Comparative Evaluation of the Efficacy of Triclosan-Coated and Chlorhexidine-Coated Suture on Bacterial Load Reduction in Periodontal Flap Surgery: A Clinicomicrobiological Study

Abstract

Background:

Sutures are essential for wound closure but may facilitate microbial colonization, increasing the risk of surgical site infections. Antibacterial-coated sutures, such as triclosan (TCS) and chlorhexidine (CCS), have been developed to mitigate this concern.

Materials and Methods:

A double-blind, randomized clinical trial was conducted on 20 patients undergoing periodontal flap surgery, comparing TCS and CCS. Healing was assessed on postoperative day 8 using Landry’s Healing Index; microbial burden was quantified through CFU enumeration and Gram staining.

Results:

Healing scores were comparable between groups (TCS: 4.1 ± 0.7; CCS: 3.9 ± 0.7; P = 0.63). However, CCS exhibited significantly lower CFU counts (0.011 × 10⁶ ± 0.031 × 10⁶) than TCS (4.3 × 10⁶ ± 4.8 × 10⁶) (P < 0.001). Gram staining revealed polymicrobial oral flora in both groups.

Conclusion:

Chlorhexidine-coated sutures exhibited superior antimicrobial efficacy without compromising early wound healing.

INTRODUCTION

The success of periodontal surgeries depends on achieving primary wound closure and minimizing bacterial presence at the healing site. Sutures utilized for flap margin approximation are typically retained for 5-7 days.[1] Nevertheless, sutures may serve as a nidus or scaffold of bacterial colonization, thereby increasing the risk of postoperative infections, including bone infections, abscesses, and sepsis at the surgical site.[2]

Prolonged microbial exposure significantly elevates likelihood of surgical site infections (SSIs) and tissue necrosis, among the most prevalent complications following surgical procedures.[1] The use of sutures coated with antibacterial agents, like chlorhexidine or triclosan, can inhibit harmful microorganisms. Triclosan is acknowledged as broad-spectrum antibacterial agent with established anti-inflammatory properties. Conversely, chlorhexidine exhibits bacteriostatic effects and demonstrates bactericidal activity at lower and higher concentrations respectively.[3]

Therefore, a few novel sutures have been developed to combat postoperative infections, including antibacterial, drug-eluting, stem cell-seeded, and smart sutures. Drug-eluting sutures can be a preferable alternative to conventional ones, as they prevent wound infections from spreading, leading to better wound healing.[4] Since then, usage has increased in various general along periodontal surgical procedures. However, concerns over triclosan, such as antibiotic cross-resistance and limited efficacy, raise questions about its broader applicability.[5] Against this backdrop, the present study aims to compare coated sutures in terms of their ability to reduce bacterial load and prevent surgical site infections, as assessed through colony-forming units (CFUs).

MATERIALS AND METHODS

A prospective, randomized, double-blind trial included 20 systemically healthy patients (25-60 years) with moderate to severe chronic periodontitis. Participants exhibited clinical attachment loss ≥3 mm and required flap surgery on at least four teeth. Exclusion criteria included recent antibiotic/anti-inflammatory use, systemic illness, smoking, pregnancy/lactation, and edentulism.

Subjects were randomly allocated via computer-generated sequence to receive either triclosan-coated polyglactin 910 sutures or chlorhexidine-coated polyglycolic sutures (Megasorb Plus^™, MERIL). A standard surgical protocol (sulcular incision, full-thickness flap elevation, debridement, root planing) was followed. Sutures were assigned intraoperatively from opaque envelopes to maintain blinding. Postoperative care comprised ibuprofen and warm water rinses; no systemic antibiotics or antiseptics were prescribed.

On postoperative day 8, sutures were removed for microbiological analysis (CFU counts, Gram staining), and clinical healing was assessed using the Landry Wound Healing Index. Statistical analysis was performed on clinical and microbiological outcomes.

Parameters evaluated

1. Healing Index (HI): Wound healing was assessed on postoperative day 8 using Landry’s Healing Index,[6] which scores surgical sites from 1 (very poor) to 5 (excellent) based on tissue color, bleeding, epithelialization, and presence of granulation tissue or suppuration.

2. Microbiological Evaluation (CFU Count): Sutures were aseptically retrieved and transported in sterile containers. Quantification of bacterial colonization was performed via serial dilution (up to 1:10⁶), with inoculation on blood agar and incubation at 37°C for 72 hours. Colony-forming units CFU/mL = n / (s × d), where n is the colony count, s is the sample volume (0.1 mL), and d is the dilution factor (10⁶). Representative colonies underwent Gram staining for preliminary identification under ×100 oil immersion microscopy.

Statistical analysis was carried out using SPSS IBM version 20.

RESULTS

The demographic profiles were comparable between the triclosan and chlorhexidine groups. Mean age was 34.5 ± 10.37 years (triclosan) and 32.4 ± 9.92 years (chlorhexidine), with no significant difference (P = 0.66). Male-to-female ratios were 70:30 in the triclosan group and 60:40 in the chlorhexidine group, also not statistically significant (P = 0.64).

By day 8, both groups showed significant healing improvement (P < 0.001). The triclosan group had a mean score of 4.1 ± 0.7, and the chlorhexidine group had 3.9 ± 0.7, with no significant difference between them (P = 0.63). Categorical analysis revealed comparable healing: triclosan group—20% “Good,” 50% “Very Good,” 30% “Excellent”; chlorhexidine group—30% “Good,” 50% “Very Good,” 20% “Excellent.” No cases fell under “Poor” or “Very Poor” categories; distribution differences were not statistically significant (P = 0.82, Fisher’s exact test).

The chlorhexidine group showed significantly lower microbial load than the triclosan group. Mean CFU count was 4.3 × 10⁶ ± 4.8 × 10⁶ for triclosan and 0.011 × 10⁶ ± 0.031 × 10⁶ for chlorhexidine (P < 0.001), indicating superior antimicrobial efficacy of chlorhexidine-coated sutures [Table 1].

Table 1.

Intergroup comparison of wound healing and microbial load

Study group		Healing index (baseline)		Healing index (day 8)		Healing index distribution (day 8)		CFU (mean±SD)		P
Triclosan		1.7±0.46		4.1±0.7		Good: 2 (20%) Very good: 5 (50%) Excellent: 3 (30%)		4.3×106±4.8×106		<0.001 (HS)
Chlorhexidine		1.6±0.49		3.9±0.7		Good: 3 (30%) Very good: 5 (50%) Excellent: 2 (20%)		0.011×106±0.031×106		<0.001 (HS)

P values for intergroup comparison: Baseline Healing Index: P=0.73 (NS), Day 8 Healing Index: P=0.63 (NS)

DISCUSSION

Sutures facilitate wound closure and tissue approximation but can serve as reservoirs for microbial colonization, contributing to surgical site infections and delayed healing. Antibacterial-coated sutures, such as TCS and CCS, aim to mitigate these risks by reducing bacterial adherence. TCS, a broad-spectrum antimicrobial, has a well-established safety and efficacy profile, while data on CCS, especially in periodontal surgery, remain limited. This study evaluates and compares clinical healing, antimicrobial performance of TCS- and CCS-coated sutures following periodontal flap procedures. It is rapidly eliminated from the body (>99% within 3.8 days), which demonstrates a favorable safety profile, with no evidence of carcinogenicity, sensitization, or tissue reactivity.[7]

By postoperative day 8, both triclosan-coated (4.1 ± 0.7) and chlorhexidine-coated (3.9 ± 0.7) suture groups exhibited significant improvement in wound healing, with no statistically significant intergroup difference (P = 0.63). These findings affirm the biocompatibility and clinical efficacy of antibacterial-coated sutures in periodontal procedures.[8]

The CCS group showed a significantly lower mean CFU count (0.011×10⁶ ± 0.031×10⁶) than the TCS group (4.3 × 10⁶ ± 4.8 × 10⁶) (P < 0.001), indicating superior antimicrobial efficacy. Gram staining revealed typical oral polymicrobial flora. Chlorhexidine’s broad-spectrum activity against pathogens like S. aureus, S. epidermidis, and E. coli is well-established, supporting its use in high-risk oral settings. However, molecular data suggest CHX may alter wound healing by downregulating RAC1 and upregulating fibrotic markers (TIMP1, SERPINE1), potentially promoting fibrosis. No clinical effects were observed within 8 days, but longer-term studies are needed. Triclosan inhibits bacterial fatty acid synthesis via enoyl-acyl carrier protein reductase suppression but may be less effective in biofilms without adjunctive agents. Despite environmental concerns, current evidence shows no adverse healing impact.[9]

Antibacterial-coated absorbable sutures outperform traditional materials like silk, which are linked to greater inflammation. A broader study is needed to assess their long-term effects on tissue regeneration and healing, with standardized materials for consistent comparisons.

CONCLUSION

Triclosan- and chlorhexidine-coated sutures offer targeted antimicrobial action, reducing biofilm formation and postoperative infections in periodontal surgery. They may enhance healing and limit the need for systemic antibiotics, supporting antimicrobial stewardship. However, further large-scale, long-term studies are needed to confirm their clinical efficacy, safety, and cost-effectiveness.

Conflict of interest

There are no conflicts of interest.

Funding Statement

Nil.