kyrrolos hanna - single ebp case study
TRANSCRIPT
Kyrrolos Hanna, Latrobe university of Bendigo, 2015
Evidence Based Practice
Contents
Abstract………………………………………………………………………………………………3
Introduction………………………………………………………………………………………4-6
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31st/05th/2015
Kyrrolos Hanna, Latrobe university of Bendigo, 2015
Materials and methods……………………………………………………………………………6-7
Results………………………………………………………………………………………….8-10
Discussion…………………………………………………………………………………….11-12
Conclusion…………………………………………………………………………………….12
References…………………………………………………………………………………….12-13
Appendix………………………………………………………………………………………13-18
The effectiveness of Chlorhexidine in combination with
Hydrogen peroxide in treating Necrotizing Ulcerative
Gingivitis: a case study
Abstract
Aims: This before and after study aimed to assess and compare the relative clinical success of Chlorhexidine in
combination with hydrogen peroxide in effectively treating the signs and symptoms of Necrotizing ulcerative
gingivitis at 9 day intervals over a one month period.
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Kyrrolos Hanna, Latrobe university of Bendigo, 2015
Methods: a Patient presenting with Necrotizing Ulcerative Gingivitis (n=1) was subject to an antimicrobial
regime consisting of 10ml of chlorhexidine gluconate (2%) and 10ml of hydrogen peroxide (1.5%), twice daily, in
9 day cycles, over the length of 1 month. This was evaluated by comparing intra oral photographs and pain
scales taken at the first and last visit. Frequency was assessed with the use of a chart and compliance was
evaluated by comparing this chart with standardized measurements of weight. Pertinent literature was reviewed
to select articles according to previously defined inclusion criteria.
Results: chlorhexidine gluconate (2%) and hydrogen peroxide (1.5%) significantly reduced the clinical
characteristics of Necrotizing Ulcerative Gingivitis in the patient with regards to inflammation and associated
pain.
Conclusion: although the outcome of this study showed a positive reduction in the severity of the signs and
symptoms of Necrotizing Ulcerative Gingivitis, the clinical significance of chlorhexidine and hydrogen peroxide
is inconclusive. However it may have implications in the management of such periodontal conditions.
Academic databases: Expanded Academic ASAP, EBSCO - Dentistry & Oral Sciences Source, Whiley online
library, Science direct, Cochrane library, Elsevier Journals and PubMed
Key words: Necrotizing Ulcerative Gingivitis, chlorhexidine, hydrogen peroxide, treatment, signs, symptoms,
pain, mechanisms, effects, etc.
Abbreviations: NUG (Necrotizing Ulcerative Gingivitis), CHX (chlorhexidine), H2O2 (hydrogen Peroxide).
Periodontal disease is a term used to describe
inflammation of the periodontal tissues and can
present in many forms (1). Studies show that it is
mostly caused by the accumulation of bacterial
plaque and poor oral hygiene where other factors
such as environmental, genetic and systemic
factors can contribute to periodontal disease
pathogenesis (2-4).
Necrotizing Ulcerative Gingivitis
The 5th classification of periodontal disease is NUG
which is different from other periodontal diseases in
that it presents with necrosis of the gingival tissues
(2, 5). This is a rare disease and has been shown
that its prevalence is higher in patients with poor
oral hygiene (2, 3, 5, 6). The cause of NUG is
similar to other periodontal diseases in that it is
mainly cause by bacterial plaque, although
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Kyrrolos Hanna, Latrobe university of Bendigo, 2015
additional dynamics can contribute to its
pathogenesis such as stress, socioeconomic status,
smoking, and an altered host resistance (1, 2, 5).
Recent studies have found that there are specific
bacteria involved in NUG including fusiform
bacteria, Prevotella intermedia, and spirochetes (1,
5, 6).
The clinical signs of NUG can be generalized or
localized with rapid or sudden onset but is more
common in the anterior region of the mouth (2, 5). It
is characterized by a crater-like or “punched out”
interdental papilla, gingival bleeding and intense
pain where features including a fetid breath and a
grayish pseudomembranous film covering an
ulcerated papilla are common clinical appearances
(2, 5, 6). This condition can be accompanied by
secondary conditions such as lymphadenopathy,
fever and malaise which reflects a systemic aspect
to the incidence of NUG (2, 5). It is important to
note that severity can vary from case to case and
diagnosis of NUG should be based on specific
clinical examinations and investigations (see
Appendix 1 table 6) (2, 5). There can also be
differential diagnosis of NUG (see Appendix 2
table 7) (2, 5). The current literature states that the
reduction of oral bacteria, pain management and
providing the patient with specific oral hygiene
instructions are essential in achieving optimum
treatment outcomes (1, 2, 5). Professional removal
of calculus produces a rapid response and is aimed
primarily at reducing etiological factors to reduce or
eliminate inflammation, thereby promoting
periodontal healing (1, 2, 5).
It has been well established that mechanical plaque
removal in adjunction with antimicrobial mouthwash
is effective in inhibiting or reducing supra gingival
plaque formation, especially when mechanical oral
hygiene is difficult or impossible (1, 3, 7-10).
As suggested in the literature, chemotherapeutic
agents can be utilized in not only achieving and
maintaining optimum periodontal health but in
treating NUG(2). This consists of the bactericidal
and bacteriostatic properties of CHX and the
oxygenating effects of H2O2 (3, 9).
Chlorhexidine Gluconate
CHX is classified as a cationic antiseptic and is
found in mouthwash, gels, sprays, varnish and
toothpastes (3, 4, 11-13). This product has a wide
antimicrobial spectrum which effects gram positive
and negative bacteria, resulting in inhibition of
plaque formation (7, 9, 11, 14). It also comes in
varying concentrations where levels of 0.12% and
0.2% have been effective in significantly reducing
plaque and resolving gingivitis (3, 7-11, 14-16). The
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Table 1 Treatment of NUG (1, 2, 5, 6)
Control painPrescribe antibiotics if patient is immunocompromisedAmoxicillin, 250 mg 3 x daily for 7 days and/or Metronidazole, 250 mg 3 x daily for 7 daysPerform debridement
Local anesthesia Use of the ultrasonic for irrigation properties
Provide patient with specific oral hygiene instructionsMeticulous plaque controlAntibacterial mouthwash: chlorhexidine 0.12% in combination with hydrogen peroxide 1.5% twice dailySmoking cessationPatient counsellingFollow up with a comprehensive periodontal evaluation
Kyrrolos Hanna, Latrobe university of Bendigo, 2015
recommended dosage of CHX is 10 ml of a 0.2%
solution, twice daily and has been shown to reduce
plaque by approximately 60% and reduce the
severity of gingivitis by 50–80% (3, 5, 7, 9, 10, 12,
14).
CHX acts on the bacterial cell wall by changing the
osmotic equilibrium in the cells membrane (9, 11).
This inevitably leads to cell lysis by precipitation of
bacterial contents (9, 11). The advantages of CHX
are essentially in its substantive abundance in the
mouth due to its binding effect on the hard and soft
tissues, allowing it to accumulate over a long period
after application (3, 9, 11, 14, 17). Studies show
that its effectiveness has been proven many times
over and this is why CHX is widely known as the
gold standard in plaque control (3, 4, 9, 11, 13, 14,
17). Disadvantages to the use of CHX is not only in
its bitter and unpleasant taste, but that repeated use
often produces stains and taste disturbances (4, 9-
11, 13, 16). It is also for this reason that the use of
CHX should be limited to no more than 2 weeks at a
time to reduce the accompanying side effects (9,
10, 13).
Hydrogen Peroxide
H2O2 is classified as an oxygenating, being known
for its use in the management of NUG (2, 4, 9-11).
Studies have demonstrated the efficacy of 1.5%
H2O2 in reducing plaque in the way that it
introduces oxygen to an anaerobic environment and
consequently disrupts the function of anaerobic
bacteria such as those found in the case of NUG (4,
9, 10). In addition, several studies have indicate that
the use of H2O2 can be helpful in controlling dental
stains associated with the use of CHX (4, 10, 11).
This occurs due to oxidation and reduction
reactions incorporated in the mechanisms of H2O2
which release by products that break the alkene
double bonds responsible for tooth discoloration(4).
This essential reduces plaque scores and prevents
stains, thus facilitating the effects of CHX and
assisting in the treatment of NUG(4).
Furthermore, a combination of CHX and H2O2, as
an adjunct to routine mechanical tooth cleansing
can be perceived as a rational implementation in
reducing the clinical signs and symptoms of
necrotizing periodontal diseases(9). This
combination enhances the efficacy of CHX in
reducing plaque formation and therefore
compliments the treatment of NUG(9).
Materials and method
Case description
A 19 year old female studying beauty therapy at
Bendigo TAFE presents to the student clinic for
routine examination. The patient reports that she
smokes 10 cigarettes a day and is concerned about
swollen and bleeding gums with accompanied pain.
Clinical examination shows generalized severe
inflammation of the gingiva, punched out papilla and
a greyish film along the cervical margins which is
descriptive of Type 5 A Necrotizing Ulcerative
Gingivitis.
Intervention
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Kyrrolos Hanna, Latrobe university of Bendigo, 2015
The patient was given instructions to rinse with a
capful (10ml) of Colgate Savacol (alcohol free) for 2
minutes, 30 minutes after brushing and half a capful
(10ml) of Colgate Peroxyl for 1 minute after
Savacol. The patient was also instructed to limit
their use to twice a day for 9 day cycles due to
availability of appointment scheduling and evidence
based recommendations. Intra-oral photographs
were taken of the frontal view of the anterior teeth
for baseline characteristics and stored onto Digora
imaging software. A pain scale was provided to the
patient to illustrate sensitivity and intensity of
associated pain. The patient was requested to
supply a chart entailing the frequency of use for the
9 day intervals which was tallied upon final
evaluation.
Assessment
The effectiveness of the use of CHX and H2O2 was
evaluated by assessing visual characteristics and
recording pain expressed by the patient in the form
of a second pain scale. Intra oral photographs were
taken for a second time and compared with the
initial intra oral photographs. Observation of
characteristics such as inflammation, punched out
papilla and greyish film along the cervical margin
were key criteria in the comparison of the before
and after photos.
Fig 1 Colgate Savacol, alcohol free and Colgate Peroxyl utilized in the combination of Chlorhexidine and Hydrogen peroxide
Patient compliance
Validity of the patient’s compliance to this regime
was tested by gaining set values of weight and
using simple conversions to solve the rate of
frequency. The standardized weights for both
Savacol and Peroxyl that needed to be solved
included the original weight of the bottle (where vs is
360g and vp is 295g), the weight of the bottle alone
(where bs is 38g and bp is 36g), the weight of the
cap alone (where cs is 11g and cp is 6g) and the
weight of 10ml of solution (where ws is 11g and wp
is 11g).
Note: Lower case scripts illustrate the bottle in
question, (i.e.) ‘s’ for Savacol and ‘p’ for Peroxyl.
The bottles were then weighed at the 9th and 27th
day in the regime and deducted from the original
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Kyrrolos Hanna, Latrobe university of Bendigo, 2015
standard weights to establish how much solution
was actually removed from the bottle. The
difference was then divided by the suggested
volumes of 10ml to figure out how many times this
specific dosage was taken. The results were then
cross referenced with the chart provided by the
patient in order to investigate credibility of the chart
(see table 5).
The following formulations were developed in order
to calculate the exact amount of Savacol and
Peroxyl used during the 1st and 2nd cycles.
f s=(vs−bs−cs )−(xs−bs−cs)
w s
f p=(v p−bp−c p )−(x p−bp−c p)
wp
f❑=number of×used
v❑=origionalweight of bottle
x❑=current weight of bottle
c❑=weight of cap alone
b=weight of bottle alone
w=weight of 10mlof solution
Results
The results showed a significant
reduction in the clinical
characteristics of NUG. The
contrast between the Intra oral
photographs taken at the first visit
compared to the one taken at the
last visit showed a noteworthy
improvement with regards to the
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Table 2 Clinical comparison of intra oral photographs before and after implementation of
CHX H2O2
Before After
Fig 2 Intra oral photograph depicting
the frontal view of the Anterior teeth
taken at the first visit
Fig 3 Intra oral photograph depicting the
frontal view of the anterior teeth, taken at
the final visit
Clinical characteristics
Inflamed gingivae Reduction in inflammation
Red gingivae Pink gingivae
Cratered papilla Firm papilla
Grayish film Absence of grayish film
Kyrrolos Hanna, Latrobe university of Bendigo, 2015
inflammation of the gingivae, color of the gingivae, physical appearance of the papilla and presence of a grayish
film along the cervical margin.
In addition, the associated pain expressed by the patient at the initial examination compared with the pain
expressed at the final visit was substantially reduced.
As suggested by the chart supplied, the patient reported that there was a steady intake of Savacol and Peroxyl
in the first cycle whereas there was two evening sessions that were not recorded in the second cycle.
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Table 3 Comparison of pain scale supplied at the initial examination to pain scale supplied at the final appointmentBefore After
Fig 4 Pain pre-scale reflecting the patients perception of the
associated pain as Intense, dreadful, horrible pain
Fig 5 Pain post-scale reflecting how the patient no longer feels the so
called associated pain
Statistical tests
According to table 6 the frequency
reported by the patient in their chart did
not correlate with the results of the
volumes measured in the first cycle but
was more accurate at the following
cycle. The readings obtained show that
by the 9th day reported usage was <
the exact usage and
that by the 27th day reported usage
was more or less the same.
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Fig 6Fig 7 Structural formulation of Chlorhexidine Gluconate
Table 4 A chart demonstrating the frequency of intake of CHX and H2O2 as reported by the patient
AM PMCycle 1 Savacol Peroxyl Savacol Peroxyl
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
Day 8
Day 9
Cycle 2
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
Day 8
Day 9
Table 5 Comparison of reported frequency to exact frequency and specific formulations / calculations conducted
Evaluation
Mouth wash
Reported frequency
Calculations Measured use
Exact frequency
Validity Amount of times missed
Cycle 1
9 days
Savacol 18
f s=(360−38−11 )−(x s−38−11)
11
xs=154 g f s=14The Reported amount of usage did not match the measured amount of usage
4
Peroxyl 18
f p=(295−36−6 )−(x p−36−6)
11
x p=110 g f p=10The reported amount of usage did not match the measured amount of usage
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Cycle 2
27 days
Savacol 16
f s=(360−38−11 )−(x s−38−11)
11
xs=176 g f s=16The reported amount of usage did match the measured amount of usage
None
Peroxyl 16
f p=(295−36−6 )−(x p−36−6)
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x p=165 g f p=15The reported amount of usage slightly varied from the measured amount of usage
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Kyrrolos Hanna, Latrobe university of Bendigo, 2015
Discussion
Qualitative data analysis was interpreted by
comparing the results observed with the use of the
pain scale and intraoral photographs. Validity and
reliability of the implementation of these products
was conducted through analysis of charts and
volumetric measurements. The results gathered
supported the evidence that the combination of
CHX and H2O2 is effective in treating NUG (2, 4, 5,
10, 14, 18, 19). It was clear that there had been
improvement in regards to visual signs associated
with NUG with regards to inflammation and redness
of the gingivae. Similarly the results showed a
distinctive reduction in the severity of pain
expressed by the patient and this in turn endorses
the current views of studies in this area (2).
Limitations
Upon further assessment of the patient’s medical
history it was revealed that the patient had
undertaken a course of antibiotic therapy
(Metronidazole) during the period of
implementation. This has been identified as an
extraneous variable that could have affected the
results of this intervention and essentially renders
the effect of the chemical aids as partially
inaccurate (1, 2, 5). Although the current literature
suggests that antibiotic therapy is recommended in
the case of systemic toxicity (1, 2, 5), this additional
variable could have taken part in the reduction of
the clinical signs and symptoms of NUG. Hence the
true success of these aids is questionable due to
the potential interference of the course of antibiotic
therapy.
With regards to credibility of the reported use, it was
observed that there was a noteworthy difference
between the first and second cycle. The statistical
tests in place were developed in order to ensure
patient compliance and ensure adherence to the
instructions provided. However this only had a
direct effect after the first test was conducted after
the first cycle. It can be established that this
assessment provided the patient with the directive
for stringent adherence to the regime and therefore
the results may not decipher if these chemical aids
were effective with regards to user-friendliness
aspects.
In light of the large discrepancy between the
reported usage and measured usage in the first
cycle, the results up to that point were not reflective
of one another and therefore a detailed picture of
intake cannot be made. With regards to the two
sessions missed in the second cycle, it could not be
established as to whether the times were forgotten
or that the patient simply did not record them for
those intervals.
In addition, the results of the measured use of
Peroxyl was 1 capful less than the reported use of
Peroxyl in the second cycle. In retrospect,
consideration of spillage must be taken into account
when equating these two measurements. However,
in view of the remarkable effect of this combination
this variable has been deemed insignificant in
tarnishing the validity of the recognized outcomes.
It is important to note that the use of the pain scale
may limit the ability to assess the true reduction in
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Kyrrolos Hanna, Latrobe university of Bendigo, 2015
pain intensity due to its subjective nature and so
marginal error is expected. This however was
slightly controlled by using the same operator and
surgery to produce a similar environment.
Another limitation is the fact that patient treatment
was undertaken during the implementation of these
aids. The variable of debridement in this given time
could have played a role in the reduction of the
signs and symptoms of NUG and therefore also
deems the results inaccurate.
Conclusion
The outcome of this study showed a positive
reduction in the severity of the signs and symptoms
of Necrotizing Ulcerative Gingivitis with the use of
chlorhexidine and hydrogen peroxide. However the
limitations of antibiotic therapy, spillage, periodontal
treatment and the subjective nature of the
expression of pain diminished conclusive evidence
for this intervention. Furthermore, a larger sample
size and an extended period of time would have
proved beneficial and produced a clear outcome on
the benefits of chlorhexidine and hydrogen peroxide
in the treatment of Necrotizing Ulcerative Gingivitis.
References1. Periodontology AAo. Treatment of Plaque-induced Gingivitis, Chronic Periodontitis, and Other Clinical Conditions. Pediatric Dentistry. 2010 10//2010 Reference Manual;32(6):290-9. PubMed PMID: 54737456.2. Alpagot T. Necrotizing Ulcerative Gingivitis and Periodontitis, and Chronic Periodontitis. People's Medical Publishing House USA Ltd (PMPH); 2003. p. 52-3.3. Cristian M, Luca R. UTILIZATION OF CHLORHEXIDINE IN PROPHILACTIC TECHNIQUES OF
PROFESSIONAL HYGIENIZATION. International Journal of Medical Dentistry. 2014 07//Jul-Sep2014;4(3):171-6. PubMed PMID: 99582769.4. Jhingta P, Bhardwaj A, Sharma D, Kumar N, Bhardwaj VK, Vaid S. Effect of hydrogen peroxide mouthwash as an adjunct to chlorhexidine on stains and plaque. Journal of Indian Society of Periodontology. 2013 07//Jul-Aug2013;17(4):449-53. PubMed PMID: 91265246.5. Atout RN, Todescan S. Managing Patients with Necrotizing Ulcerative Gingivitis. Journal of the Canadian Dental Association. 2013 03//;79(2):1-4. PubMed PMID: 88167399.6. Falkler WA, Jr, Martin SA, Vincent JW, Tall AA, Nauman RK, et al. A clinical, demographic and microbiologic study of ANUG patients in an urban dental school. Journal of Clinical Periodontology. 1987 07//;14(6):307-14. PubMed PMID: 13467446.7. Charles CH, Mostler KM, Bartels LL, Mankodi SM. Comparative antiplaque and antigingivitis effectiveness of a chlorhexidine and an essential oil mouthrinse: 6-month clinical trial. Journal of Clinical Periodontology. 2004;31(10):878-84.8. Garcia RI. Mouthrinses and Dentifrices are Effective Antigingivitis and Antiplaque Agents. Journal of Evidence Based Dental Practice. 2008 3//;8(1):13-4.9. Eley B. Antibacterial agents in the control of supragingival plaque -- a review. British Dental Journal. 1999 03/27/;186(6):286. PubMed PMID: 9354177.10. Gusberti FA, Sampathkumar P, Siegrist BE, Lang NP. Microbiological and clinical effects of chlorhexidine digluconate and hydrogen peroxide mouthrinses on developing plaque and gingivitis. Journal of Clinical Periodontology. 1988 01//;15(1):60-7. PubMed PMID: 13476974.11. Paraskevas S. Randomized controlled clinical trials on agents used for chemical plaque control. International Journal of Dental Hygiene. 2005;3(4):162-78.12. Ribeiro LGM, Hashizume LN, Maltz M. The effect of different formulations of chlorhexidine in reducing levels of mutans streptococci in the oral cavity: A systematic review of the literature. Journal of Dentistry. 2007 05//;35(5):359-70. PubMed PMID: 24711341.13. Wu CD, Savitt ED. Evaluation of the safety and efficacy of over-the-counter oral hygiene products for the reduction and control of plaque and gingivitis. Periodontology 2000. 2002;28(1):91-105.
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14. Van Strydonck DAC, Slot DE, Van der Velden U, Van der Weijden F. Effect of a chlorhexidine mouthrinse on plaque, gingival inflammation and staining in gingivitis patients: a systematic review. Journal of Clinical Periodontology. 2012;39(11):1042-55.15. Gunsolley JC. A meta-analysis of six-month studies of antiplaque and antigingivitis agents. (cover story). Journal of the American Dental Association (JADA). 2006 12//;137(12):1649-57. PubMed PMID: 23501375.16. chlorhexidine Csoad, mouth rinses on the level
of dental staining and gingival indices{Najafi N, Mohammad Hassan, Taheri M, Mokhtari MR, Forouzanfar A, Farazi F, et al. Comparative study of 0.2% and 0.12% digluconate chlorhexidine mouth rinses on the level of dental staining and gingival indices. Dental
Research Journal. 2012 05//;9(3):305-8. PubMed PMID: 92014451.17. Tomás I, Cousido MC, García-Caballero L, Rubido S, Limeres J, Diz P. Substantivity of a single chlorhexidine mouthwash on salivary flora: Influence of intrinsic and extrinsic factors. Journal of Dentistry. 2010 07//;38(7):541-6. PubMed PMID: 51153652.18. Miyasaki KT, Genco RJ, Wilson ME. Antimicrobial Properties of Hydrogen Peroxide and Sodium Bicarbonate Individually and in Combination Against Selected Oral, Gram-negative, Facultative Bacteria. Journal of Dental Research. 1986 09//;65(9):1142-8. PubMed PMID: 36543720.19. Gunsolley JC. Clinical efficacy of antimicrobial mouthrinses. Journal of Dentistry. 2010 06/02/Jun2010 Supplement 1;38:S6-S10. PubMed PMID: 52243869.
Appendix
The following tools were utilized within the implementation and investigation outlined in the case study.
This consisted of:
Foundation knowledge in the form of tables
Additional diagnostic evidence in the form of intra oral photographs
Patient instructions in the form of pamphlets, charts and scales.
By incorporating these reusable tools into the implementation process, a rationalized approach to
patient instructions and analysis of the outcomes of this case were established.
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Appendix 1 (table 6) Investigations in assessing NUG (2, 5)
Medical historyNutrition and health habitsConsultation with a general practitioner if immunosuppressive disease is suspectedDental historyPainExtraoral examinationLymphadenopathy of the head and neckIntraoral examinationClinical features of NUG
Appendix 2 (table 7) Differential diagnosis of NUG (1, 2, 5)
Primary Herpetic GingivostomatitisDesquamative GingivitisAgranulocytosisCyclic NeutropeniaLeukemiaAscorbic Acid DeficiencyGingivitisAphthos Stomatitis
Kyrrolos Hanna, Latrobe university of Bendigo, 2015
Fig 8 & 9 Colgate brochure implemented in the provision of CHX and H2O2
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Kyrrolos Hanna, Latrobe university of Bendigo, 2015
Fig 10 Ethical clearance at the time of the initial intra oral photography
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Kyrrolos Hanna, Latrobe university of Bendigo, 2015
Fig 11 Ethical clearance at the time of the final intra oral photography
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Kyrrolos Hanna, Latrobe university of Bendigo, 2015
Patient pain scale Please discribe the pain associated with your condition based on the scale provided below. This
description is to compare the symptoms of your condition before the impementation of a combination
of chemical aids.
Please discribe the pain associated with your condition based on the scale provided below. This
description is to compare the symptoms of your condition after the impementation of a combination of
chemical aids.
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Kyrrolos Hanna, Latrobe university of Bendigo, 2015
Patient Hygiene chartPlease fill out this chart every time the chemical aids Savacol and Peroxyl are used.
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AM PMCycle 1 Savacol Peroxyl Savacol Peroxyl
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
Day 8
Day 9
Cycle 2
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
Day 8
Day 9