Effect of Sodium Hypochlorite Solution on the Subgingival Microflora of Juvenile Periodontitis Lesions
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PEDIATRICDENTISTRY/Copyright@ 1983 by TheAmerican Academy of PedodonticslVol.5, No. 3 Effect of sodium hypochlorite solution on the subgingival microflora of juvenile periodontitis lesions John E. Adcock, DDS, MS Wesley C. Berry, Jr., DDS, MS Kenneth L. Kalkwarf, DDS, MS Abstract The effect of gingival curettage facilitated by lacked visible surface deposits. sodium hypochlorite solution on the subgingiva] Newmanand coworkers~ categorized an increase in micro flora of 21 juvenile periodontitis lesions was gram-negative rods in the flora of juvenile periodontitis. evaluated. Dark-field analysis and anaerobic culturing Newmanand Socransky7 later reported that bacterial of juvenile periodontitis lesions were made samples obtained from juvenile periodontitis lesions con- immediately prior to treatment with gingival tained increased portions of gram-negative anaerobic rods curettage facilitated by sodium hypochlorite and a significant number of Capnocytophaga species. solution-- immediately after therapy, 30 days post- Slots~ also found that the microflora of juvenile therapy, and 90 days post-therapy. Results indicate periodontitis was dominated by gram-negative anaerobic that the therapy is capable of significantly altering rods. In 1979 three separate studies found Actinobacillus the quantity and quality of subgingival organisms actinomycetemcomitans in high proportions in juvenile Foundin the juvenile periodontitis lesion and periodontitis pockets. 9-11 Recent investigations have maintaining this alteration over a 30- to 90-day reported invasion of bacteria into the connective tissue period. adjacent to deep periodontal pockets J2.,3 One report has demonstrated a similar tissue invasion associated with a Localized, advanced periodontal destruction in the juvenile periodontitis lesion.~9 molar and incisor regions of the adolescent dentition has A few studies have evaluated the effect of nonsurgical been known by many different names: diffuse atrophy, periodontal therapy on the bacterial flora of juvenile ,~ periodontosis, juvenile periodontitis, and precocious periodontitis lesions. Genco and coworkers15, con- periodontitis. Because of the different names and cluded that scaling and root planing alone often were not diagnostic criteria, there has been muchconfusion regard- capable of reducing the numbers of pathogenic organisms ing this condition. In the recent literature, two clinical in juvenile periodontitis cases. In a recent study, Slots terms have been predominated: periodontosis and juvenile and coworkers~7 demonstrated that scaling and root periodontitis. Juvenile periodontitis maybe defined as a planing (averaging six hours of debridement) were in- severe, inflammatory disease of the periodontium capable of eliminating Capnocytophaga and A. ac- characterized by a rapid, localized loss of alveolar bone tinomycetemcomitansfrom juvenile periodontitis lesions. around the secondary incisors and first molars in young Gingival curettage facilitated by sodium hypochlorite individuals.1 solution has been investigated. ’~-2o The early objective of In recent investigations, a unique microbial flora has using sodium hypochlorite solution to aid in curettage been shownto be associated with juvenile periodontitis. was to enhance removal of inflamed soft tissue.’~ The In 1974, Sumney and coworkers 2 demonstrated little solution has been shown to be bacteriocidal and has no plaque accumulation on the root surfaces affected by detrimental effects on soft tissue healing.~9-20 juvenile periodontitis as well as a prominence of gram- Since isolated lesions characteristic of juvenile negative3,4 bacteria. In 1975 a group of investigators periodontitis are populated by a unique flora and tradi- described patterns of gram-negative rod colonization in tional nonsurgical periodontal therapy has been shown juvenile periodontitis lesions and characterized a fusiform to be ineffective in altering this flora, this study was bacteria. In 1976 Listgarten5 studied the microflora designed to investigate the antimicrobial effects of sodium associated with periodontal health and diseases in man. hypochlorite solution on the subgingival microflora He reported that patients with juvenile periodontitis associated with juvenile periodontitis. 190 SODIUMHYPOCHLORITE & JUVENILE PERIODONTITIS: Adcock et al. Methods and Materials down the cannula, dislodging the foil cap. The broach Patients selected for this protocol met these criteria: then scraped the bottom of the pocket and adjacent tooth surfaces, the fibers trapping loose organisms. The barbed 1. Less than 18 years of age broach was withdrawn into the cannula and the entire 2. Clinical and radiographic evidence of juvenile apparatus was removed. The tinfoil cap later was re- periodontitis (localized 6 mmor greater probing movedfrom the gingival.crevice using a scaler. Oncethe depth and bone loss around first molars and/or sample was obtained, the broach was introduced into a incisors) prereduced anaerobically sterilized mediumcontaining 3. No periodontal therapy, including prophylaxis or tryptic soy broth and thioglycolate maintained in an plaque control instruction, within the past six argon environment. (The addition of thioglycolate months allowed the broth to function as a transport media.) 4. No evidence of a systemic disturbance as diabetes, The sample was dispersed by placing a cavitron tip on hematologic problems, or connective tissue disturb- the stainless steel wire approximately four centimeters ances which might influence the course of the above the broach and running the instrument at high juvenile periodontitis or possible therapeutic power without water spray for 5 seconds. Five seconds approaches of vibration allowed dispersion of the organisms from the 5. No antibiotic therapy within the previous six broach without affecting viability of the sonic-sensitive months. spirochetes. While some organisms may have become en- Eleven patients originally met the criteria for patient trapped within the cotton fibers and not totally dispersed selection, eight of whomwere from one family. (As the by the vibration, the effect was uniform in all phases of investigation progressed, one patient dropped out.) The the study. patients ranged in age from 7 to 17 years. The onset of The sample solutions were evaluated with dark-field juvenile periodontitis usually is associated with puberty, microscopyutilizing 0.2 ml of the dispersed solution. The but siblings aged 7 and 10 from the family of eight ex- solution was placed on a precleaned glass slide, covered hibited both clinical and radiographic evidence of juvenile with a glass cover slip and immediately examined with periodontitis, and were included in this study. a microscope equipped with a dark-field condenser, 95x Oneto three molars and/or incisors exhibiting clinical dark-field objective, and a 10x eyepiece. Bacteria were and radiographic evidence of the disease were identified identified and placed into four groups: as experimentalteeth in each patient. A total of 22 experi- 1. Spirochete -- coiled-appearing mental sites were identified. Onecontrol tooth exhibiting 2. Fusiform -- tapered ends with a ratio of 8:1; length no clinical evidence of periodontal disease was chosen in to width each patient. The control region served to evaluate the 3. Rod -- straight or curved effect of sodium hypochlorite solution on the bacteria 4. Coccus -- length exceeding diameter by no more associated with a shallow sulcus. Comparison of post- than 2:1 treatment samples between the experimental and control 5. Other. regions would parallel each other if there were an anti- bacterial effect of the solution. At least 100 bacteria were identified from 10 fields. Initial bacterial samples were obtained from the After the samples were dispersed, they were transferred gingival crevice using an instrument modified from into an anaerobic tent for plating. Plating was ac- reports by Newmanand Socransky.7 A syringe was complished on tryptic soy agar plates madeselective for modified so oxygen-free argon gas could be passed gram-negative bacteria by the addition of vancomycin through an attached 20-gauge cannula, 4 mmlong (Figure and menadione.2’ (Menadione was included to support 1). The plunger region was modified to permit passage the growth of bacteroides, commonin advanced perio- of the barbed broach soldered to a long stainless steel dontal defects.) Two plates were prepared from each wire. The barbed broach was woundwith sterile cotton sample by placing and spreading two drops of the dis- fibers. In use, the tip of the cannula, cappedwith tinfoil persed solution on the surface of the plate. The plates to prevent contamination of supragingival plaque, was were grown in anaerobic jars in a 90%nitrogen and 10% inserted into the pocket. The broach then was passed carbon dioxide environment. After three days of growth, the colony types were dif- ACRYLIC PLUG ferentiated by color, texture, surface characteristics, etc. r~’ut:’N’~ ~ 5CC I)ISPOSABLESYRINGE 20 Each different colony type was streak-isolated on fresh plates and incubated anaerobically in the environment TINFOILCAP described previously. After pure isolates were obtained, ~ HOLLOWGL~ TUBING portions were grown aerobically to determine which [i~r~ 1. Diagrammatic representation of microbial sampling isolates were facultative. The isolates were gram-stained apparatus. using normal techniques. The gram stains were evaluated PEDIATRIC DENTISTRY:Volume 5, Number 3 191 10.0 P<.O~ 9.0 for determination of gram-negative