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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 12  |  Issue : 2  |  Page : 58-64

Comparing the effectiveness of boric acid and chlorhexidine irrigation as an adjunct to mechanical periodontal therapy in chronic periodontitis patients – A randomized clinical trial


Department of Public Health Dentistry, VS Dental College and Hospital, Bengaluru, Karnataka, India

Date of Submission22-Jan-2022
Date of Decision29-Jun-2022
Date of Acceptance25-Aug-2022
Date of Web Publication19-Dec-2022

Correspondence Address:
Dr. Preetika Parmar
VS Dental College and Hospital, Bengaluru - 560 004, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohs.ijohs_3_22

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  Abstract 


Introduction: Oral health is a part of the overall health and has a significant impact on both the physical and the psychological state. Dental caries and periodontal disease are the two major oral diseases that affect the human population worldwide.
Aim: The aim of the study is to compare the effectiveness of boric acid and chlorhexidine (CHX) irrigation as an adjunct to scaling and root planing in chronic periodontitis patients visiting VS Dental College and Hospital, Bengaluru.
Materials and Methodology: A total of 123 subjects were randomly allocated to three groups (group 1 - boric acid, group 2 - CHX, group 3 - distilled water as a control group). The study subjects were assessed for all the clinical parameters at baseline and 1 and 3 months after the intervention. ANOVA test was used to compare the results between the groups.
Results: The mean age among group 1 was 50 ± 5.1 years, in group 2 was 49 ± 5.4 years, and in group 3 was 48 ± 7.1 years. There was a significant reduction in plaque scores, gingival scores, and bleeding on probing scores in the boric acid group compared to distilled water group and CHX group at 1 and 3 months after treatment. Probing depths (PDs) and clinical attachment level scores are significantly decreased from baseline level to 1 and 3 months after intervention in the boric acid group compared to the CHX group and distilled water group.
Conclusion: Boric acid or CHX can be used effectively in periodontal pockets as an adjunct to nonsurgical periodontal treatment compared with conventional treatment.

Keywords: Boric acid, chlorhexidine, periodontal disease, scaling and root planing


How to cite this article:
Parmar P, Radha G, Rekha R. Comparing the effectiveness of boric acid and chlorhexidine irrigation as an adjunct to mechanical periodontal therapy in chronic periodontitis patients – A randomized clinical trial. Int J Oral Health Sci 2022;12:58-64

How to cite this URL:
Parmar P, Radha G, Rekha R. Comparing the effectiveness of boric acid and chlorhexidine irrigation as an adjunct to mechanical periodontal therapy in chronic periodontitis patients – A randomized clinical trial. Int J Oral Health Sci [serial online] 2022 [cited 2023 Feb 1];12:58-64. Available from: https://www.ijohsjournal.org/text.asp?2022/12/2/58/364226




  Introduction Top


Periodontal disease contributes significantly to global burden of oral disease. The prevalence in India reported was 57%, 67.7%, 89.6%, and 79.9% in the age groups of 12, 15, 35–44, and 65–74 years, respectively.[1] The disease further leads to gingival bleeding, periodontal pocket formation, connective tissue destruction, and alveolar bone resorption, ultimately causing tooth loss, which is one of the major reasons for tooth loss in adults.[2]

It is currently accepted that in association with adequate oral hygiene instructions, removal of supragingival and subgingival plaque and calculus by scaling and root planing (SRP) reduces the amount of subgingival bacteria; however, the nonsurgical mechanical treatment of root surfaces does not necessarily eliminate all of the pathogens harbored in the subgingival environment.[3]

This is particularly true for deep periodontal pockets that significantly hamper the effectiveness of nonsurgical procedures. It was reported that in pockets with PDs >4 mm, up to 66% of the instrumented root surfaces retained plaque and calculus. It was shown that Porphyromonas gingivalis (Pg), Treponema denticola (Td), and Tannerella forsythia (Tf) are the most important species present in greater number in subgingival plaque from patients with periodontitis compared with healthy individuals. This suggests that these three bacteria, which form the “red complex,” play an important role in the pathogenesis of periodontal disease.[4]

Therefore, the procedures for eliminating periodontal pathogens are of great interest, on stopping the destruction of periodontal support. This is routinely performed in the dentist's office by mechanical SRP, where subgingival calculus is removed together with the majority of bacteria. Variation in the ability of a dentist to gain access in deep and tortuous pockets and bacterial invasion into gingival and dental tissues often results in substantial variation of the effectiveness of SRP.[5]

For this reason, antibiotics and antiseptic drugs were introduced and administered systemically and locally to treat moderate-to-severe periodontitis. However, this treatment modalities should be restricted to patients, who respond poorly to mechanical treatment, and thus, the dose can be minimized reducing the systemic absorption and lessening the risk of adverse side effects which also improve patient's compliance.[6]

As an antiseptic, chlorhexidine (CHX) is effective against a broad spectrum of antibacterial activity and shows substantivity, safety, and a lack of toxicity. It has also been used effectively in the treatment of periodontal disease over the last four decades. However, subgingival irrigation using CHX solutions was not effective in the treatment of periodontitis because of the lack of effective concentrations and unique anatomy of periodontal pocket.[7]

Boron (B) is the chemical element with the atomic number 5. It is found in abundance in the environment as boric acid and borate. It is also present in fruits, vegetables, and legumes. Intake of boron in physiological amounts is known to influence numerous metabolic parameters. It plays a vital role in osteogenesis and the maintenance of bones.[8] Ince et al. suggested that boron supplementation in diets increases the glutathione level in blood. They also speculated that boron supplementation in diets decreases lipid peroxidation and enhances the antioxidant defense mechanism and vitamin levels.[9]

Boron has an effect in the antibacterial activity, inflammatory activity, and immune responses. Furthermore, it has been noted that boron exhibits in vitro activity against some of the bacteria associated with periodontal disease, such as Prevotella intermedia (Pi), Pg, Eubacterium (En), and Td. Hence, in light of this information, it can be assumed that boron might play a role in the limitation of periodontal inflammation.[10]

Considering the limited evidence in the literature, the aim of the study was to compare the effectiveness of boric acid and CHX irrigation as an adjunct to mechanical periodontal therapy in chronic periodontitis patients visiting VS Dental College and Hospital, Bengaluru, at baseline, 1 month, and 3 months.


  Materials and Methodology Top


Data were collected from the patients visiting Department of Oral Medicine and Radiology of VS Dental College and Hospital, Bengaluru. Ethical clearance was obtained by the institutional review board of VS Dental College and Hospital. All study subjects were explained about the purpose and nature of the study design. The study was conducted during August 2016–March 2017. A purposive sampling was used to select the study subjects, and a total of 123 study sample was estimated.

Inclusion criteria

  1. Aged 30 years or more
  2. Minimum of 20 teeth should be present
  3. Should have 8 or more sites with PD more than 4 mm.


Exclusion criteria

  1. Periodontal treatment within the past 12 months
  2. Systemic disease that can influence periodontal therapy
  3. Use of any antibiotic or anti-inflammatory drugs in the past 6 months
  4. Pregnancy or use of hormone contraceptives
  5. Smoking.


Study tool

  1. Questionnaire was given to collect demographic details and oral health behaviors
  2. Clinical examination was carried by using following parameters


    1. Gingival index (GI) by Loe and Silness
    2. Plaque index (PI) by Silness and Loe
    3. Community periodontal index (CPI) by the
    4. WHO
    5. Bleeding on probing (BOP) by Ainamo and Bay.


Preparation of boric acid solution

0.75% concentration of boric acid (4.5 pH) is used in this study as this concentration of boric acid is nontoxic to human gingival fibroblasts and human periodontal ligament fibroblasts.[11]

Procedure

Dissolve 0.02 g of boric acid in 30 ml of distilled water to prepare 0.75% concentration of boric acid.

Training and calibration of examiner were done in the Department of Public Health Dentistry. Before start of the study, intraexaminer reliability was assessed using kappa statistics for the clinical measures of GI, PI, BOP, and CPI.[12],[13],[14],[15] It was done to ensure uniform interpretation and application. The intraexaminer reproducibility was tested by repeating the examination on patients after a time interval of at least 30 min. The intraexaminer reproducibility was 0.87, 0.85, 0.93, and 0.86, which is perfect agreement. The training of the examiner for the SRP was done in the Department of Periodontics, VS Dental College and Hospital, Bengaluru.

The results were analyzed using SPSS, version 19 (SPSS Inc. Chicago, IL, USA) in frequencies and percentages described as basic information. Continuous variables were expressed as mean ± standard deviations using ANOVA test and intention-to-treat analysis. Categorical variables were expressed in percentage and underwent a Chi-square test. The level of statistical significance was defined as P < 0.05.

Flowchart showing methodology of the study



(baseline: Supragingival scaling and oral hygiene instruction given for all three groups)


  Results Top


A total of 123 subjects were randomly allocated to three groups (group 1 - boric acid, group 2 - CHX, and group 3 - distilled water). The study subjects were assessed for PI, GI, BOP, PD, and clinical attachment level (CAL), at baseline and [Figure 1] 1 [Figure 2] and 3 months [Figure 3] after the intervention. The data of all 123 subjects were included in the final analysis [Table 1],[Table 2],[Table 3].
Figure 1: Comparison of mean PI, GI, BOP, PD, and CAL scores at baseline among the three groups, PI: Plaque index, GI: Gingival index, BOP: Bleeding on probing, PD: Probing depths, CAL: Clinical attachment level

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Figure 2: Comparison of mean PI, GI, BOP, PD, and CAL scores at 1 month among the three groups, PI: Plaque index, GI: Gingival index, BOP: Bleeding on probing, PD: Probing depth, CAL: Clinical attachment level

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Figure 3: Comparison of mean PI, GI, BOP, PD, and CAL scores at 3 months among the three groups, PI: Plaque index, GI: Gingival index, BOP: Bleeding on probing, PD: Probing depth, CAL: Clinical attachment level

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Table 1: Distribution of study subjects according to demographic characters, oral hygiene practices, and oral health behavior

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Table 2: Mean difference comparison of plaque scores, gingival scores at baseline and 1 and 3 months among groups

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Table 3: Mean difference comparison of bleeding on probing scores, pocket depth scores, clinical attachment loss scores at baseline and 1 and 3 months among groups

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Of 123 subjects, there were 22 (31.9%), 23 (33.3%), and 24 (34.8%) females in group 1, 2, and 3 respectively, while 19 (35.2) males in group 1, 18 (33.3) males in group 2, and 17 (31.5%) males in group 3. The results were not statistically significant (P > 0.05). The mean age among group 1 was 50 ± 5.1 years, in group 2 was 49 ± 5.4 years, and in group 3 was 48 ± 7.1 years, and the results were not statistically significant (P > 0.05).


  Discussion Top


The mean age among group 1 was 50 ± 5.1 years, in group 2 49 ± 5.4 years, and in group 3 was 48 ± 7.1 years.

In the present study, it was reported that there was a significant reduction in plaque scores, gingival scores, and BOP scores in the boric acid group compared to distilled water group and CHX group at 1 month after treatment, which was in accordance with Saglam et al. These results were similar to other researches, conducted by Vignarajah et al.,[16] Walsh et al.,[17] and Soh et al.,[18] who reported superior results for CHX in PI, GI, and BOP. Contrary to the findings of our study, some investigators such as Braatz et al.[19] and Watts et al.[20] reported that adjunctive irrigation with CHX did not provide any additional clinical benefits compared with conventional treatment.

In this study, it was reported that there was a significant reduction in plaque scores, gingival scores, and BOP scores in the boric acid group compared to distilled water group and CHX group at 3 months after treatment, the reason of these findings can be the effect of boric acid irritation along with the SRP during the initial healing period in the periodontal tissues, and these findings were in accordance with Saglam et al.

The study found no significant reduction in the scores for PI, GI, BOP, PD, and CAL from baseline to 1 month among the groups, and there was no significant reduction in the scores for PI, GI, BOP, PD, and CAL from 1 to 3 months among the groups which was in contrast with the study by Saglam et al. The study found significantly greater reduction in the scores for PI, GI, BOP, PD, and CAL from baseline to 3 months for boric acid group compared to CHX and distilled water group, which was in accordance with the study by Saglam et al. The results obtained in this randomized controlled trial showed that the adjunctive subgingival administration of boric acid significantly improved the positive therapeutic effects of extensive SRP on chronic periodontitis and it supported by clinical parameters.

It was found that the cost of boric acid powder was much lesser than the cost of commercially available CHX solution, so it can be used as an adjunct to the mechanical therapy in the treatment of periodontal diseases. The only drawback with the use of boric acid was it has to prepare fresh every time for each patient. In this study, the follow-up period of 3 months was short which is one of the limitations because the periodontal fibers may not show improvement after the elimination of infection for around a period of 6 months. The investigator was not blinded, only the study subjects were blinded, and a nonblinded study can have some observation bias. The subjects who were visiting the dental hospital were selected for the study which may affect the generalizability. Future studies, in general population, would be required and with long-term follow-up periods.


  Conclusion Top


The present study showed that the use of boric acid or CHX as an irrigation along with SRP was beneficial in the treatment of periodontal disease compared to the conventional therapy. Hence, it can be concluded that boric acid irrigation is safe and cost-effective, and it can be used as an adjunct to SRP in the treatment of patients with chronic periodontitis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Haffajee AD, Socransky SS. Microbial etiological agents of destructive periodontal diseases. Periodontol 2000 1994;5:78-111.  Back to cited text no. 1
    
2.
Jenkins WM, MacFarlane TW, Gilmour WH. Longitudinal study of untreated periodontitis. I. Clinical findings. J Clin Periodontol 1988;15:324-30.  Back to cited text no. 2
    
3.
Cobb CM. Clinical significance of non-surgical periodontal therapy: An evidence-based perspective of scaling and root planing. J Clin Periodontol 2002;29 Suppl 2:6-16.  Back to cited text no. 3
    
4.
Slots J. Subgingival microflora and periodontal disease. J Clin Periodontol 1979;6:351-82.  Back to cited text no. 4
    
5.
Drisko CH. Nonsurgical periodontal therapy. Periodontol 2000 2001;25:77-88.  Back to cited text no. 5
    
6.
Quirynen M, Teughels W, De Soete M, van Steenberghe D. Topical antiseptics and antibiotics in the initial therapy of chronic adult periodontitis: Microbiological aspects. Periodontol 2000 2002;28:72-90.  Back to cited text no. 6
    
7.
Mariotti AJ, Rumpf DA. Chlorhexidine-induced changes to human gingival fibroblast collagen and non-collagen protein production. J Periodontol 1999;70:1443-8.  Back to cited text no. 7
    
8.
Nielsen FH. Is boron nutritionally relevant? Nutr Rev 2008;66:183-91.  Back to cited text no. 8
    
9.
Ince S, Kucukkurt I, Cigerci IH, Fatih Fidan A, Eryavuz A. The effects of dietary boric acid and borax supplementation on lipid peroxidation, antioxidant activity, and DNA damage in rats. J Trace Elem Med Biol 2010;24:161-4.  Back to cited text no. 9
    
10.
Luan Q, Desta T, Chehab L, Sanders VJ, Plattner J, Graves DT. Inhibition of experimental periodontitis by a topical boron-based antimicrobial. J Dent Res 2008;87:148-52.  Back to cited text no. 10
    
11.
Saglam M, Arslan U, Bozkurt SB, Hakki SS. Boric acid irrigation as an adjunct to mechanical periodontal therapy in patients with chronic periodontitis: A randomized clinical trial. J Periodontol 2013;84:1297-308.  Back to cited text no. 11
    
12.
Loe H, Silness J. Periodontal disease in pregnancy. I. Prevalence and severity. Acta Odontol Scand 1963;21:533-51.  Back to cited text no. 12
    
13.
Silness J, Loe H. Periodontal disease in pregnancy. II. Correlation between oral hygiene and periodontal condition. Acta Odontol Scand 1964;22:121-35.  Back to cited text no. 13
    
14.
World Health Organization. Oral Health Surveys: Basic Methods. Geneva Switzerland: World Health Organization; 2013.  Back to cited text no. 14
    
15.
Ainamo J, Bay I. Problems and proposals for recording gingivitis and plaque. Int Dent J 1975;25:229-35.  Back to cited text no. 15
    
16.
Vignarajah S, Newman HN, Bulman J. Pulsated jet subgingival irrigation with 0.1% chlorhexidine, simplified oral hygiene and chronic periodontitis. J Clin Periodontol 1989;16:365-70.  Back to cited text no. 16
    
17.
Walsh TF, Glenwright HD, Hull PS. Clinical effects of pulsed oral irrigation with 0.2% chlorhexidine digluconate in patients with adult periodontitis. J Clin Periodontol 1992;19:245-8.  Back to cited text no. 17
    
18.
Soh LL, Newman HN, Strahan JD. Effects of subgingival chlorhexidine irrigation of periodontal inflammation. J Clin Periodontol 1982;9:66-74.  Back to cited text no. 18
    
19.
Braatz L, Garrett S, Claffey N, Egelberg J. Antimicrobial irrigation of deep pockets to supplement non-surgical periodontal therapy. II. Daily irrigation. J Clin Periodontol 1985;12:630-8.  Back to cited text no. 19
    
20.
Watts EA, Newman HN. Clinical effects on chronic periodontitis of a simplified system of oral hygiene including subgingival pulsated jet irrigation with chlorhexidine. J Clin Periodontol 1986;13:666-70.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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