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Table of Contents
ORIGINAL ARTICLE
Year : 2013  |  Volume : 1  |  Issue : 2  |  Page : 90-94

Comparative evaluation of microbial colony counts on sutures with and without use of periodontal pack: a split mouth, randomized controlled study


1 Professor, Department of Periodontics, KMSDCH, Sumandeep Vidyapeeth, Piparia, Vadodara-391760, Gujarat, India
2 Sr. Lecturer, Dept. Periodontics, Goenka Research Institute of Dental Sciences, Piparia, Vadodara-391760, Gujarat, India
3 Professor & HOD, Department of Periodontics, KMSDCH, Sumandeep Vidyapeeth, Piparia, Vadodara-391760, Gujarat, India
4 PG Student, Department of Periodontics, KMSDCH, Sumandeep Vidyapeeth, Piparia, Vadodara-391760, Gujarat, India

Date of Web Publication21-Aug-2018

Correspondence Address:
M A Shah
Professor, Department of Periodontics, KMSDCH, Sumandeep Vidyapeeth, Piparia, Vadodara-391760, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2347-6486.239501

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  Abstract 


Background & Aim: Periodontal dressings are commonly used following surgical procedures due to varied reasons. Though several studies have been done on periodontal dressings, not many have stressed upon the microbial load due to plaque retention. This study was undertaken to evaluate the use of the periodontal dressing following routine periodontal flap surgery to no dressing, in terms of added microbial load due to increased plaque retention.
Methods: 20 patients from the Dept. of Periodontics, K. M. Shah Dental College and Hospital, undergoing flap surgical procedures in bilaterally identical areas were selected. Following the flap surgical procedure, half the area (20 sites) was given a periodontal dressing (test group) and the other half (20 sites) was left undressed (control group). Sutures were removed at day 7 from both the sides and plaque samples from the sutures were taken for culture on nutrient agar and blood agar and were assessed for colony forming units (CFU).
Results: The cultures from the test group showed higher CFU on both blood and nutrient agar (p<0.05) as compared to the control. The mean debris index for the control group, was 1.2 and that for the test group was 2.8 (p<0.05).
Conclusion: Periodontal dressings facilitate debris and microbial growth and add to the microbial load of the surgically dressed areas.

Keywords: CFU (colony forming unit), microbial load, periodontal dressing, periodontal pack


How to cite this article:
Shah M A, Shah B K, Dave D H, Shah S S. Comparative evaluation of microbial colony counts on sutures with and without use of periodontal pack: a split mouth, randomized controlled study. J Integr Health Sci 2013;1:90-4

How to cite this URL:
Shah M A, Shah B K, Dave D H, Shah S S. Comparative evaluation of microbial colony counts on sutures with and without use of periodontal pack: a split mouth, randomized controlled study. J Integr Health Sci [serial online] 2013 [cited 2022 Aug 12];1:90-4. Available from: https://www.jihs.in/text.asp?2013/1/2/90/239501




  Introduction Top


As early as the 1920s, Ward advocated the use of a periodontal dressing following gingival surgery in order to reduce pain, infection, root sensitivity and to minimize caseous deposit formation within the wound site. Since this time, surgical techniques have been developed to include not only simple gingivectomies but also flap procedures, such as modified Widman or apically repositioned flaps, crown lengthening, mucogingival surgery and more recently, periodontal regeneration. Simultaneously, the role of periodontal dressings has also been developed accordingly.

A wide variety of reasons have been given for the use of periodontal dressings. These reasons fall into two principal groups: a dressing may be employed as a physical adjunct to periodontal surgery, or it may be used therapeutically with or without surgery.

In the case of gingivectomies the aims were primarily to protect the wound, prevent formation of excessive granulation tissue and minimise pain[1]. In flap surgery the role of the dressing is to aid flap positioning, and to protect areas of denuded bone where healing occurs by secondary intention[2],[3]. In periodontal regeneration, the use of a dressing is advised to protect the grafted site, prevent flap displacement and loss of graft material[4]. Dressings have also been used to protect free gingival grafts and their donor sites[5],[6] and to facilitate the retention of drugs delivered locally in subgingival sites[7].

The value of periodontal dressings has been questioned in terms of healing response, patient preference and microbial load.

Studies with split mouth design have been used to compare healing of surgical sites with or without a periodontal dressing. It has been found that the use of a dressing makes little difference to healing following gingivectomy procedures, similarly no healing advantage was demonstrated when a pack was used following reverse bevel flap surgery[8] or modified Widman flap procedures[9].

Reports of the postoperative pain and discomfort experienced by patients have presented contrasting results. In 1983 Allen & Caffesse[9] reported similar levels of discomfort with or without a dressing, whereas, others reported more pain when a dressing was used, but less sensitivity and fewer eating difficulties. Reports of patient preference for the use of a dressing are also controversial.

The adverse effects of periodontal dressings have been attributed to both plaque accumulation[10],[11] and to the constituents (such as eugenol) which may have a toxic or sensitizing potential[12]. Many different dressings have been formulated and evaluated both in human and animal experiments. The incorporation of bactericidal or bacteriostatic agents in dressings has been of limited clinical value[3],[13]. O’Neil (1975) reported the varied antimicrobial effect of five different dressings in vitro, and Haugen et al (1977) demonstrated a decrease in antibacterial activity of dressings with time. Despite conflicting findings, periodontal dressings continue to be required as outlined earlier, even though not necessarily as the routine following surgery[3].

Though several studies have been done on periodontal dressings, not many have stressed upon the microbial load due to plaque retention.

This study was undertaken to evaluate the use of the periodontal dressing following routine periodontal flap surgery to no dressing in terms of added microbial load due to increased plaque retention.


  Methods Top


Prior to the commencement of the study, approval was obtained from institutional ethics committee and informed consent was taken from the participants.

Patients undergoing flap surgery and willing to take part in the study were selected. Out of 40 quadrants/sextants, 20 were randomly given periodontal dressing following flap surgery and the others weren’t given periodontal dressing[Sample Where, s2 = 0.5 and D = 1 with 95% C.I. and 80% power.].Randomization was done by coin toss method.

Patients having any systemic history, smokers or tobacco users, patients allergic to periodontal dressing or its contents, and patients with completely dislodged packs at the time of suture removal were excluded from the study.

Pre-operatively thorough scaling and root planing were done. Patients requiring periodontal flap surgery were selected.

Surgical procedure:

Similar areas were selected for surgery. Periodontal surgery was performed under local anesthesia and 3-0 black braided silk suture material was used for flap approximation and achieving hemostasis following the surgery.Area on one side was covered by periodontal dressing and the other side was not given any dressing. Standard postoperative care instructions were given. Patient was instructed to use 0.2% Chlorhexidine mouthwash twice daily.Post-operative assessment was done on day 7 by a blinded examiner.

Debris evaluation:

Debris accumulation on the buccal tooth surface after pack removal was scored on a scale of 0-3based on modification of the criteria given by Greene & Vermilion (1964)[21]for oral hygiene evaluation, mainly for debris evaluation.

Plaque evaluation:

Plaque evaluation was also made, based on Silness and Loe, 1964, according to which, 0 =absence of plaque, 1 = plaque covering less than 1/3 of the tooth/dressing surface,2=plaque greater than 1/3 but less than 2/3 of tooth/dressing surface,3=plaque covering more than 2/3 of the tooth/dressing surface. Both buccal and palatal surfaces were scored, which gives a maximum value of 6.

Lost dressings were not included in the study. Therefore the final value used in analysis for plaque retained on the pack was calculated by summing the buccal and palatal scores and dividing by either 2 or 1 depending upon whether the dressing was retained. This gave a “mean” score for the pack within a range of0-3.

Microbiological analysis:

The microbiologist was blinded to the samples obtained from the test or the control group. Microbial load analysis for surgical areas of both the groups, was done by culturing the plaque samples from sutures removed from the operated site. The sutures were kept in a sterile container till it was transported to the laboratory. Once it reached the laboratory, the sutures were added to the nutrient broth [Figure 1] so that the plaque from the sutures was suspended in the nutrient broth. This suspension was then used for streaking the nutrient agar and the blood agar plates of 90mm diameter [Figure 2]. These plates were then incubated at 37° c temperature [Figure 3]. The plates were then observed for Colony Forming Units (CFU) at 12 hours upto 48 hours [Figure 4]. The CFUs were labelled as profuse (> 1,25,000), moderate (1,00,000 – 1,25,000), scanty (< 1,00,000).Intergroup difference was statistically assessed using the Mann Whitney test.
Figure 1: Nutrient Broth

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Figure 2: Streaking the agar plate

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Figure 3: Incubator machine

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Figure 4: CFU on blood agar and nutrient agar respectively

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Figure 5: CFUs on blood agar

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Figure 6: CFUs on nutrient agar

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Figure 7: Comparing CFUs on blood and nutrient agar

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  Results Top


All the 20 patients completed the study. Two patients had lost the pack from the palatal surface and so only buccal sides were scored. No untoward events or allergic reactions were noted for any of the patients. The mean debris index for the control group, that is no periodontal pack, is 1.2 and the mean debris index for the test group, that is with the periodontal dressing, is 2.8 and the difference is statistically significant (p<0.05, Mann Whitney test). The sutures from the surgically treated areas, both from the packed and the unpacked were removed at day 7 after surgery and were then used for culturing in blood agar and nutrient agar. For cultures on blood agar of sutures with no dressing, 14 out of 20 samples showed scanty CFUs and 6 showed moderate CFUs. Where 4 out of 20 showed moderate CFUs and 16 showed profuse CFUs [Table 1], [Graph 1]. Cultures on nutrient agar of sutures with no periodontal dressing showed scanty CFUs in 16 out of 20 and 4 showed moderate CFUs. Similarly, 2 out of 20 nutrient agar cultures from sutures with periodontal dressing, showed with moderate CFUs and 18 showed profuse CFUs [Table 2], [Graph 2]. Graph 3 shows pictorial comparison of CFUs on the blood and the nutrient agar.
Table 1: CFUs on blood agar with & without periodontal dressing

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Table 2: CFUs on nutrient agar with & without periodontal dressing

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  Discussion Top


The periodontal dressing following periodontal surgeries have been used in order to reduce pain, infection, root sensitivity and to minimize caseous deposit formation within the wound site. But there are several studies which have reported plaque accumulation under these dressings. So whether the periodontal dressing is protective or has plaque retentive properties, which add to the inflammatory burden of the surgical site, is the reason why this study was undertaken. The aim of this study was to evaluate the microbial load over a periodontal surgical site with or without dressing by culturing the plaque retained on the surgical sutures. The sutures used here were non-resorbable 3.0 black braided silk sutures. According to the study by Banche G, silk sutures have the least affinity for adherence of microorganisms.

A non-eugenol dressing material Coe-Pak was used to avoid the allergic tendencies to eugenol. Patients with a systemic history or smokers or tobacco users were excluded from this study as they are known to cause an alteration in the oral microflora[23] which may affect the results.

Periodontal microflora at the surgical site is altered on the application of a dressing material, raising the need for the surgical area to be irrigated within 7 days of its application.[14]The debris reported in this study in the dressed area is 2.8 as compared to 1.2 which is in accordance to other studies suggesting greater debris and plaque accumulation in the dressed areas.[11],[16],[17]

All the patients were given 0.2% chlorhexidine mouthwash after surgery. Chlorhexidine is a proven anti-plaque agent. (Renggli 1966, Muhlemann 1968, Loe and Schiott 1970, Flotra et al 1972, Loe et al 1972)[16]. Also chlorhexidine mouthwash is shown to have an effect on the microflora which might be the reason why there are less CFUs on the undressed side when compared to the dressed side as they come in direct contact of chlorhexidine. These results reinforce the results of the study by Schiott et al who found a 300% increase in the bacterial counts of the controls who were refrained from brushing whereas for the test group who were put on a 10ml 0.2% chlorhexidine mouthrinse, the number of bacteria were reduced by 85% in 24 hours, reaching a 95% reduction on day 5.24.

CFUs were assessed on two different types of media, which were blood agar and nutrient agar. On blood agar, 70% of the cultures from the undressed areas showed scanty CFUs as compared to 80% of the dressed areas showed profuse CFUs. [Table 3] On nutrient agar, 80% of the cultures from the undressed areas showed scanty CFUs as compared to 90% of the dressed areas showed profuse CFUs.
Table 3: Comparing CFUs on blood agar & nutrient agar with & without periodontal dressing

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Several periopathogens show a positive culture on blood agar like Actinobacillus actinomycetemcomitans, Porphyromonasgingivalis, Prevotellaintermedia,Prevotellanigriscens,Fusobacterium nucetum, Eubacterium species, etc.. This has been reflected in the culture results obtained in this study. Not all oral micro-organisms can be cultured on blood agar and hence nutrient agar has also been used as a culture medium in this study. Many of the periopathogens are strict anaerobes, and anerobic culture has not been done in this study. Anaerobic cultures and cultures specific to periopathogens need to be examined in the further studies.


  Conclusion Top


Within the limitations of this study, we can conclude that periodontal dressings provide a closed environment for the micro-organisms to multiply and thus increase themicrobial load at the surgical site. Periodontal dressings if used should be removed at day 7 and if the need arises, the area should be irrigated and then re-packed. The use of periodontal dressings is more dependent on the operator’s and the patient’s choice with limited benefits after a conventional flap surgical procedure and so its use must be with caution.[24]


  Acknowledgment Top


The authors thank the Supratech lab. Ahmedabad, Gujarat, India, for their technical help & support.



 
  References Top

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Addy M, Dolby AE. The use of chlorhexidine mouthwash compared with a periodontal dressing following gingivectomy procedure. J ClinPeriodontol1976;3:59-65.  Back to cited text no. 1
    
2.
Ariaundo AA, Tyrell HA.Repositioning and increasing the zone of attached gingiva.J Periodontol1957;28:106-10.  Back to cited text no. 2
    
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Sachs HA, Farnoush A, Checci L, Joseph CE.Current status of periodontal dressings.J Periodontol1984;55:689-96.  Back to cited text no. 3
    
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Farnoush A. Techniques for the protection and coverage of the donor sites in free soft tissue grafts.J Periodontol1978;39:403-5.  Back to cited text no. 6
    
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Goodson JM, Hogan PE, Dunham SL. Clinical responses following periodontal treatment by local drug delivery.J Periodontol1985;56(suppl):81-7.  Back to cited text no. 7
    
8.
Greensmith AL, Wade AB. Dressings after reverse bevel flap procedures. J ClinPeriodontol1974;I:97-106.  Back to cited text no. 8
    
9.
Allen DR, CaffesseRG.Comparison of results following modified Widman flap surgery with and without surgical dressing.J Periodontol1983;54:470-5.  Back to cited text no. 9
    
10.
Heaney TG, Appleton J.The effect of periodontal dressings on the healthy periodontium.J ClinPeriodontol1976;3: 66-76.  Back to cited text no. 10
    
11.
Newman PS, Addy M. Comparison of hypertonic saline and chlorhexidine mouth rinses after inverse bevel flap procedure.J Periodontol1982;53:315-8.  Back to cited text no. 11
    
12.
Haugen E, Hensten-Pettersen A. The sensitizing potential of periodontal dressings.J Dent Res1979;57:95O-3.  Back to cited text no. 12
    
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Newman HN. Modes of application of antiplaque chemicals. J ClinPeriodontol 1986;13:965-74.  Back to cited text no. 13
    
14.
T. G. Heaney, T. H. Melville, and W. M. Oliver. The effect of two dressings on the flora of periodontal surgical wounds.J Oral Surg 1972;33(1);146-51.  Back to cited text no. 14
    
15.
Greensmith A & Wade B. Dressing after reverse bevel flap procedures. J ClinPeriodontol: 1974: 1: 97-106.  Back to cited text no. 15
    
16.
Pluss E, Egenberglr P, Rateitschak K. Effect of chlorhexidine on dental plaque formation under periodontal pack. J ClinPeriodontol 1975: 2: 136-142.  Back to cited text no. 16
    
17.
Haugen E, Gjermo P. Clinical assessment of periodontal dressings Journal of Clinical Periodontology 1978: 5: 50-58.  Back to cited text no. 17
    
18.
Jones TM, Cassingham RJ. Comparison of healing following periodontal surgery with and without dressings in humans.J Periodontol 1979;50(8):387-93.  Back to cited text no. 18
    
19.
Cheshire PD, Griffiths GS, Griffiths BM, Newman HN. Evaluation of the healing response following placement of Coe-pak and an experimental pack after periodontal flap surgery. J ClinPeriodontol1996, Mar;23:188-93.  Back to cited text no. 19
    
20.
Cheshire PD. Griffiths GS, Griffiths BM. Newman HN. Evaluation of the healing response following placement of Coe-pak and an experimental pack after periodontal flap surgerv. J ClinPeriodontot 1996, 23: 188-193.  Back to cited text no. 20
    
21.
Greene JC & Vermilion JR.Thesimplified oral hygiene index. J Am Dent Ass 1964;68:7-13.  Back to cited text no. 21
    
22.
Banche G, Roana J, Mandrass N, Amasio M, Gallesio C, Allizond V, et al. Microbial adherence on various intra-oral suture materials in patients undergoing dental surgery. J Oral and Maxillofacial Surg, 65:8;1503-7.  Back to cited text no. 22
    
23.
Zambon JJ, Grossi SG, Machtei EE, et al. Cigarette smoking increases the risk for subgingival infection with periodontal pathogens. J Periodontol 67:1050, 1996.  Back to cited text no. 23
    
24.
Schiott CR et al. The effect of chlorhexidine mouthrinses on the human oral flora.J Periodon Res 5:84-89, 1970.  Back to cited text no. 24
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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