Efficacy in healing by application of a gel based on chlorhexidine digluconate 0.20% and hyaluronic acid 1%.

Author: Dr. Carla Mozas

Master's degree in periodontology and implants recognised by the EFP. International University of Catalonia. Publication in "Peri-implant diseases" Journal Clinical Periodontology 2019.

Healing with chlorhexidine

Healing is the repair of a wound with fibrous tissue through a complex biological process resulting from cell division and protein synthesis, which generates a non-functional tissue end product called a scar.

The healing cascade is divided into:

  1. Coagulation
  2. Inflammation
  3. Proliferation: re-epithelialisation occurs from the wound edges.
  4. Maturation

Specifically, the inflammatory phase occurs on the third or fourth day. It includes haemostasis of the bleeding by the arrival of platelets and the formation of the fibrin thrombus at the wound bed. The fibrinogen protein can be seen as a whitish layer inside the wound, which helps to stop bleeding and heal for subsequent proliferation where tissue begins to generate with the neoformation of vessels in the wound bed. At this point, the scar tissues become bright red in appearance due to the connective tissue that is being created.

Healing in implant placement

In the following case of implant placement (fig.1), the healing around the healing abutments that prevent primary tissue closure can be observed. With this healing by secondary intention, it can be seen how 7 days after surgery, at the suture removal visit, there is still fibrin between the edges of both flaps. Slightly delayed inflammatory phase as a result of the separation between the edges of the wound.

Healing in implant placement

  • Fig 1. A. Postoperative period after placement of two implants without primary soft tissue closure.
  • Fig 1. B. 7-day postoperative period with suture removal and closure by secondary intention.

Chlorhexidine is an antiseptic substance with bactericidal and fungicidal action. Its function is to inhibit bacterial growth. In dentistry it is widely used to reduce inflammation, reduce plaque accumulation and prevent postoperative infection.

Hyaluronic acid (HA) is a naturally occurring non-sulphated glycosaminoglycan with a high molecular weight of 4000-20,000,000 daltons that may play a regulatory role in the inflammatory response: high molecular weight HA synthesised by hyaluronan synthase enzymes in periodontal tissues, gingiva, periodontal ligament and alveolar bone undergoes extensive degradation to lower molecular weight molecules in chronically inflamed tissue, such as gingival tissue inflammation or postoperative implant surgery.

In addition, HA supports structural and homeostatic integrity of tissues by regulating osmotic pressure and tissue lubrication and promotes symptom remission, not only in the marginal gingiva, but also in deeper periodontal tissues, through mechanisms known to be established for hyaluronan in wound healing1 .

Hyaluronan is a non-sulphated glycosaminoglycan found in the extracellular matrix of all vertebrate tissues, which plays a multifunctional role in wound healing without scarring, while also playing a key role in the physiology of the oral cavity and in the field of dentistry1.

Notably, HA is one of the most hygroscopic molecules known in nature and also exhibits significant viscoelastic properties that reduce the penetration of viruses and bacteria into tissue. The molecule is also a key component in the series of steps associated with the wound healing process in both mineralised and non-mineralised tissues1.

PERIOKIN HYALURONIC 1% ORAL GEL

  • Fig 2. PerioKIN Hyaluronic 1% gel. Composition: Chlorhexidine digluconate: 0.20 % + Hyaluronic acid: 1%.

Studies on hyaluronic acid treatment

Published studies such as those by Jentsch et al.2, Pistorius et al.3, and Sahayata et al. demonstrated that topical treatment with 0.2% HA twice daily for a period of 3 weeks had a beneficial effect on patients affected by gingivitis, improving plaque indices, bleeding rate, probing depth and gingival crevicular fluid compared to patients treated with normal oral hygiene procedures. The same beneficial effects were found when chronic periodontitis was treated with ultrasonic mechanical instrumentation and HA as a coadjuvant for which a positive effect on PPD reduction and prevention of recolonisation by periodontal pathogens was determined.

In particular, Nolan and colleagues demonstrated that topical application of 0.2% HA gel twice daily for 2 weeks appears to be an effective and safe therapy in patients with recurrent aphthous ulcers.

Lee et al. described that HA has also been used in conjunction with open flap debridement (OFD) for the treatment of sub-bony defects, offering additional benefit in terms of CAL gain, PPD reduction and predictability compared to patients with chronic periodontitis who underwent OFD treatment alone.

The following case is similar to the previous one in terms of implant placement, but in this one, at the end of the surgery, PerioKIN Hyaluronic 1% gel was placed and the patient was prescribed to apply it twice a day for 7 days. The photographs show the difference in the progress of healing compared to the other case. Fig 3 C and D. also show the seventh day after surgery, when the suture is removed. Both patients are of similar age and neither had risk factors. However, it can be seen, as in figure 3 C and D, that on day 7 healing is much more advanced than in Fig 1B. The cellular proliferation phase can be seen with that characteristic intense red between tissues but visibly already epithelialised.

Studies on healing

  • Fig 3. A. Postoperative period after placement of two implants without primary soft tissue closure.
  • Fig 3. B. Postoperative period after placement of two implants without primary soft tissue closure with the application of PerioKin Hyaluronic 1% gel over the incision and healing caps.
  • Fig 3. C. 7 days postoperative and closure by secondary intention with tissue epithelialisation.
  • Fig 3. D. 7 days postoperative with suture removal and closure by secondary intention with tissue epithelialisation.

Case of treatment with PerioKIN Hyaluronic gel 1%.

Another similar case would be with respect to such delicate treatments as mucogingival treatments. These are very sensitive processes in which early vascularization of the tissues is essential to avoid tissue necrosis. With the placement of PerioKIN Hyaluronic 1% gel in gingival grafts, an early vascularization of the tissues is key to avoid necrosis. advanced healing This is a time-consuming procedure that offers many advantages and a greater probability of success in this type of treatment.

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This is the case of Fig 4 in which a free gingiva graft is performed in the fifth sextant in order to gain keratinized gingiva. After only 7 days, the patient came to the clinic for a control and removal of the suture of the palate. vascularization in the graft from the recipient bed, as well as a virtually invisible junction between the edges of the incisions and the margins of the grafted tissue.

Gum healing

  • Fig 4. Postoperative photograph after 7 days of healing of a free gingival graft in 4.2-3.1.

Thanks to the high viscosity and molecular weight of the 1% hyaluronic acid in PerioKIN Hyaluronic 1% gel, it is easy to apply (Video1) and, above all, it bonds to the tissue over time thanks to the adhesion it creates. According to professionals, the recommendation is to slightly dry the saliva before applying the gel and thanks to its texture, adhesion is produced in all the area that is impregnated. Patients can apply the gel with the tip provided in the gel tube and it is recommended to apply it twice a day for at least 7 days.

 

  • Video 1: Placement of PerioKin Hyaluronic 1% gel on a 7-day-old graft after suture removal. It is placed on the graft with a swab and adheres firmly to the gingiva thanks to its thickness due to its high molecular weight.

It can be concluded from these differences in the same treatments (fig. 1 and 3), and from cases such as the one in figure 4, that PerioKIN Hyaluronic 1% gel has shown how the antiseptic action of chlorhexidine together with the healing properties of hyaluronic acid reduces scarring over time.

 

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