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

12199

One-stage full-mouth disinfection Johan A. J. Keestra1, Wim Coucke2

and Marc Quirynen1
1
Department of Periodontology, School of

combined with a periodontal Dentistry, Oral Pathology & Maxillo-facial

Surgery, Faculty of Medicine, Catholic
University Leuven, Leuven, Belgium;

dressing: a randomized
2
Department of Clinical Biology, Scientific
Institute of Public Health, Brussels, Belgium

controlled clinical trial

Keestra JAJ, Coucke W, Quirynen M. One-stage full-mouth disinfection combined
with a periodontal dressing: a randomized controlled clinical trial. J Clin
Periodontol 2014; 41: 157–163. doi: 10.1111/jcpe.12199.

Abstract
Aim: To compare the clinical benefit of a periodontal dressing applied after a
one-stage full-mouth disinfection (OSFMD) in patients with chronic periodontitis
up to 3 months after therapy.
Material and Methods: This randomized, controlled split-mouth study included
24 patients. After OSFMD, a test and a control side were selected by means of a
computer-generated randomization list. Test sides received a periodontal dressing
(Coepakâ) for 7 days and the control sides received no periodontal dressing.
After 7 days the periodontal dressing was removed and the pain experience was
recorded. 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 the
moderate pockets of single- and multi-rooted teeth compared with the control
group. A significant (p < 0.05) lower percentage of sites with probing pocket
depth ≥5 mm were shown for the periodontal dressing group compared with the
control group (2.7  16.3% versus 4.8  21.4%). The pain intensity was signifi-
Key words: chronic periodontitis; full-mouth
cantly reduced when using a periodontal dressing (5.13  0.89 versus disinfection; non-surgical therapy; periodontal
3.42  1.27). dressing
Conclusion: The use of a periodontal dressing for 7 days after a OSFMD offers
an additional short-term clinical improvement and lowers the pain intensity. Accepted for publication 17 November 2013

Periodontitis is an inflammatory dis- modifying factors (Socransky & Haf-
ease that results in the destruction of fajee 1992). The primary clinical signs
the teeth-supporting tissues. It is a are bleeding on probing (BOP),
result of an imbalance between the pocket formation (PPD), gingival
wide range of microorganisms, the recession (REC) and at a later stage
host response and some essential increased tooth mobility. The goals of
treatment are to reduce the infection,
Conflict of interest and source of resolve inflammation and create a
funding statement clinical condition, which is compati-
ble with periodontal health (Lang &
This article has been prepared without
Tonetti 2003).
any sources of institutional, private or
It has been shown that non-surgi-
corporate financial support, and there
are no potential conflicts of interest.
cal periodontal therapy, consisting
of scaling and root planing, results
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
in clinical improvements (Badersten
et al. 1981). This is usually done in a
quadrant wise approach (QSRP). In
1995 Quirynen and co-workers
introduced the one-stage full-mouth
disinfection (OSFMD). With this
procedure scaling and root planing
was performed in two sessions
within 24 h and was supplemented
with supra- and subgingival use of
chlorhexidine (Quirynen et al. 1995,
2006, Mongardini et al. 1999).
Periodontal dressings were intro-
duced in 1923 in order to protect
157
158 Keestra et al.
wounds after periodontal surgery
(Ward 1923). Nowadays, it is still
used after resective periodontal
surgery as well as after recession
coverage. The periodontal dressing
protects the tissue and keeps the tis-
sue in close contact with the teeth. It
stabilizes the coagulum and protects
it from different forces during talk-
ing and eating (Wikesj€ o et al. 1992).
Wound healing is a complex pro-
cess involving different phases such
as; homeostasis phase, inflammatory
phase, proliferation and remodelling
phase (Stadelmann et al. 1998). The
first and most important step is the
formation of a fibrin clot. This clot
will protect the wound and attract
inflammatory cells. When a tissue is
wounded, platelets start to release
inflammatory factors, cytokines and
growth factors to facilitate the heal-
ing (Barrientos et al. 2008). When all
the steps are successfully accom-
plished, the healing will result in
reduction of the swelling, recession
of the gingival margin due to resolu-
tion of inflammation and formation
of long junctional epithelium.
Sigusch et al. (2005) introduced
the use of a periodontal dressing as
an adjunctive tool for the treatment
of patients with aggressive periodon-
titis. The group with the periodontal
dressing applied for 7 days showed a
significant pocket reduction and clin-
ical attachment gain compared with
the control group. Genovesi et al.
(2012) applied a periodontal dressing
for 7 days after non-surgical therapy
for the treatment of patients with
moderate-to-advanced periodontitis.
The results were similar to the
results of Sigusch et al. (2005).
The aim of this randomized clinical
trial was to evaluate, in a split-
mouth design, the effect of a peri-
odontal dressing applied for 7 days
after OSFMD.
Material and Methods
This study was designed as a ran-
domized-controlled split-mouth trial
to compare the clinical effects of two
different periodontal treatments,
OSFMD alone or combined with a
periodontal dressing for 7 days with
a 3 months follow-up period. The
ethical committee at the University
Hospital Leuven approved the pro-
tocol. All participants had to sign an
informed consent before entering the
Fig. 1. Study design.
study. The study started in Septem-
ber 2010 and ended in June 2012.
Twenty-six volunteers were
selected for this prospective study
(Fig. 1). All patients consulted or
were referred to the Department of
Periodontology of the University
Hospitals Leuven for the treatment of
chronic periodontitis. The general
health 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, wisdom
teeth excluded.
• Previously untreated moderate
chronic periodontitis (Armitage
1999) with radiographic evidence
of generalized alveolar bone loss
>30%.
• Presence of at least one pocket
with probing pocket depth (PPD)
≥6 mm per quadrant, which was
BOP.
• Presence of at least three teeth
per quadrant.
Exclusion criteria
• Periodontal treatment in the last
3 years.
• Antibiotic intake 6 months before
the screening visit.
• Pregnancy.
• Systemic diseases with an impact
on periodontal healing (e.g. Dia-
betes).
The purpose of the study was
explained to the patients who met the
inclusion criteria and they were asked
to participate by signing an informed
consent form. The following clinical
parameters (in sequential order) were
recorded by only one trained and cali-
brated periodontist (J.K.).
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
• The plaque score (PS) was
detected visually or with the
probe at 4 sites per tooth (mesial,
distal, buccal and lingual); the
scores ranged from 0 (absent) to
1 (present) (O’Leary et al. 1972).
• The PPD was recorded to the
nearest 0.5 mm at six sites per
single-rooted teeth and ten sites
for multi-rooted teeth.
• The amount of gingival recession
(REC, the distance from the ce-
mento-enamel junction to the
gingival margin) was measured to
the nearest 0.5 mm at the same
sites as the PPD.
• The BOP was evaluated 30 s
after probing in the depth of the
pockets 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 site
as the sum of the PPD and the
REC.
These variables were recorded
using 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 scraping
in the case of tongue coating). After
1 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 h
and 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 a
0.12% chlorhexidine spray.
• Subgingival irrigation of all the
pockets three times within

10 min. with the chlorhexidine
1% gel using a syringe (the tip of
the needle was blunted so that
the resistance offered by the bot-
tom of the pocket could be felt).
Additionally, the patients had to
rinse twice daily for 1 min. with a
0.12% chlorhexidine solution for
2 months (Quirynen et al. 1995,
2006, Mongardini et al. 1999).
The first treatment was started at
the right side (first and fourth quad-
rant). At the end of the first treat-
ment, a test and control side was
selected by means of a computer-
generated randomization list. If the
first quadrant was selected as the test
side, the third quadrant was selected
after the second treatment as the test
side. Hereby, the periodontal dressing
was always placed in one upper and
one lower quadrant. The operator
(J.K.) mixed the periodontal dressing
(Coepakâ, Alsip, IL, USA) according
to the manufacturer’s instructions.
The oral hygiene instructions were
given and each patient had to avoid
brushing the periodontal dressing
area as long as the periodontal dress-
ing was in place.
After 1 week, the periodontal
dressing was removed from the test
sides and oral hygiene instructions
were repeated, identical to the first
time. The patients had to compare
the difference between the sides with
the periodontal dressing and the
sides without the periodontal dress-
ing. During this appointment the
patients had to fill out a pain inten-
sity scale on a scale from 0 to 10
(0 = no pain, 5 = moderate pain and
10 = worst imaginable pain) and the
amount of pain medication was
recorded. After 3 months, all clinical
examinations were recorded by only
one trained and calibrated periodon-
tist (J.K.).
Statistical analyses
A power analysis was carried out.
Based on these calculations, it was
defined that 22 patients would be
necessary. Considering a drop out of
about 15%, it was established that
at least 25 patients were needed. The
concordance correlation coefficient
was used to quantify the degree of
agreement or congruence between
two measurements. Linear mixed
models were fit to assess the
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Full-mouth disinfection with periodontal dressing
difference between the two treat-
ments. Treatment was used as a
fixed factor. Position, tooth number
and patient were used as nested ran-
dom factors. Normal quantile plots
and residual dot plots were used to
assess the normality and variability
distribution of the data and did not
indicate any deviation from the basic
assumptions. Significance was
determined by using an a of 0.05;
p-values lower than 0.05 were
considered significant. S-Plus 7 (Tib-
co, Palo Alto, CA, USA) was used
for the statistical analyses.
Results
Twenty-six patients passed the inclu-
sion / exclusion criteria. Two
patients were excluded because they
did not show up at the final appoint-
ment after 3 months. Finally, a total
of twenty-four patients were statisti-
cally analysed. Table 1 presents the
demographic characteristics. All
patients belonged to the Caucasian
race with an average age of 48.3
(range 33–64 years). The total num-
ber of teeth and mean percentage of
sites (with PPD < 4 mm, PPD
4–6 mm and PPD > 6 mm) were
equally distributed.
The mean values for PS and BOP
are presented in Table 2. The control
group showed a significant reduction
of the PS with 37% (p = 0.0001) and
BOP with 39% (p = 0.0001) com-
pared to the baseline. The test group
also showed a significant reduction of
the PS with 48% (p = 0.0001) and
BOP with 51% (p = 0.0001) com-
pared to the baseline. The test group
showed a significantly higher reduc-
tion of the PS with 11% (p < 0.0001)
and BOP with 12% (p < 0.0001).
The pain sensation was measured
7 days after OSFMD, the results are
presented in Table 2. When com-
Table 1. Demographic characteristics and mean  SD full-mouth clinical parameters
Variable
Gender (male/female)
Age (years)
Smokers (n)
Total tooth (n)
Multi rooted (n)
Single-rooted (n)
Mean % (number) of sites with
PPD <4 mm
PPD 4–6 mm
PPD >6 mm
159
pared with the control group the test
group showed a significant reduction
of the pain intensity, which was 1.71
(p < 0.0001).
The mean values for PPD, REC
and CAL are presented in Table 2.
The control group showed a signifi-
cant reduction of the PPD with
1.20 mm (p = 0.0001) and CAL with
0.74 mm (p = 0.0001) compared to
the baseline. The test group also
showed a significant reduction of the
PPD with 1.49 mm (p = 0.0001) and
CAL with 1.01 mm (p = 0.0001)
compared to the baseline. The test
group showed a significantly higher
reduction of the PPD with 0.29
(p < 0.0001) mm and CAL with
0.26 mm (p < 0.0001). The control
group showed a significant increase
of the REC with 0.45 mm
(p = 0.0001) compared to the base-
line. The test group also showed a
significant increase of the REC with
0.48 mm (p = 0.0001) compared to
the baseline. The test group showed
no significant difference of the REC.
Those three clinical parameters were
also divided into moderate pockets
(4–6 mm) and deep pockets (>6 mm).
The control group showed a signifi-
cant reduction of the PPD of the
moderate pockets with 1.87 mm
(p = 0.0018) and for the deep pockets
3.27 mm (p = 0.0018). The significant
reduction was also seen for the CAL
of the moderate pockets with
1.20 mm (p = 0.0018) and for the
deep pockets 1.83 mm (p = 0.0018)
compared to the baseline. The test
group also showed a significant
reduction of the PPD of the moderate
pockets with 2.20 mm (p = 0.0018)
and for the deep pockets 3.56 mm
(p = 0.0018). Again the significant
reduction was also seen for the CAL
of the moderate pockets with
1.53 mm (p = 0.0018) and for the
deep pockets 2.10 mm (p =
Control Test
13/11 13/11
48.4  9.2 48.4  9.2
0 0
304 303
79 79
225 224
57.4  49.5 54.9  48.8
36.1  48 37.4  48.4
6.5  24.7 7.8  26.8
160 Keestra et al.

Table 3. Number and percentage of sub-

<0.0001
<0.0001
<0.0001
<0.0001
<0.0001

0.6032
0.4011
>0.9999

>0.9999

<0.0001
<0.0001

0.4000
p value
Inter group comparison
jects presenting low [1–4 sites with probing
pocket depth (PPD) ≥5 mm], moderate risk

at 3 months
(5–8 sites with PPD ≥5 mm) or high (≥9
sites with PPD ≥5 mm) risk for disease pro-

2.22
2.11
0.19
0.05
0.05

0.15
0.03
0.04

0.04
0.13
0.03

0.12
SE
gression according to Lang & Tonetti (2003)

BOP, bleeding on probing; CAL, clinical attachment level; PPD, probing pocket depth; PS, plaque score; REC, gingival recession; SE, standard error; SD, standard deviation.
Categories Control Test (%) p value

1.71
0.29
0.32

0.30
0.03
0.01

0.33
0.01
0.26

0.27
10.8
12.1
(%)

Low risk 10 (41.7) 16 (66.7) 0.0422

Moderate 5 (20.8) 5 (20.8) >0.9999
p value

0.0001
0.0001

0.0001
0.0018

0.0018
0.0001
0.0018

0.0018
0.0001

0.0018
0.0018
risk
High risk 9 (37.5) 3 (12.5) <0.0001
Change test

2.48
3.01

0.08
0.07

0.16
0.05
0.06

0.13
0.07

0.13
0.07
SE

0.0018) compared to the baseline. The

test group showed a significantly
higher reduction of the PPD of the
1.49
2.20

3.56
0.48
0.66

1.44
1.01

2.10
1.53
48.2
50.6

moderate pockets with 0.32 mm

(p < 0.0001) and for the CAL of the
moderate pockets 0.33 mm
0.95
0.69

1.20
1.02
0.92

1.03
1.46

1.37
1.07 (p < 0.0001). The deep pockets of the
3 months test

SD

43.4
42.9

test group showed no significantly

higher reduction of the PPD with
2.22
2.57

4.01
0.81
0.89

1.76
3.03

5.78
3.46

0.30 mm and for the CAL 0.27 mm

25.1
24.3

compared with the control group.

The control group showed a signifi-
1.27
1.72
0.74

0.96
0.85
0.71

0.80
1.81

1.22
0.96

cant increase of the REC of the mod-

Baseline test

SD

44.4
43.7

erate pockets with 0.67 mm

(p = 0.0018) and for the deep pockets
3.42
3.69
4.79

7.46
0.33
0.23

0.26
4.03

7.72
5.02

1.43 mm (p = 0.0018) compared to

73.0
74.3

the baseline. The test group also

showed a significant increase of the
p value

0.0001
0.0001

0.0001
0.0018

0.0018
0.0001
0.0018

0.0018
0.0001

0.0018
0.0018

REC of the moderate pockets with

0.66 mm (p = 0.0018) and for the
Change control

deep pockets 1.44 mm (p = 0.0018)

compared to the baseline. The test
2.47
3.01

0.08
0.07

0.16
0.05
0.06

0.13
0.07

0.13
0.07
SE

group showed no significant differ-

ence of the REC of moderate pockets
1.20
1.87

3.27
0.45
0.67

1.43
0.74

1.83
1.20

or deep pockets. Additionally the out-

37.4
38.5

come variables for single-rooted teeth

Table 2. Outcome variables for single and multi-rooted teeth together

(Table S1) and for multi-rooted teeth

(Table S2) are available online.
1.03
0.84

1.29
1.03
1.04

1.17
1.44

1.19
1.16
SD

47.2
47.4

The data for the residual sites at

3 months
control

subject level are presented in

Table 3. It presents numbers and
2.43
2.94

4.31
0.78
0.90

1.62
3.21

5.93
3.84
33.4
34.0

percentage of subjects exhibiting dif-

ferent thresholds of residual sites
with PPD ≥5 mm according to the
0.89
1.64
0.72

0.73
0.84
0.77

0.76
1.76

1.00
1.04
SD

45.5
44.8

individual risk profile for periodon-

Baseline
control

tal disease progression introduced by

Lang & Tonetti (2003). The test
5.13
3.62
4.79

7.47
0.33
0.25

0.24
3.94

7.71
5.03

group showed fewer subjects (n = 3)

70.8
72.2

for high risk of disease progression

(≥9 with PPD ≥5 mm), in compari-
REC deep pockets (>6 mm)

CAL deep pockets (>6 mm)

PPD deep pockets (>6 mm)

son with the control group (n = 9).

REC moderate pockets

CAL moderate pockets

Conversely, the test group showed

PPD moderate pockets

more subjects (n = 16) for low risk

of disease progression (1–4 sites with
BOP (% of sites)
PS (% of sites)

PPD ≥5 mm), in comparison with

Pain intensity

the control group (n = 10).

REC (mm)

CAL (mm)
PPD (mm)

(4–6 mm)

(4–6 mm)

(4–6 mm)
Variable

Table 4 presents the mean per-

centage of sites with PPD ≥5 mm,
PPD ≥6 mm and PPD ≥7 mm after
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Full-mouth disinfection with periodontal dressing
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 <0.0001
PPD ≥ 6 mm 1.2  10.9 0.7  8.2 0.0066
PPD ≥ 7 mm 0.4  6.2 0.2  4.9 0.0333
3 months. The test group had attachment gain compared to
significant less percentage of sites OSFMD. In contrast the results for
with PPD ≥5 mm (2.7% versus the teeth with deep pockets showed
4.8%, p < 0.0001), PPD ≥6 mm no significant additional pocket
(0.7% versus 1.2%, p = 0.0066) and depth reduction nor additional clini-
PPD ≥7 mm (0.2% versus 0.4%, cal attachment gain albeit there
p = 0.0333) compared with control could be a tendency that this effect
group. occur. These non-significant results
could be explained because there
were not enough deep pockets pres-
Discussion
ent in the study population.
This randomized controlled clinical Residual pockets are important
trial demonstrated that the applica- to evaluate the success of the peri-
tion of a periodontal dressing after odontal treatment or to decide if
OSFMD for 7 days resulted in additional periodontal surgery is
significant clinical improvements needed. Mostly, when residual pock-
compared to OSFMD without peri- ets of 5 mm or higher are present
odontal dressing. after non-surgical therapy, periodon-
For the teeth with moderate pock- tal surgery may be necessary. The
ets the results with the periodontal periodontal dressing group showed a
dressing group showed a significant significant lower percentage of sites
additional pocket depth reduction with PPD ≥5 mm compared with the
and a clinical additional attachment control group. Less sites of the peri-
gain compared to OSFMD. In con- odontal dressing group could needed
trast, the results for the teeth with periodontal surgery.
deep pockets showed no significant The presence of residual pockets
additional pocket depth reduction (≥5 mm) after periodontal surgery is
nor additional clinical attachment one of the most important risk indi-
gain although there could be a ten- cator for recurrence of periodontitis
dency that this effect occur. These in maintenance patients (Lang &
non-significant results could be Tonetti 2003). The periodontal dress-
explained because there were not ing group presented significant lower
enough deep pockets present in the mean number/percentage of the low
study population. Hung had system- risk group (1–4 sites with
atically assessed the effect of non- PPD ≥ 5 mm) after 3 months com-
surgical therapy. The periodontal pared with the control group. The
dressing group showed higher results control group was able to bring
compared to the systematic review 41.7% patients to a low risk profile
(Hung & Douglass 2002). For the mod- and the periodontal dressing group
erate pockets the results showed a was able to bring 66.7% patients to
pocket depth reduction of 1.02 mm ver- a low risk profile.
sus 2.20 mm and a clinical attachment The present analysis showed the
gain of 0.53 mm versus 1.53 mm. The additional benefit of using a peri-
deep pockets showed a pocket depth odontal dressing combined with
reduction of 1.98 mm versus 3.56 mm OSFMD in a short-term basis. The
and a clinical attachment gain of periodontal dressing might well
1.14 mmversus2.10 mm. accelerate the healing instead of
The same results were seen for improving it. This additional result
the single and multi-rooted teeth. could be disappearing in a few
For the teeth with moderate pockets months or stay stable over time. Sig-
the results with the periodontal usch et al. (2005) showed that the
dressing group showed a significant result of the periodontal dressing
additional pocket depth reduction group remained stable in the next
and a significant additional clinical 24 months.
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
161
A potential limitation of the pres-
ent analysis is the lack of blindness
since operator and examiner were
the same. This lack of blindness
could possibly affect the final out-
come. The examiner might have
remembered which sides were treated
with periodontal dressing. However,
it is entirely possible that, over the
course of 3 months, the examiner
could have forgotten.
Pain is a common problem after
non-surgical therapy. Pain varies
over time. It is not felt in a constant
intensity (Boormans et al. 2009).
It is thus difficult for patients to
summarize their differing pain levels
with a single number. This is a dis-
advantage when using the numeric
rating scale (Kahneman et al. 1993).
The control group showed a 5.1 on
the pain intensity scale, according to
the numeric rating scale moderate
pain. The periodontal dressing group
had 3.4 on the pain intensity scale
which is mild pain. This was signifi-
cantly lower than the control group.
Is this clinically relevant compared
to the possible side effects? In the
beginning, chewing and speaking are
difficult. If the periodontal dressing
is placed with great pressure it could
cause impaired healing or swelling.
After several days, it could create an
unpleasant taste, odour and colour.
It is very important that the patient
is well informed about the usage of
periodontal dressing.
The amount of plaque is critical
for the success of periodontal treat-
ment. A PS of less than 11% for the
periodontal dressing sides could be
the cause because of the additional
results. A level of plaque has not yet
been established that results in peri-
odontal health. A full-mouth PS of
20–40% might be tolerable by most
patients. (Axelsson et al. 2004) It is
important to realize that the PS has
to be related to the host response
(Van Dyke & Serhan 2003). In a
split-mouth design it would be
expected that the oral hygiene would
be the same but it was interesting to
see that the PS differs between test
en control sides. The lower PS could
be the explanation for the additional
result on the periodontal dressing
sides but it does not explain why
there is less plaque present.
When the gingiva is damaged
after non-surgical therapy wounds
can form. Healing after non-surgical
162 Keestra et al.
therapy occurs because existing tis-
sues repair themselves. In a couple
of seconds the homeostasis process
starts, forming a blood clot. The
blood clot has three main functions:
protection denuded tissue, provi-
sional matrix for cell migration and
reservoir of growth factors and cyto-
kines (Stadelmann et al. 1998). Dur-
ing this coagulation process, some
products act as chemotactic agents
attracting phagocytic cells to the
inflammation side. The platelets pro-
duce some proteins that could be
antimicrobial, for example, beta-
lysine which causes lysis of Gram-
positive bacteria (Yeaman 2010).
The platelets also produce growth
factors and cytokines that stimulate
the wound healing (Barrientos et al.
2008). When all the steps are suc-
cessfully accomplished, the healing
will result in reduction of the swell-
ing, recession of the gingival margin
due to resolution of inflammation
and formation of long junctional
epithelium. The saliva and the move-
ments of the cheeks are probably the
main cause that only a small portion
of the blood remains present. When
the periodontal dressing is applied at
the wound, the blood clot is more
protected, the gingiva is more stabi-
lized, more portion of the blood clot
might be present and the gingiva will
adhere more closely to the tooth.
This may be the reason for the bet-
ter clinical outcomes and the reduc-
tion of pain after non-surgical
therapy.
A few studies have investigated
the possible antimicrobial effect of
the periodontal dressing (O’Neil
1975, Haugen et al. 1977, Cheshire
et al. 1996). The periodontal dress-
ing that was used consisted of zinc
oxide non-eugenol. The reaction is
based on a metallic oxide and fatty
acids. According to the information
from the manufacturer two possible
anti-infective ingredients were visible,
lorothidol (fungicide) and chlorothy-
mol (antibacterial). No anti-inflam-
matory ingredients were observed.
So far, there is no study available
that can actually prove whether
these ingredients have an effect on
the plaque accumulation. O’Neil sta-
ted in 1975 that the use of an anti-
microbial agent is not necessary in
the periodontal dressing because it
forms a physical barrier to saliva,
bacterial contamination and food
impaction. Further research is
needed to prove if periodontal dress-
ing has some anti-infective effect.
Our data are in agreement with
two other studies. Sigusch et al.
(2005) introduced the use of a peri-
odontal dressing as an adjunctive
tool in the treatment of patients with
aggressive periodontitis. The patients
were treated with non-surgical ther-
apy, systemic antibiotics (Metronida-
zole 500 mg b.i.d. for 8 days) and
periodontal dressing. Three treat-
ment groups were used; in group 1
the periodontal dressing was remo-
ved after 3–4 days, in group 2 the
periodontal dressing was removed
after 7–8 days and the control
group. The non-surgical therapy
consisted of two parts, part one scal-
ing and root planing in 3–4 sessions
and part two manual root curettage
in one session. The usage of chlorh-
exidine was not mentioned. After
6 months group 1 showed an addi-
tional pocket depth reduction of
0.7 mm and also an additional prob-
ing attachment gain of 0.7 mm com-
pared with the control group. Group
2 showed an additional pocket depth
reduction of 1.8 mm and also an
additional probing attachment gain
of 1.8 mm. Genovesi et al. (2012)
used a periodontal dressing for
7 days during the non-surgical
treatment of patients with moderate-
to-advanced periodontitis in a split-
mouth design. The patients were
treated with a full-mouth scaling and
root planing within 24 h and this
was followed by curettage of the epi-
thelium. Also here, the usage of
chlorhexidine was again not men-
tioned. After 2 months, the peri-
odontal dressing group showed an
additional pocket depth reduction of
0.8 mm compared with the control
group. The additional probing
attachment gain for the periodontal
dressing group was 1.1 mm com-
pared with the control group.
The results of this randomized
clinical trial show the additional
effects that a periodontal dressing has
when it is combined with OSFMD.
The additional effects of the peri-
odontal dressing could be explained
by: protection of the wound, stabil-
ization of the tissues, availability of
the blood clot and maybe some anti-
microbial effects of the periodontal
dressing. Within the limitations of
this study a periodontal dressing has
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
additional benefits that are statisti-
cally significant for the moderate
pockets. It is important to mention
that periodontal dressing causes less
pain after OSFMD. To reduce the
pain a periodontal dressing could be
a good alternative to pain medica-
tion. Further randomized clinical tri-
als are necessary to confirm this
result and this should be done with
more patients involved, as this may
lead to a significant effect in the
deep pockets as well.
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© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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Principal findings: Periodontal dress-
ing applied after OSFMD showed
significant superior results in all clin-
ical parameters compared to
OSFMD alone after 3 months. The
results included a significant reduc-
tion of pain after OSFMD and
reducing the residual pockets up to
3 months post-treatment.
163
Supporting Information
Additional Supporting Information
may be found in the online version
of this article:
Table S1. Outcome variables for
single-rooted teeth.
Table S2. Outcome variables for
multi-rooted teeth.
Address:
Johan A.J. Keestra
Department of Periodontology,
School of Dentistry, Oral
Pathology & Maxillo-facial Surgery, Faculty
of Medicine, Catholic University Leuven,
Kapucijnenvoer 33, B-3000 Leuven, Belgium.
E-mail: hanskeestra@gmail.com
Practical implications: Periodontal
dressing applied after OSFMD can
reduce the pain after OSFMD and
offers a clinical benefit for the
treatment of patients with chronic
periodontitis.