One-stage full-mouth disinfectioncombined with a periodontaldressing: a randomizedcontrolled clinical trialKeestra JAJ, Coucke W, Quirynen M. One-stage full-mouth disinfection combinedwith a periodontal dressing: a randomized controlled clinical trial. J ClinPeriodontol 2014; 41: 157–163. doi: 10.1111/jcpe.12199.

AbstractAim: To compare the clinical benefit of a periodontal dressing applied after aone-stage full-mouth disinfection (OSFMD) in patients with chronic periodontitisup to 3 months after therapy.Material and Methods: This randomized, controlled split-mouth study included24 patients. After OSFMD, a test and a control side were selected by means of acomputer-generated randomization list. Test sides received a periodontal dressing(Coepak�) for 7 days and the control sides received no periodontal dressing.After 7 days the periodontal dressing was removed and the pain experience wasrecorded. After 3 months, the clinical periodontal parameters were recorded.Results: The periodontal dressing group showed a significant (p < 0.05) addi-tional pocket depth reduction and additional clinical attachment gain for themoderate pockets of single- and multi-rooted teeth compared with the controlgroup. A significant (p < 0.05) lower percentage of sites with probing pocketdepth ≥5 mm were shown for the periodontal dressing group compared with thecontrol group (2.7 � 16.3% versus 4.8 � 21.4%). The pain intensity was signifi-cantly reduced when using a periodontal dressing (5.13 � 0.89 versus3.42 � 1.27).Conclusion: The use of a periodontal dressing for 7 days after a OSFMD offersan additional short-term clinical improvement and lowers the pain intensity.

Johan A. J. Keestra1, Wim Coucke2

and Marc Quirynen1

1Department of Periodontology, School of

Dentistry, Oral Pathology & Maxillo-facial

Surgery, Faculty of Medicine, Catholic

University Leuven, Leuven, Belgium;2Department of Clinical Biology, Scientific

Institute of Public Health, Brussels, Belgium

Key words: chronic periodontitis; full-mouth

disinfection; non-surgical therapy; periodontal

dressing

Accepted for publication 17 November 2013

Periodontitis is an inflammatory dis-ease that results in the destruction ofthe teeth-supporting tissues. It is aresult of an imbalance between thewide range of microorganisms, thehost response and some essential

modifying factors (Socransky & Haf-fajee 1992). The primary clinical signsare bleeding on probing (BOP),pocket formation (PPD), gingivalrecession (REC) and at a later stageincreased tooth mobility. The goals oftreatment are to reduce the infection,resolve inflammation and create aclinical condition, which is compati-ble with periodontal health (Lang &Tonetti 2003).

It has been shown that non-surgi-cal periodontal therapy, consistingof scaling and root planing, results

in clinical improvements (Baderstenet al. 1981). This is usually done in aquadrant wise approach (QSRP). In1995 Quirynen and co-workersintroduced the one-stage full-mouthdisinfection (OSFMD). With thisprocedure scaling and root planingwas performed in two sessionswithin 24 h and was supplementedwith supra- and subgingival use ofchlorhexidine (Quirynen et al. 1995,2006, Mongardini et al. 1999).

Periodontal dressings were intro-duced in 1923 in order to protect

Conflict of interest and source of

funding statement

This article has been prepared withoutany sources of institutional, private orcorporate financial support, and thereare no potential conflicts of interest.

© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 157

J Clin Periodontol 2014; 41: 157–163 doi: 10.1111/jcpe.12199

wounds after periodontal surgery(Ward 1923). Nowadays, it is stillused after resective periodontalsurgery as well as after recessioncoverage. The periodontal dressingprotects the tissue and keeps the tis-sue in close contact with the teeth. Itstabilizes the coagulum and protectsit from different forces during talk-ing and eating (Wikesj€o et al. 1992).

Wound healing is a complex pro-cess involving different phases suchas; homeostasis phase, inflammatoryphase, proliferation and remodellingphase (Stadelmann et al. 1998). Thefirst and most important step is theformation of a fibrin clot. This clotwill protect the wound and attractinflammatory cells. When a tissue iswounded, platelets start to releaseinflammatory factors, cytokines andgrowth factors to facilitate the heal-ing (Barrientos et al. 2008). When allthe steps are successfully accom-plished, the healing will result inreduction of the swelling, recessionof the gingival margin due to resolu-tion of inflammation and formationof long junctional epithelium.

Sigusch et al. (2005) introducedthe use of a periodontal dressing asan adjunctive tool for the treatmentof patients with aggressive periodon-titis. The group with the periodontaldressing applied for 7 days showed asignificant pocket reduction and clin-ical attachment gain compared withthe control group. Genovesi et al.(2012) applied a periodontal dressingfor 7 days after non-surgical therapyfor the treatment of patients withmoderate-to-advanced periodontitis.The results were similar to theresults of Sigusch et al. (2005).

The aim of this randomized clinicaltrial was to evaluate, in a split-mouth design, the effect of a peri-odontal dressing applied for 7 daysafter OSFMD.

Material and Methods

This study was designed as a ran-domized-controlled split-mouth trialto compare the clinical effects of twodifferent periodontal treatments,OSFMD alone or combined with aperiodontal dressing for 7 days witha 3 months follow-up period. Theethical committee at the UniversityHospital Leuven approved the pro-tocol. All participants had to sign aninformed consent before entering the

study. The study started in Septem-ber 2010 and ended in June 2012.

Twenty-six volunteers wereselected for this prospective study(Fig. 1). All patients consulted orwere referred to the Department ofPeriodontology of the UniversityHospitals Leuven for the treatment ofchronic periodontitis. The generalhealth of all the patients was good.The following inclusion/exclusion cri-teria had to be fulfilled:

Inclusion criteria

• Age between 30 and 75 years.

• A minimum of 18 teeth, wisdomteeth excluded.

• Previously untreated moderatechronic periodontitis (Armitage1999) with radiographic evidenceof generalized alveolar bone loss>30%.

• Presence of at least one pocketwith probing pocket depth (PPD)≥6 mm per quadrant, which wasBOP.

• Presence of at least three teethper quadrant.

Exclusion criteria

• Periodontal treatment in the last3 years.

• Antibiotic intake 6 months beforethe screening visit.

• Pregnancy.

• Systemic diseases with an impacton periodontal healing (e.g. Dia-betes).

The purpose of the study wasexplained to the patients who met theinclusion criteria and they were askedto participate by signing an informedconsent form. The following clinicalparameters (in sequential order) wererecorded by only one trained and cali-brated periodontist (J.K.).

• The plaque score (PS) wasdetected visually or with theprobe at 4 sites per tooth (mesial,distal, buccal and lingual); thescores ranged from 0 (absent) to1 (present) (O’Leary et al. 1972).

• The PPD was recorded to thenearest 0.5 mm at six sites persingle-rooted teeth and ten sitesfor multi-rooted teeth.

• The amount of gingival recession(REC, the distance from the ce-mento-enamel junction to thegingival margin) was measured tothe nearest 0.5 mm at the samesites as the PPD.

• The BOP was evaluated 30 safter probing in the depth of thepockets at four sites per tooth(mesial, distal, buccal and lin-gual); the scores ranged from 0(absent) to 1 (present).

• The clinical attachment level(CAL) was calculated for each siteas the sum of the PPD and theREC.

These variables were recordedusing the Merritt B probe (Hu-Frie-dy, Chicago, IL, USA).

After the clinical examination,oral hygiene instructions were given(the modified-Bass technique, inter-dental cleaning and tongue scrapingin the case of tongue coating). After1 or 2 weeks OSFMD was per-formed by one periodontist (J.K.).Scaling and root planing using ultra-sonic and hand instruments was per-formed in two sessions within 24 hand was supplemented with:

• Tongue brushing (by the patient)for 60 s with chlorhexidine 1% gel.

• Rinsing twice with a chlorhexi-dine 0.12% solution for 1 min.

• Spraying the pharynx with a0.12% chlorhexidine spray.

• Subgingival irrigation of all thepockets three times within

Fig. 1. Study design.

© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

158 Keestra et al.

10 min. with the chlorhexidine1% gel using a syringe (the tip ofthe needle was blunted so thatthe resistance offered by the bot-tom of the pocket could be felt).

Additionally, the patients had torinse twice daily for 1 min. with a0.12% chlorhexidine solution for2 months (Quirynen et al. 1995,2006, Mongardini et al. 1999).

The first treatment was started atthe right side (first and fourth quad-rant). At the end of the first treat-ment, a test and control side wasselected by means of a computer-generated randomization list. If thefirst quadrant was selected as the testside, the third quadrant was selectedafter the second treatment as the testside. Hereby, the periodontal dressingwas always placed in one upper andone lower quadrant. The operator(J.K.) mixed the periodontal dressing(Coepak�, Alsip, IL, USA) accordingto the manufacturer’s instructions.The oral hygiene instructions weregiven and each patient had to avoidbrushing the periodontal dressingarea as long as the periodontal dress-ing was in place.

After 1 week, the periodontaldressing was removed from the testsides and oral hygiene instructionswere repeated, identical to the firsttime. The patients had to comparethe difference between the sides withthe periodontal dressing and thesides without the periodontal dress-ing. During this appointment thepatients had to fill out a pain inten-sity scale on a scale from 0 to 10(0 = no pain, 5 = moderate pain and10 = worst imaginable pain) and theamount of pain medication wasrecorded. After 3 months, all clinicalexaminations were recorded by onlyone trained and calibrated periodon-tist (J.K.).

Statistical analyses

A power analysis was carried out.Based on these calculations, it wasdefined that 22 patients would benecessary. Considering a drop out ofabout 15%, it was established thatat least 25 patients were needed. Theconcordance correlation coefficientwas used to quantify the degree ofagreement or congruence betweentwo measurements. Linear mixedmodels were fit to assess the

difference between the two treat-ments. Treatment was used as afixed factor. Position, tooth numberand patient were used as nested ran-dom factors. Normal quantile plotsand residual dot plots were used toassess the normality and variabilitydistribution of the data and did notindicate any deviation from the basicassumptions. Significance wasdetermined by using an a of 0.05;p-values lower than 0.05 wereconsidered significant. S-Plus 7 (Tib-co, Palo Alto, CA, USA) was usedfor the statistical analyses.

Results

Twenty-six patients passed the inclu-sion / exclusion criteria. Twopatients were excluded because theydid not show up at the final appoint-ment after 3 months. Finally, a totalof twenty-four patients were statisti-cally analysed. Table 1 presents thedemographic characteristics. Allpatients belonged to the Caucasianrace with an average age of 48.3(range 33–64 years). The total num-ber of teeth and mean percentage ofsites (with PPD < 4 mm, PPD4–6 mm and PPD > 6 mm) wereequally distributed.

The mean values for PS and BOPare presented in Table 2. The controlgroup showed a significant reductionof the PS with 37% (p = 0.0001) andBOP with 39% (p = 0.0001) com-pared to the baseline. The test groupalso showed a significant reduction ofthe PS with 48% (p = 0.0001) andBOP with 51% (p = 0.0001) com-pared to the baseline. The test groupshowed a significantly higher reduc-tion of the PS with 11% (p < 0.0001)and BOP with 12% (p < 0.0001).

The pain sensation was measured7 days after OSFMD, the results arepresented in Table 2. When com-

pared with the control group the testgroup showed a significant reductionof the pain intensity, which was 1.71(p < 0.0001).

The mean values for PPD, RECand CAL are presented in Table 2.The control group showed a signifi-cant reduction of the PPD with1.20 mm (p = 0.0001) and CAL with0.74 mm (p = 0.0001) compared tothe baseline. The test group alsoshowed a significant reduction of thePPD with 1.49 mm (p = 0.0001) andCAL with 1.01 mm (p = 0.0001)compared to the baseline. The testgroup showed a significantly higherreduction of the PPD with 0.29(p < 0.0001) mm and CAL with0.26 mm (p < 0.0001). The controlgroup showed a significant increaseof the REC with 0.45 mm(p = 0.0001) compared to the base-line. The test group also showed asignificant increase of the REC with0.48 mm (p = 0.0001) compared tothe baseline. The test group showedno significant difference of the REC.Those three clinical parameters werealso divided into moderate pockets(4–6 mm) and deep pockets (>6 mm).The control group showed a signifi-cant reduction of the PPD of themoderate pockets with 1.87 mm(p = 0.0018) and for the deep pockets3.27 mm (p = 0.0018). The significantreduction was also seen for the CALof the moderate pockets with1.20 mm (p = 0.0018) and for thedeep pockets 1.83 mm (p = 0.0018)compared to the baseline. The testgroup also showed a significantreduction of the PPD of the moderatepockets with 2.20 mm (p = 0.0018)and for the deep pockets 3.56 mm(p = 0.0018). Again the significantreduction was also seen for the CALof the moderate pockets with1.53 mm (p = 0.0018) and for thedeep pockets 2.10 mm (p =

Table 1. Demographic characteristics and mean � SD full-mouth clinical parameters

Variable Control Test

Gender (male/female) 13/11 13/11Age (years) 48.4 � 9.2 48.4 � 9.2Smokers (n) 0 0Total tooth (n) 304 303Multi rooted (n) 79 79Single-rooted (n) 225 224Mean % (number) of sites withPPD <4 mm 57.4 � 49.5 54.9 � 48.8PPD 4–6 mm 36.1 � 48 37.4 � 48.4PPD >6 mm 6.5 � 24.7 7.8 � 26.8

© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Full-mouth disinfection with periodontal dressing 159

0.0018) compared to the baseline. Thetest group showed a significantlyhigher reduction of the PPD of themoderate pockets with 0.32 mm(p < 0.0001) and for the CAL of themoderate pockets 0.33 mm(p < 0.0001). The deep pockets of thetest group showed no significantlyhigher reduction of the PPD with0.30 mm and for the CAL 0.27 mmcompared with the control group.The control group showed a signifi-cant increase of the REC of the mod-erate pockets with 0.67 mm(p = 0.0018) and for the deep pockets1.43 mm (p = 0.0018) compared tothe baseline. The test group alsoshowed a significant increase of theREC of the moderate pockets with0.66 mm (p = 0.0018) and for thedeep pockets 1.44 mm (p = 0.0018)compared to the baseline. The testgroup showed no significant differ-ence of the REC of moderate pocketsor deep pockets. Additionally the out-come variables for single-rooted teeth(Table S1) and for multi-rooted teeth(Table S2) are available online.

The data for the residual sites atsubject level are presented inTable 3. It presents numbers andpercentage of subjects exhibiting dif-ferent thresholds of residual siteswith PPD ≥5 mm according to theindividual risk profile for periodon-tal disease progression introduced byLang & Tonetti (2003). The testgroup showed fewer subjects (n = 3)for high risk of disease progression(≥9 with PPD ≥5 mm), in compari-son with the control group (n = 9).Conversely, the test group showedmore subjects (n = 16) for low riskof disease progression (1–4 sites withPPD ≥5 mm), in comparison withthe control group (n = 10).

Table 4 presents the mean per-centage of sites with PPD ≥5 mm,PPD ≥6 mm and PPD ≥7 mm afterT

able

2.

Outcomevariablesforsingle

andmulti-rootedteethtogether

Variable

Baseline

control

3months

control

Changecontrol

Baselinetest

3monthstest

Changetest

Intergroupcomparison

at3months

SD

SD

SE

pvalue

SD

SD

SE

pvalue

SE

pvalue

PS(%

ofsites)

70.8

45.5

33.4

47.2

�37.4

2.47

0.0001

73.0

44.4

25.1

43.4

�48.2

2.48

0.0001

�10.8

2.22

<0.0001

BOP(%

ofsites)

72.2

44.8

34.0

47.4

�38.5

3.01

0.0001

74.3

43.7

24.3

42.9

�50.6

3.01

0.0001

�12.1

2.11

<0.0001

Pain

intensity

5.13

0.89

3.42

1.27

�1.71

0.19

<0.0001

PPD

(mm)

3.62

1.64

2.43

1.03

�1.20

0.08

0.0001

3.69

1.72

2.22

0.95

�1.49

0.08

0.0001

�0.29

0.05

<0.0001

PPD

moderate

pockets

(4–6

mm)

4.79

0.72

2.94

0.84

�1.87

0.07

0.0018

4.79

0.74

2.57

0.69

�2.20

0.07

0.0018

�0.32

0.05

<0.0001

PPD

deeppockets(>6mm)

7.47

0.73

4.31

1.29

�3.27

0.16

0.0018

7.46

0.96

4.01

1.20

�3.56

0.16

0.0018

�0.30

0.15

0.6032

REC

(mm)

0.33

0.84

0.78

1.03

0.45

0.05

0.0001

0.33

0.85

0.81

1.02

0.48

0.05

0.0001

0.03

0.03

0.4011

REC

moderate

pockets

(4–6

mm)

0.25

0.77

0.90

1.04

0.67

0.06

0.0018

0.23

0.71

0.89

0.92

0.66

0.06

0.0018

�0.01

0.04

>0.9999

REC

deeppockets(>6mm)

0.24

0.76

1.62

1.17

1.43

0.13

0.0018

0.26

0.80

1.76

1.03

1.44

0.13

0.0018

0.01

0.13

>0.9999

CAL(m

m)

3.94

1.76

3.21

1.44

�0.74

0.07

0.0001

4.03

1.81

3.03

1.46

�1.01

0.07

0.0001

�0.26

0.03

<0.0001

CALmoderate

pockets

(4–6

mm)

5.03

1.04

3.84

1.16

�1.20

0.07

0.0018

5.02

0.96

3.46

1.07

�1.53

0.07

0.0018

�0.33

0.04

<0.0001

CALdeeppockets(>6mm)

7.71

1.00

5.93

1.19

�1.83

0.13

0.0018

7.72

1.22

5.78

1.37

�2.10

0.13

0.0018

�0.27

0.12

0.4000

BOP,bleedingonprobing;CAL,clinicalattachmentlevel;PPD,probingpocket

depth;PS,plaquescore;REC,gingivalrecession;SE,standard

error;SD,standard

deviation.

Table 3. Number and percentage of sub-jects presenting low [1–4 sites with probingpocket depth (PPD) ≥5 mm], moderate risk(5–8 sites with PPD ≥5 mm) or high (≥9sites with PPD ≥5 mm) risk for disease pro-gression according to Lang & Tonetti (2003)

Categories Control(%)

Test (%) p value

Low risk 10 (41.7) 16 (66.7) 0.0422Moderaterisk

5 (20.8) 5 (20.8) >0.9999

High risk 9 (37.5) 3 (12.5) <0.0001

© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

160 Keestra et al.

3 months. The test group hadsignificant less percentage of siteswith PPD ≥5 mm (2.7% versus4.8%, p < 0.0001), PPD ≥6 mm(0.7% versus 1.2%, p = 0.0066) andPPD ≥7 mm (0.2% versus 0.4%,p = 0.0333) compared with controlgroup.

Discussion

This randomized controlled clinicaltrial demonstrated that the applica-tion of a periodontal dressing afterOSFMD for 7 days resulted insignificant clinical improvementscompared to OSFMD without peri-odontal dressing.

For the teeth with moderate pock-ets the results with the periodontaldressing group showed a significantadditional pocket depth reductionand a clinical additional attachmentgain compared to OSFMD. In con-trast, the results for the teeth withdeep pockets showed no significantadditional pocket depth reductionnor additional clinical attachmentgain although there could be a ten-dency that this effect occur. Thesenon-significant results could beexplained because there were notenough deep pockets present in thestudy population. Hung had system-atically assessed the effect of non-surgical therapy. The periodontaldressing group showed higher resultscompared to the systematic review(Hung&Douglass 2002).For themod-erate pockets the results showed apocketdepthreductionof1.02 mmver-sus 2.20 mm and a clinical attachmentgain of 0.53 mm versus 1.53 mm. Thedeep pockets showed a pocket depthreduction of 1.98 mm versus 3.56 mmand a clinical attachment gain of1.14 mmversus2.10 mm.

The same results were seen forthe single and multi-rooted teeth.For the teeth with moderate pocketsthe results with the periodontaldressing group showed a significantadditional pocket depth reductionand a significant additional clinical

attachment gain compared toOSFMD. In contrast the results forthe teeth with deep pockets showedno significant additional pocketdepth reduction nor additional clini-cal attachment gain albeit therecould be a tendency that this effectoccur. These non-significant resultscould be explained because therewere not enough deep pockets pres-ent in the study population.

Residual pockets are importantto evaluate the success of the peri-odontal treatment or to decide ifadditional periodontal surgery isneeded. Mostly, when residual pock-ets of 5 mm or higher are presentafter non-surgical therapy, periodon-tal surgery may be necessary. Theperiodontal dressing group showed asignificant lower percentage of siteswith PPD ≥5 mm compared with thecontrol group. Less sites of the peri-odontal dressing group could neededperiodontal surgery.

The presence of residual pockets(≥5 mm) after periodontal surgery isone of the most important risk indi-cator for recurrence of periodontitisin maintenance patients (Lang &Tonetti 2003). The periodontal dress-ing group presented significant lowermean number/percentage of the lowrisk group (1–4 sites withPPD ≥ 5 mm) after 3 months com-pared with the control group. Thecontrol group was able to bring41.7% patients to a low risk profileand the periodontal dressing groupwas able to bring 66.7% patients toa low risk profile.

The present analysis showed theadditional benefit of using a peri-odontal dressing combined withOSFMD in a short-term basis. Theperiodontal dressing might wellaccelerate the healing instead ofimproving it. This additional resultcould be disappearing in a fewmonths or stay stable over time. Sig-usch et al. (2005) showed that theresult of the periodontal dressinggroup remained stable in the next24 months.

A potential limitation of the pres-ent analysis is the lack of blindnesssince operator and examiner werethe same. This lack of blindnesscould possibly affect the final out-come. The examiner might haveremembered which sides were treatedwith periodontal dressing. However,it is entirely possible that, over thecourse of 3 months, the examinercould have forgotten.

Pain is a common problem afternon-surgical therapy. Pain variesover time. It is not felt in a constantintensity (Boormans et al. 2009).It is thus difficult for patients tosummarize their differing pain levelswith a single number. This is a dis-advantage when using the numericrating scale (Kahneman et al. 1993).The control group showed a 5.1 onthe pain intensity scale, according tothe numeric rating scale moderatepain. The periodontal dressing grouphad 3.4 on the pain intensity scalewhich is mild pain. This was signifi-cantly lower than the control group.Is this clinically relevant comparedto the possible side effects? In thebeginning, chewing and speaking aredifficult. If the periodontal dressingis placed with great pressure it couldcause impaired healing or swelling.After several days, it could create anunpleasant taste, odour and colour.It is very important that the patientis well informed about the usage ofperiodontal dressing.

The amount of plaque is criticalfor the success of periodontal treat-ment. A PS of less than 11% for theperiodontal dressing sides could bethe cause because of the additionalresults. A level of plaque has not yetbeen established that results in peri-odontal health. A full-mouth PS of20–40% might be tolerable by mostpatients. (Axelsson et al. 2004) It isimportant to realize that the PS hasto be related to the host response(Van Dyke & Serhan 2003). In asplit-mouth design it would beexpected that the oral hygiene wouldbe the same but it was interesting tosee that the PS differs between testen control sides. The lower PS couldbe the explanation for the additionalresult on the periodontal dressingsides but it does not explain whythere is less plaque present.

When the gingiva is damagedafter non-surgical therapy woundscan form. Healing after non-surgical

Table 4. Mean number (mean percentage) � SD of sites with probing pocket depth (PPD)≥5 mm, as well as sites with PPD ≥6 mm and ≥7 mm at 3 months

PPD category threshold Control Test p value

PPD ≥ 5 mm 4.8 � 21.3 2.7 � 16.3 <0.0001PPD ≥ 6 mm 1.2 � 10.9 0.7 � 8.2 0.0066PPD ≥ 7 mm 0.4 � 6.2 0.2 � 4.9 0.0333

© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Full-mouth disinfection with periodontal dressing 161

therapy occurs because existing tis-sues repair themselves. In a coupleof seconds the homeostasis processstarts, forming a blood clot. Theblood clot has three main functions:protection denuded tissue, provi-sional matrix for cell migration andreservoir of growth factors and cyto-kines (Stadelmann et al. 1998). Dur-ing this coagulation process, someproducts act as chemotactic agentsattracting phagocytic cells to theinflammation side. The platelets pro-duce some proteins that could beantimicrobial, for example, beta-lysine which causes lysis of Gram-positive bacteria (Yeaman 2010).The platelets also produce growthfactors and cytokines that stimulatethe wound healing (Barrientos et al.2008). When all the steps are suc-cessfully accomplished, the healingwill result in reduction of the swell-ing, recession of the gingival margindue to resolution of inflammationand formation of long junctionalepithelium. The saliva and the move-ments of the cheeks are probably themain cause that only a small portionof the blood remains present. Whenthe periodontal dressing is applied atthe wound, the blood clot is moreprotected, the gingiva is more stabi-lized, more portion of the blood clotmight be present and the gingiva willadhere more closely to the tooth.This may be the reason for the bet-ter clinical outcomes and the reduc-tion of pain after non-surgicaltherapy.

A few studies have investigatedthe possible antimicrobial effect ofthe periodontal dressing (O’Neil1975, Haugen et al. 1977, Cheshireet al. 1996). The periodontal dress-ing that was used consisted of zincoxide non-eugenol. The reaction isbased on a metallic oxide and fattyacids. According to the informationfrom the manufacturer two possibleanti-infective ingredients were visible,lorothidol (fungicide) and chlorothy-mol (antibacterial). No anti-inflam-matory ingredients were observed.So far, there is no study availablethat can actually prove whetherthese ingredients have an effect onthe plaque accumulation. O’Neil sta-ted in 1975 that the use of an anti-microbial agent is not necessary inthe periodontal dressing because itforms a physical barrier to saliva,bacterial contamination and food

impaction. Further research isneeded to prove if periodontal dress-ing has some anti-infective effect.

Our data are in agreement withtwo other studies. Sigusch et al.(2005) introduced the use of a peri-odontal dressing as an adjunctivetool in the treatment of patients withaggressive periodontitis. The patientswere treated with non-surgical ther-apy, systemic antibiotics (Metronida-zole 500 mg b.i.d. for 8 days) andperiodontal dressing. Three treat-ment groups were used; in group 1the periodontal dressing was remo-ved after 3–4 days, in group 2 theperiodontal dressing was removedafter 7–8 days and the controlgroup. The non-surgical therapyconsisted of two parts, part one scal-ing and root planing in 3–4 sessionsand part two manual root curettagein one session. The usage of chlorh-exidine was not mentioned. After6 months group 1 showed an addi-tional pocket depth reduction of0.7 mm and also an additional prob-ing attachment gain of 0.7 mm com-pared with the control group. Group2 showed an additional pocket depthreduction of 1.8 mm and also anadditional probing attachment gainof 1.8 mm. Genovesi et al. (2012)used a periodontal dressing for7 days during the non-surgicaltreatment of patients with moderate-to-advanced periodontitis in a split-mouth design. The patients weretreated with a full-mouth scaling androot planing within 24 h and thiswas followed by curettage of the epi-thelium. Also here, the usage ofchlorhexidine was again not men-tioned. After 2 months, the peri-odontal dressing group showed anadditional pocket depth reduction of0.8 mm compared with the controlgroup. The additional probingattachment gain for the periodontaldressing group was 1.1 mm com-pared with the control group.

The results of this randomizedclinical trial show the additionaleffects that a periodontal dressing haswhen it is combined with OSFMD.The additional effects of the peri-odontal dressing could be explainedby: protection of the wound, stabil-ization of the tissues, availability ofthe blood clot and maybe some anti-microbial effects of the periodontaldressing. Within the limitations ofthis study a periodontal dressing has

additional benefits that are statisti-cally significant for the moderatepockets. It is important to mentionthat periodontal dressing causes lesspain after OSFMD. To reduce thepain a periodontal dressing could bea good alternative to pain medica-tion. Further randomized clinical tri-als are necessary to confirm thisresult and this should be done withmore patients involved, as this maylead to a significant effect in thedeep pockets as well.

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Supporting Information

Additional Supporting Informationmay be found in the online versionof this article:

Table S1. Outcome variables forsingle-rooted teeth.Table S2. Outcome variables formulti-rooted teeth.

Address:Johan A.J. KeestraDepartment of Periodontology,School of Dentistry, OralPathology & Maxillo-facial Surgery, Facultyof Medicine, Catholic University Leuven,Kapucijnenvoer 33, B-3000 Leuven, Belgium.E-mail: hanskeestra@gmail.com

Clinical Relevance

Scientific rationale for the study:Previous studies have suggested thatscaling and root planing combinedwith a periodontal dressing appliedfor 7 days might have some benefi-cial effects for the treatment of peri-odontitis. However, more studiesare needed to verify this.

Principal findings: Periodontal dress-ing applied after OSFMD showedsignificant superior results in all clin-ical parameters compared toOSFMD alone after 3 months. Theresults included a significant reduc-tion of pain after OSFMD andreducing the residual pockets up to3 months post-treatment.

Practical implications: Periodontaldressing applied after OSFMD canreduce the pain after OSFMD andoffers a clinical benefit for thetreatment of patients with chronicperiodontitis.

© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

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