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
only between 7 days to 14 days’ time period whereas the The analysed CFU colony unit for both Group A and
Group B (chlorine dioxide) showed statistical significant B showed significant result. However, Group A was found
results throughout the study. The use of saline in Group C to be better than Group B, and, Group C showed no effect.
had no clinical relevance. Similar type of results were found for Early Healing Index.
(Table 2)

Fig 1:- Clinical pictures of immediate suture placement and

14 days post-operative healing pictures of Group A Fig 2:- Preparation of wells and Zone of inhibition for
(Chlorhexidine), Group B (Chlorine Dioxide) and Group C microbiologic evaluation.
(Saline)

Table 2:- Comparative results of microbiologic parameter

CFU- Colony Forming Units and EHI – Early wound
Healing Index of Group A (Chlorhexidine), Group B
(Chlorine Dioxide) and Group C (Saline)

Table 1:- Comparative results of clinical parameters -

Halitosis, Plaque Index (PI) and Gingival Index (GI) of
Group A (Chlorhexidine), Group B (Chlorine Dioxide) and
Group C (Saline)

The Plaque Index was found to be statistically

significant only for Chlorhexidine group throughout the
study timeline. Both Group B and C had very little effect
on plaque maintenance. Group A and B, both showed
significant result for Gingival Index. However, the Group C
showing better results only from baseline to 14 days could
be attributed to reduced inflammation post-operatively.
(Table 1)
Fig 3:- Microbiologic parameter CFU- Colony Forming
Units assessed in Group A (Chlorhexidine), Group B
Zone of inhibition and Total colony forming unit was
(Chlorine Dioxide) and Group C(Saline) at 7th and 14th day
performed (Fig 2). For Zone of inhibition Blood Agar
post-operatively.
plates were plated separately by periodontal bacteria. Wells
were prepared on agar plate using punch and filled with
IV. DISCUSSION
mouthwash. Plates were incubated for 24hrs at 370 C and
later assessed for zone of inhibition and it was found that
In present study, chlorine dioxide (0.1%) mouth
zone of inhibition for normal saline was 0mm,
rinsing showed good compliance with patient. In this
chlorhexidine mouthwash it was 18mm and for chlorine di
randomized controlled clinical trial, 0.2 % CHX and 0.1%
oxide it was 9mm. For total colony forming units Plaque
chlorine dioxide mouthrinses, showed relevant clinical
samples were collected using curette and inoculated on
finding in terms of reduction in probing depth, pathogens
blood agar plates for 24 hours and CFUs were analyzed
and oral mal-odour. However, saline mouthwash was
per 1ml.(Fig 3)
comparative better than them in terms of early wound
healing.

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Volume 5, Issue 6, June – 2020 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
The major set-back of gold standard CHX, is the poor histological analysis was done to evaluate the healing
patient compliance in terms of side effects noted and mechanism.
documented. This includes altered taste, pigmentation on
mucosa and irritation. Owing to these side-effects, poor V. CONCLUSION
patient acceptability is observed. In such clinical scenario,
the subjects may become irregular or even discontinue With the limitations both mouthwash inhibited plaque
using the mouthrinse.[21] formation up to 7 days however after 14 days Chlorine
dioxide mouthwash was found to be a less effective in
Chlorhexidine mouthwashes has anti-plaque, anti- plaque inhibition than chlorhexidine. Chlorhexidine have
septic, anti-gingivitis property and they inhibit formation of better antibacterial efficacy in comparison to chlorine
VSCs[22]. The result of gingival index in the current study dioxide mouthwash. The results conclude of ClO2
was not in accordance to above mentioned study. The mouthwash improving post-operative bad breath in the
findings by Gürgan et al in their study concluded side subjects.
effects of CHX in just one week rather than two weeks in
some population.[16] The U.S. Food and Drug FOOTNOTE
Administration (FDA) has approved Sodium chlorite
(NaClO2) as a non-toxic antimicrobial agent which is * chlorhexidine mouthwash
†
equivalent to ClO2.[23] From the results obtained in this chlorine di oxide mouthwash (freshchlor, Group pharma)
study, it can be concluded that ClO2 was well tolerated by
patients with no alteration in taste, discoloration of mucosa ACKNOWLEDGMENT
and also reduced malodor. Frascella et al, in his clinical
trial testing the effectiveness of a ClO2 mouthwash, We hereby, acknowledge our gratitude to GROUP
concluded its clinical improvement in VSCs level and PHARMA Ltd for providing Chlorine dioxide mouthwash
malodor. These parameters were tested at different time sample.
intervals of 96 hours and were compared to placebo. [11]
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ISSN No:-2456-2165
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