J Dent Res 74(8): 1459-1467, August, 1995
Full- vs. Partial-mouth Disinfection in the
Treatment of Periodontal Infections: Short-
term Clinical and Microbiological
Observations
M. Quirynen, C.M.L. Bollen, B.N.A. Vandekerckhove, C. Dekeyser, W. Papaioannou, and H.
Eyssen1
Catholic University of Leuven, Faculty of Medicine; Department of Periodontology and 'Rega Institute, Laboratory of Microbiology, Capucijnenvoer
7, B-3000 Leuven, Belgium
Abstract. In a standard periodontal treatment strategy with
consecutive root planings (per quadrant at a one- to two-week
interval), re-infection of a disinfected area might occur before
completion of the treatment. This study examines, both clinically and
microbiologically, whether a full-mouth disinfection within 24 hours
significantly improves the outcome of periodontal treatment. Ten
patients with advanced chronic periodontitis were randomly allocated
to a test and a control group. The patients from the control group
received scalings and root planings as well as oral hygiene instructions
per quadrant at two-week intervals. Full-mouth disinfection in the test
group was sought by the removal of all plaque and calculus (in two
visits within 24 hours). In addition, at each of these visits, the tongue
was brushed with a 1% chlorhexidine gel for one min and the mouth
rinsed with a 0.2% chlorhexidine solution for two min. Furthermore,
subgingival chlorhexidine (1%) irrigation was performed in all
pockets. The recolonization of the pockets was retarded by oral
hygiene and 0.2% chlorhexidine rinses during two weeks. The clinical
parameters were recorded, and plaque samples were taken from the
right upper quadrant at baseline and after one and two months. The
test group patients showed a significantly higher reduction in probing
depth for deep pockets at both follow-up visits (p < 0.05). At the one-
month visit, differential phase-contrast microscopy revealed
significantly lower proportions of spirochetes and motile rods in the
test group (p = 0.01). Culturing showed that the test group harbored
significantly fewer pathogenic organisms at one month (p = 0.005). At
two months, the same sites harbored singificantly more "beneficial"
bacteria (p = 0.02). Moreover, all sites of the test group initially
harboring P. gingivalis (6/10) became negative after treatment. These
findings suggest that it is possible to achieve a significant
improvement of the treatment outcome (both microbiologically and
clinically) with a one-stage full-mouth disinfection.
Key words: bacterial infection, chlorhexidine, dental plaque, dental
calculus, periodontal disease, periodontal therapy, root planing.
Received September 21,1994; Accepted April 13,1995
Introduction
The concept of bacterial specificity in periodontal infections has
become largely accepted (Slots and Rams, 1991; Socransky and
Haffajee, 1992). Three factors are currently considered for the
establishment of an active periodontal infection: (1) a susceptible host,
(2) the presence of periodontopathogens, and (3) the absence of
beneficial species (Socransky and ITaffajee, 1992; Wolff et al., 1994).
Whereas Actinobacillus actinomycetemcomitans, Bacteroides
forsythus, Eikenella corrodens, Fusobacterium nucleatum,
Peptostreptococcus micros, Porphyromonas gingivalis, Prevotella
intermedia, Campylobacter rectus, and spirochetes are frequently
associated with periodontal destruction, Actinomyces species,
Streptococcus mitis and sanguis, Veillonella parvula, and
Capnocytophaga ochracea are considered beneficial, although their
role is not always well-understood (Socransky and Haffajee, 1992;
Wolff et al., 1994). Some of these periodontopathogens should be
considered as exogenous (P. gingivalis, A. actinomycetemcomitans),
whereas others are endogenous (Slots, 1986; Van Winkelhoff, 1994).
This has been confirmed by the observed transmission of identical
bacteria between spouses or family members (Alaluusua et al., 1991;
Petit et al., 1994). The degree of elimination of the exogenous
periodontopathogens, e.g., by antibiotic therapy, was found to have a
major impact on the treatment outcome (Slots and Rams, 1990; Pavicic
et al., 1994). Therefore, the target organisms during periodontal
therapy are the exogenous species.
Several pathogenic micro-organisms have been found to spread
subgingivally, including at sites without clinical loss of periodontal
attachment (Van Winkelhoff et al., 1994). Moreover, they can also
colonize other intra-oral niches such as the tonsils, the tongue, and
other mucous membranes (Van Winkelhoff et al., 1986,1988a;
Asikainen et al., 1991; Danser et al., 1994). Studies on artificial
transgingival abutments have also illustrated the possibility of an
intra-oral transmission of periodontopathogens (Papaioannou, 1994;
Quirynen et al., 1995).
1459
 1460 Quirynen et al. / Dent Res 74(8) 1995

Table 1. Descriptive statistics of examined population and dental status in 1st quadrant
Gender Age Smoker % of Sites with Probing Depth3 > 7 % of Sites with Angular % of Sites with Calculusa-C
mm Defectsa-b

Test group
#1 F 57 - 18.8 0 57.1
-
#2 F 46 26.3 33.3 16.7
-
#3 F 42 31.8 42.9 28.6
#4 M 56 +/- 45.5 42.9 14.3
#5 F 61 - 48.7 33.3 0

Control group

#1 F 60 - 32.3 90.0 70.0

#2 M 40 + 68.0 50.0 0
#3 F 38 + 25.0 42.9 28.6
-
#4 F 41 6.5 10.0 20.0
#5 F 45 - 5.3 25.0 33.3
a
Observation for the first quadrant only. Estimated on intra-oral long-cone
b

radiographs.
c
Supra- and/or subgingival estimated on intra-oral long-cone radiographs.

Taking all these aspects into consideration, one might hypothesize
that, in a normal periodontal treatment strategy (with consecutive root
planings per quadrant or sextant at one- to two-week intervals), a re-
infection of a disinfected area might well occur before the completion of
the treatment. This study aims to examine, both clinically and
microbiologically, the result of a full-mouth disinfection within a 24-
hour period combined with a prolonged supra-and subgingival
application of chlorhexidine.
Materials and methods
Patient selection
Ten patients were included in this double-blind (for microbiological
data), randomized, parallel study on the basis of volunteership. The
patients were referred to the Department of Periodontology of the
Catholic University of Leuven for treatment of advanced chronic
periodontitis. All subjects were medically healthy, and none of them
had used any antibiotics or antimicrobial product within the four
months before or during the study. The descriptive statistics of these
patients together with their disease status are summarized in Table 1.
Each patient had at least 2 multi-rooted teeth and 3 single-rooted teeth
in each quadrant, with, per quadrant, at least 4 sites having a probing
depth of 7 mm or greater which also bled when probed. Radiographic
evidence of severe bone loss (> 1/2 the root length) was also present.
After informed consent was obtained, the participants were randomly
distributed between two treatment groups. The project protocol had
previously received permission from the Ethical Committee of the
University Hospital.
Experimental design
The patients of the test group (five subjects) received a full-mouth
scaling and root planing within 24 hours. In the control group (five
subjects), the scaling and root planing were performed quadrant by
quadrant with a time interval of 14 days (starting with the right upper
quadrant) and without the use of
antiseptics. Just prior to the first session of scaling and root planing
(baseline), and one and two months later, clinical parameters and
plaque samples were taken from the right upper quadrant, chosen for
its accessibility. This study reports the short-term results; the patients
will be followed up to eight months after therapy.
Mechanical plaque and calculus removal
After gingival infiltration with a local anaesthetic, scalings and root
planings were performed by one investigator (BV) with an assortment
of periodontal curettes (Hu-Friedy, Chicago, IL). The time spent per
quadrant was approximately one hour. The treated quadrants were
polished with 3 pastes with a decreasing order of abrasiveness: Zircate
Prophy Paste® (Dentsply International Inc., Milford, DE), and Clean
Polish® and Super Polish® (Hawe-Neos Dental, Bioggio, Switzerland).
In the test group, the lower jaw was treated prior to the upper.
Local application of antiseptic (test group)
Immediately after instrumentation of each jaw, an optimal disinfection
was sought by (in chronologic order): (1) brushing the dorsum of the
tongue (by the patients) for 60 s with a chlorhexidine 1% gel (Hibigel®,
SmithKline Beecham Consumer Brands SA, Genval, Belgium); (2)
rinsing twice with chlorhexidine 0.2% solution (Hibident®, SmithKline
Beecham Consumer Brands SA, Genval, Belgium) during one min (for
the last 10 s the patients had to gargle, in an attempt for the Hibident®
to reach the tonsils); (3) subgingival irrigation 3x within 10 min with
chlorhexidine 1% gel (Hibigel®) of all the pockets by means of a syringe
with a needle on which marks had been put at 6 and 8 mm (a blunt
needle was introduced into the pocket until some resistance was met);
and (4) repeating the subgingival application at day 8. Additionally, the
subjects of the test group were instructed to rinse twice daily for one
min with a 0.2% solution of chlorhexidine (Hibident®) during 14 days.
Oral hygiene
Standard oral hygiene instructions were given in both groups,
J Dent Res 74(8) 1995 Full-mouth Disinfection for Periodontitis
including interdental plaque control (toothpicks and/or interdental
brushes) and brushing of the dorsum of the tongue twice a day. Plaque
control and oral hygiene re-instruction were repeated at each visit (days
2, 8, and 29 for the test group, days
1,15, and 29 for the control group).
Questionnaire
The participants were asked to complete a questionnaire at each visit.
Besides mentioning any adverse effects, they were asked to estimate the
degree of pain after treatment, on a numerical scale from 0 to 10, and to
indicate the number of painkillers taken. They were also asked to
measure their temperature. The use of antimicrobial products or
antibiotics was particularly questioned. From the initial 12 patients, two
had to be withdrawn because of the use of a wide-spectrum antibiotic
for reasons not related to this study.
Clinical examination
The clinical parameters were recorded by one investigator (BV) prior to
scaling and root planing and at one and two months, in the right upper
quadrant only: (1) gingivitis index (Miihlemann and Son, 1971); (2)
plaque index (Quigley and Hein, 1962); (3) probing depth measured to
the nearest mm at each approximal site (buccally as well as palatally)
and in the middle of each root (buccally as well as palatally) by means
of a Merrit B® probe (Hu-Friedy, Chicago, IL); (4) gingival recession (in
the middle of each root, only buccally and palatally), i.e., the distance
from the cemento-enamel junction to the gingival margin measured to
the nearest mm by the same probe; and (5) bleeding tendency up to 20 s
after the pocket was probed until a slight resistance was felt. The mean
plaque and gingivitis index and the mean percentage of pockets that
bled after being probed were calculated for each tooth type (single- or
multi-rooted).
Plaque samples
At baseline, and at one and two months, two pooled samples (from
three approximal sites) of the subgingival plaque were taken from both
single- and multi-rooted teeth (all located in the upper right quadrant).
For each tooth type (single- or multirooted), the three deepest pockets
were selected. All samples were taken from an undisturbed subgingival
flora and after removal of the supragingival plaque (Wikstrom et al.,
1991). Prior to being sampled, the sites were isolated from saliva by the
application of cotton rolls and were then gently dried with compressed
air to prevent contamination, since large differences in plaque
composition exist between different niches (Van der Velden et al.,
1986). Four sterile medium paper points (Maillefer®, Ballaigues,
Switzerland) were inserted into the selected pockets (two buccal and
two palatal) and kept in place for at least 10 s. Following removal, the
paper points were transferred into a screw-capped vial containing 1 mL
of transport medium RTF (Syed and Loesche, 1972). The two pooled
samples were homogenized by being vortexed for 30 s (Dahlen et al.,
1992).
Differential phase-contrast microscopy
Phase-contrast microscopy was performed less than 15 min after
sampling to ensure the motility of the micro-organisms (Petit et al.,
1991). A small aliquot of fluid was aspirated into a sterile tuberculine
syringe (Plastipak®, Becton Dickinson, Dublin,
1461
Ireland) and placed onto a microscope slide (Listgarten and Hellden,
1978). The samples were then analyzed with a differential phase-
contrast microscope (Laborlux S®, Wild Leitz, Heerbrugg, Switzerland)
at a magnification of 480x, according to Listgarten and Hellden (1978).
One hundred microorganisms, from fields selected at random, were
classified into four morphological categories (Mousques et ah, 1980):
coccoid cells, motile rods other than spirochetes, spirochetes, and the
others (fusiforms, rods, and filaments). The samples were transferred
to the laboratory, where they were processed in less than 24 hours. All
microbiological procedures were performed by an investigator who
did not know the history of the sample.
Culture techniques and identification
Serial 10-fold dilutions were prepared in RTF. A volume of 0.1 mL of
the first three dilutions was plated on a selective TSBV plate
(Trypticase-soy-agar [BBL Microbiology Systems, Cockeysville, MD,
USA], supplemented with 75 pg/mL of bacitracin and 5 mg/mL
vancomycin) for the selection of A. actinomycetemcomitans (Slots,
1982). These plates were incubated in air with 5% C02 for three days. A.
actinomycetemcomitans was identified mainly on the basis of colonial
morphology (small colonies with dark border and star-shaped inner
structure) and a positive catalase reaction. Representative isolates were
subjected to lactose and sucrose fermentation (Slots, 1981).
For the identification and quantification of the other organisms, the
dilutions, 10'3 to 10'6, were plated in triplicate onto blood agar plates
(Blood Agar Base II, Oxoid, Basingstoke, UK) supplemented with
hemin (5 mg/mL), menadione (1 mg/mL), and 5% sterile horse blood.
Two series of the blood agar plates were incubated in 85% N2,10% COz,
and 5% H2 and another series in air for five days at 37°C. After this
period, the total number of colony-forming units (CFU/mL) was
counted in both the aerobic and anaerobic cultures. For each colony
type (characterized by color, morphology, size, translucency, and
hemolysis) of the representative anaerobic plate, a typical colony was
subcultured by streaking onto a blood agar plate (Columbia Agar,
Oxoid, Basingstoke, UK) supplemented only with 5% sterile horse
blood. After 24 to 48 hours of anaerobic incubation, the purified
colonies were identified by means of Gram-staining, phase-contrast
microscopy, and a series of biochemical tests. For the latter, the Rapid
ID 32A® and the Strep 32® tests of the API System® (Biomerieux S.A.,
Montalieu-Vercieu, France) were used for anaerobic organisms and
streptococci species, respectively (Van Winkelhoff et al., 1988b). The
original plates were re-examined after 14 days of anaerobic incubation
to verify the number of CFU and the colony types.
The major aim of this analysis was to identify the proportions of
predominant pathogenic organisms besides spirochetes (A.
actinomycetemcomitans, B. forsythus, F. nucleatum, P. micros, P.
gingivalis, P. intermedia, Eubacteria spp.) and benificial micro-
organisms (Actinomyces spp., S. mitis and sanguis, Veillonella spp.),
as suggested by Socransky and Haffajee (1992), and Wolff and co-
workers (1994).
Statistical analysis
Probing depth. Changes in probing depth over time were compared
between both treatment groups (only for pockets initially 7 or 8 mm)
by means of a mixed procedure of the SAS statistical system (SAS
Institute Inc., 1992). A mixed model was
1462 Quirynen et al. / Dent Res 74(8) 1995

Table 2. Clinical parameters for sampled sites in the upper right quadrant per treatment modality and per tooth type at baseline and the one-and two-
month follow-up visits (means ± SD)
Tooth Treatment Plaque Gingivitis Baseline Probing Bleeding Plaque Gingivitis Probing Bleeding
Type Index Index Depth Index Index Index 1 Depth Index
GI/PI

Month

GI/PI
Single- Full 3.7 ± 0.9 2.6 ± 0.4 0.7 ± 0.2 6.7 ± 1.4 100 1.5 ±1.2 0.7 ± 0.4 0.7 ± 0.6 4.3 ± 1.7 80 ±10
rooted Partial 3.5 ± 0.9 2.3 ±1.0 0.6 ± 0.2 5.9 ±1.3 100 2.0 ±1.7 1.2 ±0.4 1.8 ±2.1 3.8 ± 1.3 90 ±10
Multi¬ Full 4.2 ± 0.6 2.8 ± 0.3 0.7 ±0.1 6.6 ±1.1 100 2.5 ±1.4 0.6 ± 0.5 0.3 ± 0.3 4.8 ± 0.6 70 ±30
rooted Partial 4.2 ± 0.5 2.2 ± 0.4 0.5 ± 0.1 6.7 ±1.4 100 3.4 ± 0.6 0.7 ±0.6 0.2 ± 0.2 5.0 ±1.2 90 ±10
(Continued on next page.)

fitted to the data, with treatment, time, and the interaction between
treatment and time as a fixed effect, and patient as a random effect.
The different tooth types nested in a patient were modeled as a random
factor. Within each tooth type, measurements of probing depth at
baseline and one month, and at baseline and two months, were
modeled as repeated measures with a compound symmetry structure.
The slopes of the two treatment modalities were compared, again
with the error stratum of the patient as background variability.
Microbiology. Differences between test and control group concerning
the microbiological data were also sought by means of a mixed-
procedure of the SAS statistical system (SAS Institute Inc., 1992). The
variables (proportion of spirochetes and motile rods together,
proportion of pathogenic organisms, and proportion of beneficial
species), expressed in percentages, were
transformed by an arcsin \/p transformation before statistical analysis.
A mixed model was fitted in which the treatment modality was a fixed
effect, and the patient a random effect. The two measurements within a
patient (2 samples per patient) were modeled as repeated measures
with a compound symmetry structure within a patient. Furthermore,
the measured variable at time 0 was used as a co-variable. The
treatment outcome after one and two months was tested against the
error stratum of the patient, leading to an F-statistic with 8 df for the
denominator.
Results
Clinical parameters
The mean plaque and gingivitis indices, probing depth, and bleeding
tendency for the sampled sites are depicted per treatment modality and
per tooth type (single- vs. multirooted teeth) in Table 2. At baseline,
comparable recordings

§ Test single-rooted H Control H Test multi-rooted H

single-rooted Control multi-rooted

Figure 1. Changes in probing depth per treatment modality for deep (7 to
8 mm) and medium (5 to 6 mm) initial pockets, respectively. (For each
patient, all pockets in the upper right quadrant were considered.) Test
group (full-mouth disinfection, both tooth types) =■ . Control group
(partial disinfection, both tooth types) = X. The changes in probing depth
with time were analyzed by means of a mixed procedure (vertical lines
indicate SD, and numbers in brackets indicate the number of
observations).
Figure 2. Changes in the relative proportion of bacterial morphotypes
(differential phase-contrast microscopy) over time, by tooth type and
treatment modality. The proportion of coccoid cells (cocci), spirochetes,
motile organisms excluding spirochetes (motile), and the remaining
organisms (others) are shown as percentages. The proportion of
spirochetes and motile rods together was analyzed by means of a
mixed-procedure test of the S.A.S. statistical package.
J Dent Res 74(8) 1995 Full-mouth Disinfection for Periodontitis 1463

showed a significantly higher reduction in the proportion of potentially

pathogenic micro-organisms (sum of spirochetes and motiles) in the
Plaque Gingivitis Probing Bleeding pockets of the test group (p = 0.01) at one month. At two months, the
Index Index 2 Depth Index differences were no longer statistically significant (p > 0.05).
Culture data
Months The relative proportion of CFU between the blood agar plates which
were incubated under aerobic and those incubated under anaerobic
GI/PI conditions are illustrated in Fig. 3. For both treatment modalities and
2.1 0.3 ± 0.3 0.3 ± 0.4 4.2 ± 1.5 60 ±30 tooth types, an increase in the relative proportion of CFUs on aerobic
±1.6 0.6 ± 0.4 0.9 ±1.4 3.8 ±1.1 60 ±30 plates was found at one month, but at two months they showed a
1.0 tendency to return to the baseline value. The differences between the
±0.9 treatment modalities and tooth types were negligible.
2.8 0.5 ± 0.5 0.2 ± 0.2 4.7 ±1.1 70 ±30 However, when the relative proportions of potentially pathogenic
±1.3 0.7 ± 0.4 0.3 ±0.1 4.7 ± 1.7 80 ±30 and beneficial species were compared (Figs. 4, 5, and 6), the differences
2.7 ± between both treatment modalities became apparent. Samples from the
were
0.4 made. In comparison with the initial scores, clinically significant test group harbored significantly fewer pathogenic organisms (Fig. 5) at
improvements for both treatment modalities were observed at the
one month (p = 0.005), and significantly more beneficial bacteria at two
follow-up visits. When the two were compared, however, the
months (p = 0.02). None of the sites from the test group initially
improvements in the full-mouth-disinfection group were always
positive for P. gingivalis (6/10) remained positive after full-mouth
greater. When the gingivitis index/plaque index ratio was considered,
disinfection in one stage. At baseline, A. actinomycetemcomitans was
a more significant decrease was observed for the test group, with a
detected in only one patient from the test group (around both multi-
mean change from 0.69 to 0.16, whereas for the control group only a
and singlerooted teeth). These sample sites remained positive at both
minor change was recorded (from 0.59 to 0.43).
follow-up visits, and the relative proportion of A.
The reduction in probing depth for deep (7 to 8 mm) and medium (5
actinomycetemcomitans even increased by a factor of 100.
to 6 mm) pockets, over time and per treatment modality, is shown in
Questionnaire
Fig. 1. The group with a full-mouth disinfection showed a significantly
higher reduction in probing depth (especially when deep pockets were The major adverse effects are summarized in Table 3. The pain
considered), after both one (p = 0.02) and two months (p = 0.03), with experienced seemed similar in both treatment groups. A greater
mean slope differences (calculated by regression analysis) of 1.01 and frequency of post-treatment rise in body temperature and labial herpes
0.81 mm, respectively. was noted in the test group.
Differential phase-contrast microscopy Discussion
The differential phase-contrast microscopic analysis (Fig. 2)
Since most periodontopathogens colonize several niches in the oral
cavity (Van Winkelhoff et al., 1986,1988a; Asikainen et al., 1991; Danser
et al., 1994) and can be transmitted from one site to another (Quirynen
et al., 1995), a full-mouth disinfection in one session seems logical when
compared with the standard strategy (of quadrant-wise disinfection at
several time intervals). In the latter approach, a re-infection is probable.
For maximal disinfection, the new protocol combined: (1) the scaling
and root planing of all teeth within 24 hours to disrupt and reduce the
number of subgingival pathogenic organisms (Mousques et al., 1980;
Walsh et al., 1986; Loos et al., 1988); (2) brushing the dorsum of the
tongue with a 1% chlorhexidine gel; (3) rinsing the mouth twice for one
min with a 0.2% chlorhexidine solution to reduce the number of
bacteria in the saliva and on the tonsils (Rindom et al., 1976); (4)
irrigating all pockets with a 1% chlorhexidine gel (3x in 10 min to
increase the contact time) to reduce (up to 99%) the number of
remaining bacteria (Oosterwaal et al., 1991); and (5) twice-daily rinsing
with chlorhexidine for two weeks to retard the subgingival re-
establishment of pathogenic species (Magnusson et al., 1984).

SINGLE - ROOTED MULTI - ROOTED

Figure 3. The effect over time of partial and full-mouth disinfection on

the number of CFU after aerobic and anaerobic incubation of samples
from single- and multi-rooted teeth. The formula used was: log
(anaerobic CFU/aerobic CFU) in which score 0 = equal amount, and
score 1 = lOx higher number of CFUs on anaerobic plate.
1464 Quirynen et al.
SPIROCHETES (n-5)
40
35
§30
o 60
i25
£20
0 1 2 MONTHS
§ Test single-rooted ■ Test multi-rooted
HI Control single-rooted □ Control multi-rooted
Figure 4. Changes over time in the relative proportion of potentially
pathogenic organisms, by tooth type and treatment modality. These
changes were analyzed by means of a mixed-procedure test of the
S.A.S. statistical package. Because spirochetes are considered
pathogenic (Socransky and Haffajee, 1992; Wolff et al., 1994) but
could not be cultured, they were included based on the phase-
contrast microscopic observations, and the proportion of the other
micro-organisms was recalculated by the formula: new proportion =
old proportion x [(100 - % spirochetes) / 100]. (A.
actinomycetemcomitans was observed only once in a very low
density, and B. forsythus and C. rectus were not detected at all.)
The probing depth reduction noted in the control group falls
within the range of previous observations (Badersten et al., 1984),
while the test group achieved greater improvement. The differences
between test and control groups (Fig. 1) were significant for pockets
with an initial depth of 7 and 8 mm. While the one-stage full-mouth
disinfection resulted in a mean pocket reduction from 7.3 to 4.0 mm
(SD ±1.2 mm), in the control group a reduction of only from 7.4 to 4.9
mm (SD ±1.4 mm) could be achieved. Since it takes several months
before microbiological
} Dent Res 74(8) 1995
8
0
7
0
O
5
0
u
.
—
I
£
4
0
O
H
O
3 Test Control
0 single¬ single-
# rooted
Figure 5. Changes over time in the total proportions of potentially
2
pathogenic organisms, by tooth type and treatment modality (n = 5).
These
0
changes were analyzed by means of a mixed-procedure test of
the S.A.S. statistical package.
1
differences
0 result in clinically detectable changes (Listgarten et al.,
1978), more significant differences might be expected at further
follow-up visits.
The differences in treatment outcome can be explained by the
differences in the microbiological data. The change in the
gingivitis/plaque ratio after two months (Table 2) already indicates a
greater reduction in the pathogenicity of the plaque in the test group.
Moreover, the culture data showed, after the one-stage full-mouth
disinfection, a more significant decrease in the proportion of
pathogenic organisms (Fig. 5) paralleling a more important increase
in beneficial species (Fig. 6).
One can only speculate on the relative importance of each of the
five abovementioned steps in the test protocol, since all of them are
known to reduce the pathogenicity of the subgingival flora.
However, some have only a short-(one week) to medium-term (two
months) effect. Indeed, several reports have illustrated that, after a
single session of scaling and root planing, the subgingival flora
returns to baseline values, "qualitatively and quantitatively', within a
two- month period, at least when oral hygiene is not optimal, as was
the case in this study (Mousques et al., 1980; Van Winkelhoff et al.
1988c; Sbordone et al., 1990). Moreover, several studies have
illustrated that an irrigation of the pockets with a chlorhexidine
solution (even if repeated weekly) failed to improve the effect of
mechanical debridement at either a microscopic or clinical level over
a six-month observation period (Braatz et al., 1985; MacAlpine et al.,
1985; Lander et al., 1986; Wennstrom et al., 1987). The supragingival
plaque growth inhibition by chlorhexidine mouthrinses (Hull, 1980)
might be responsible for the lower plaque and gingivitis scores for
the subjects in the test group at month 1. The effect of oral rinsing on
the subgingival flora, however, is negligible (Flotra et al., 1972).
The advantage of a one-stage full-mouth disinfection is the
reduced probability of an intra-oral transmission of periodon-
topathogens from one of their niches to the
/ Dent Res 74(8) 1995 Full-mouth Disinfection for Periodontitis 1465

subgingival envi-ronment of treated

teeth. Indeed, several possible ways
have been shown by which such a
transmission might occur. Saliva can
be considered a major vehicle of
transmission (Van Winkelhoff et al,
1988a). Additionally, dental
instruments, such as explorers, probes,
and syringe tips, as well as oral
hygiene material (toothbrushes and
dental floss) have the capability of
retaining pathogenic micro-organisms
(Caufield and Gibbons, 1979;
Loesche et al., 1979; Barnett et al.,
1982; Christersson et al., 1985;
Müller et al., 1989; Preus et al.,
1993). The hypothesis that a
transmission of micro-organisms is
possible has been confirmed in a recent
study utilizing titanium abutments as
"virgin soil" for the colonization of oral
bacteria (Quirynen et al., 1995).
Whether a full-mouth approach can
ever achieve the complete elimination
of some exogenous micro-organisms
from the oral cavity has to be proven
over a longer observation period.
However, for all test sites initially
positive for P. gingivalis (6/10), no § Test single-rooted H M Test multi-rooted il
recurrence of this microorganism could
Control single-rooted Control multi-rooted
be detected
Figure 6. Changes over time in the relative proportion of potentially beneficial species (in relation to the
total anaerobically cultured flora) by tooth type and treatment modality. Differences in the total
proportions of these organisms were analyzed by means of a mixed-procedure test of the S.A.S. statistical
package. (Since the subspecies of the Capnocytophaga genus were not identified, no information on
Capnocytophaga ochracea is available.)

(Fig. 4). This is in contrast to the observations of Van Winkelhoff without further oral disinfection, a subgingival recolonization by P.
and co-workers (1988c), who reported, two months after a single course gingivalis in 58% of the examined pockets. The outcome of the present
of scaling and root planing therapy for A.

Table 3. Major complaints after full-mouth disinfection (test group) or after first-quadrant scaling and root planing (control group)
Pain Pain-killers (number of Fever (°C) Herpes Labialis
(numerical score3) tablets)

Test group
#1 0 0 37.8 -
- -
#2 6 6
#3 3 1 39.0 +
#4 7 2 38.5 +
#5 10 2 - -

Control group
- -
#1 8 1
- -
#2 0 0
- -
#3 5 1
- -
#4 7 2
#5 6 2 - -
a Scores from 0 to 10: 0 = no pain, 10 = extremely painful.
1466 Quirynen et al.
actinomycetemcomitans-positive patients should be further assessed.
The only patient (test group) with two sites positive for A.
actinomycetemcomitans showed an initial increase in concentration of
this organism, but at eight months, this organism disappeared. A
possible explanation for this is the capacity for tissue invasion which
has been described for this organism (Christersson et al., 1987).
The increase in body temperature (Table 3), reported in the test
group (3/5), probably illustrates the important bacteremia during
scaling and root planing (Ellen, 1978). Perhaps the increased amount of
micro-organisms introduced into the bloodstream and/or the
prolonged treatment time (four hours within a single day)
overstimulated the host-defense mechanism. The occurrence of herpes
labialis in two of the five patients of the test group could be due to
prolonged trauma or to the rise in body temperature.
In conclusion, the one-stage full-mouth disinfection showed
significant clinical (pocket reduction) and microbiological (shift toward
a more beneficial flora) advantages on a short-term basis.
Acknowledgments
The authors wish to thank G. Depauw for his help with the
microbiological procedures and L. Duchateau for the statistical analysis.
The financial support for this project was provided by the Faculty of
Medicine, Catholic University of Leuven.
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