Prevention of Periodontal Disease – 2 Chemical Plaque Control Dr. Omar Alkaradsheh.

Prevention of Periodontal Disease Prevention of Periodontal Disease – 2– 2

Chemical Plaque ControlChemical Plaque Control

Dr. Omar AlkaradshehDr. Omar Alkaradsheh

AimsAims

Mechanism of chemical plaque Mechanism of chemical plaque controlcontrol

Types of chemical agentsTypes of chemical agents

Indications of chemical plaque Indications of chemical plaque controlcontrol


Supragingival plaque Supragingival plaque controlcontrol

Mechanism of actionMechanism of action

1.1. Prevention of Prevention of colonization of enamel colonization of enamel

2.2. Removal of attached Removal of attached organismsorganisms

3.3. AntimicrobialsAntimicrobials


1.1. Bisguanide antiseptics – Bisguanide antiseptics – ChlorhexidineChlorhexidine

2.2. Quaternary ammonium compoundsQuaternary ammonium compounds

3.3. Phenolic antisepticsPhenolic antiseptics

4.4. Metal ionsMetal ions

5.5. Natural productsNatural products

6.6. Oxygenating agentsOxygenating agents

Bisguanide - Chlorhexidine Bisguanide - Chlorhexidine (CHX)(CHX)

Chlorhexidine (CHX)Chlorhexidine (CHX) Used in the form of Used in the form of chlorhexidine digluconatechlorhexidine digluconate

Broad-spectrum bactericidal against Broad-spectrum bactericidal against Gram positive and Gram negative bacteria Gram positive and Gram negative bacteria yeasts and fungiyeasts and fungi

Mechanism Mechanism immediate antibacterial immediate antibacterial prolonged effect – for several hoursprolonged effect – for several hours Both bacteriostatic and bacteriocidal Both bacteriostatic and bacteriocidal

How does CHX work?How does CHX work?

Positive charged CHX binds toPositive charged CHX binds to Bacterial cell wallBacterial cell wall Oral surfaces (hydroxyapatite Oral surfaces (hydroxyapatite

tooth enamel)tooth enamel)

Damages permeability barriersDamages permeability barriers

Coagulation of Coagulation of macromolecules in macromolecules in cytoplasmcytoplasm

CHXX

X

Bacterial cell

XXXXXX

chlorhexidinefacts.com

CHXCHX

highly effective anti-plaque agent

more effective in preventing more effective in preventing plaque accumulation on a plaque accumulation on a clean tooth surfaceclean tooth surface

Little or no effect on Little or no effect on established plaqueestablished plaque and and established established gingivitisgingivitis where where subgingival plaque has subgingival plaque has already formedalready formed

How is CHX administered?How is CHX administered?

MouthrinseMouthrinse 0.2% (Corsodyl)0.2% (Corsodyl) 0.12% (Peridex)0.12% (Peridex)

Toothpaste/GelToothpaste/Gel Spray Spray Chewing gumChewing gum

Chlorhexidine Chlorhexidine

Antiplaque effects are Antiplaque effects are dosedose related related (not concentration related)(not concentration related)

Optimum daily dose = Optimum daily dose = 18 – 20 mg18 – 20 mg

0.2%0.2% CHX CHX 10ml 10ml 2x daily = 2x daily = 20mg20mg 0.12%0.12% CHX CHX 15ml 15ml 2x daily = 2x daily = 18mg18mg

CHX Toothpaste/GelsCHX Toothpaste/Gels

Toothpaste ingredients Toothpaste ingredients inactivate CHXinactivate CHX

1% formulations similar to 1% formulations similar to MW MW (Jenkins et al., 1993)(Jenkins et al., 1993)

Gels (1%) – no detergents or Gels (1%) – no detergents or abrasives – reduces patient abrasives – reduces patient acceptance (staining)acceptance (staining)

Kin Gingival Paste (0.12% CHX), (0.22% SF)

Curasept 0.12% Chlorhexidine Toothpaste

CHX SprayCHX Spray

More popular than mouthwash or gels More popular than mouthwash or gels for use in handicapped patientsfor use in handicapped patients

Research shows that when used by Research shows that when used by parents less effective than gels in traysparents less effective than gels in trays

Applied to the teeth by a dentist under Applied to the teeth by a dentist under optimal conditions – good resultsoptimal conditions – good results

CHX GumCHX Gum

CHX molecules are unbound (20mg CHX CHX molecules are unbound (20mg CHX diacetate)diacetate)

anti-plaque effect similar to 0.2% CHX anti-plaque effect similar to 0.2% CHX mouthwashmouthwash

Tooth staining was seen but intensity less Tooth staining was seen but intensity less with the gumwith the gum

Good method in long-term users Good method in long-term users

Is CHX safe?Is CHX safe?

poorly absorbed by the GIT - displays very low toxicity

No carcinogenic or teratogenic effects have been found following long-term use

Side effectsSide effects

1.1. Brown staining of Brown staining of teeth/fillings teeth/fillings

difficult to removedifficult to remove

result of dietary result of dietary pigments adhering to pigments adhering to tooth surfacetooth surface

+

+

CHX

Tooth

BacteriaDietary stains

Side effects (cont)Side effects (cont)

2.2. Supragingival calculus formation Supragingival calculus formation

suppresses acidogenic plaque bacteria suppresses acidogenic plaque bacteria Raises pHRaises pHppt of calcium and phosphateppt of calcium and phosphate

1 +2 = dose-dependent 1 +2 = dose-dependent cannot be reduced without loss of cannot be reduced without loss of antiplaque effectsantiplaque effects

Side effects (cont)Side effects (cont)

3.3. Taste disturbancesTaste disturbances

4.4. Mucosal desquamationMucosal desquamation

3 and 4 can be decreased by reducing the 3 and 4 can be decreased by reducing the conc. and using a larger volume to maintain conc. and using a larger volume to maintain clinical efficacy clinical efficacy

5.5. Parotid swellingParotid swelling? Mechanical obstruction of the duct? Mechanical obstruction of the duct








Quaternary ammonium Quaternary ammonium compoundscompounds

Cetylprydinium chloride (CPC)Cetylprydinium chloride (CPC)

Moderate plaque inhibitory activityModerate plaque inhibitory activity Less effective than CHXLess effective than CHX

monocationicmonocationic

CPC pre-brushing mouthrinse has not CPC pre-brushing mouthrinse has not been found to have an additional been found to have an additional beneficial antiplaque effectbeneficial antiplaque effect

Have been marketed as lozenges Have been marketed as lozenges (CEPACOL) but cause marked (CEPACOL) but cause marked stainingstaining

CPC

+








ListerineListerine Active ingredients Active ingredients

Phenol-related essential oils Phenol-related essential oils (thymol and eucalyptol)(thymol and eucalyptol)

Menthol and methyl salicylateMenthol and methyl salicylate

Inactive ingredients Inactive ingredients WaterWater Alcohol (26%)Alcohol (26%)

Less effective than CHXLess effective than CHX Side effects – bitter taste, Side effects – bitter taste,

stainingstaining

Phenolic compounds (cont)Phenolic compounds (cont)

Triclosan Triclosan

Soaps, deodorantsSoaps, deodorants

MouthwashMouthwash reduce plaque accumulation but to a much reduce plaque accumulation but to a much

lesser extent than CHXlesser extent than CHX dependent upon the presence of dependent upon the presence of co-polymers co-polymers

in the formulation to increase oral retention in the formulation to increase oral retention (Gantrez)(Gantrez)

anti-inflammatory effectanti-inflammatory effect

TriclosanTriclosan

Added to toothpaste - effect is improved byAdded to toothpaste - effect is improved by Copolymer (Gantrez) to enhance retention in the mouth Copolymer (Gantrez) to enhance retention in the mouth

OROR Zinc citrate to provide additional antibacterial activityZinc citrate to provide additional antibacterial activity

Provide significant reduction in plaque and Provide significant reduction in plaque and improvement in gingival health when improvement in gingival health when compared with fluoride toothpaste alonecompared with fluoride toothpaste alone

(Volpe et al., 1996)(Volpe et al., 1996)








Metal ionsMetal ions

Zinc Zinc additive effect with other antisepticsadditive effect with other antiseptics Attaches to dental tissue and inhibits Attaches to dental tissue and inhibits

regrowth of plaqueregrowth of plaque

Copper and Tin – local side effects of Copper and Tin – local side effects of stainingstaining








Natural products - Natural products - SanguinarineSanguinarine

Root of Root of Sanguinaria Sanguinaria canadensiscanadensis (Bloodroot) (Bloodroot)

plaque inhibitory effect less plaque inhibitory effect less than CHXthan CHX

Mouthwash is more effective Mouthwash is more effective than toothpastethan toothpaste

Gingivitis prevention is Gingivitis prevention is questionablequestionable..








Oxygenating agentsOxygenating agents

Hydrogen peroxide, sodium Hydrogen peroxide, sodium peroxyborateperoxyborate

MouthrinsesMouthrinses Inhibit obligate anaerobesInhibit obligate anaerobes Some retardation in plaque growthSome retardation in plaque growth Further investigation is needed Further investigation is needed

Alcohol containing Alcohol containing mouthwashesmouthwashes

Accidental swallowing by childrenAccidental swallowing by children

Link with oral and pharyngeal cancer ???Link with oral and pharyngeal cancer ???

Reduce the hardness of composite and Reduce the hardness of composite and hybrid-resin restorations hybrid-resin restorations related to % alcohol content of mouthwashrelated to % alcohol content of mouthwash

Bottom line Bottom line

Chlorhexidine most effective Chlorhexidine most effective chemical agentchemical agent

Indications of chemical plaque Indications of chemical plaque controlcontrol

1.1. To To replacereplace toothbrushing when this toothbrushing when this is not possibleis not possible

2.2. As an As an adjunctadjunct to toothbrushing in to toothbrushing in situations when this may be painful situations when this may be painful or inadequateor inadequate

1. Replacing Toothbrushing1. Replacing Toothbrushing

A.A. After oral/periodontal After oral/periodontal therapy and during the therapy and during the healing periodhealing period

B.B. Intermaxillary fixationIntermaxillary fixation

1. Replacing Toothbrushing1. Replacing Toothbrushing

c.c. Acute oral mucosal or gingival Acute oral mucosal or gingival infectionsinfections

DD.. Mentally or physically-handicapped Mentally or physically-handicapped patients who are unable to brush patients who are unable to brush their teeth themselvestheir teeth themselves

2. With Toothbrushing2. With Toothbrushing Following subgingival scaling/root planing Following subgingival scaling/root planing

when the gingivae may be sorewhen the gingivae may be sore (used for ~3 days)(used for ~3 days)

Following scaling - cervical Following scaling - cervical hypersensitivity due to exposed root hypersensitivity due to exposed root surfacesurface

2. With Toothbrushing2. With Toothbrushing

Following scaling in situations where the Following scaling in situations where the patient’s oral hygiene remains patient’s oral hygiene remains inadequateinadequate

Need to remedy situation quickly Need to remedy situation quickly duration of the CHX mouthwash use should duration of the CHX mouthwash use should

not >2 weeksnot >2 weeks Antibacterial agent that does not cause Antibacterial agent that does not cause

significant staining in a significant staining in a toothpaste or pre-toothpaste or pre-brush rinsebrush rinse - - TRICLOSANTRICLOSAN

Assess mouthwashAssess mouthwash

Range of antibacterial activity against the various plaque bacteria

Substantivity (retention) to the oral surface

Possible anti-inflammatory effect Acceptable taste Ability to promote fresh mouth

sensation

Categories – Group ACategories – Group A

good substantivity (oral retention) wide antibacterial spectrum good anti-plaque effects can be used to replace mechanical

cleaning methods for short periods when this is not possible

chlorhexidinechlorhexidine

Group BGroup B

little or no substantivity good antibacterial spectrum

cannot be used to replace toothbrushing but can be used as adjuvants to mechanical cleaning

cetyl pyridinium chloride, Listerine and triclosan.

Group C

antibacterial effects in vitro

plaque inhibitory effects from moderate to low or no statistical difference from the negative control

limited or no adjuvant effects when combined with mechanical cleaning and therefore cannot be recommended for this purpose

Oxygenating agents, sanguinarine (Veadent)

REMEMBER!!!REMEMBER!!!

Anti-plaque mouthwashes have no place in the treatment of existing periodontal disease (gingivitis or periodontitis) since they cannot

either reach the subgingival environment or penetrate thick layers of established plaque.

Miswak (Siwak) – chewing Miswak (Siwak) – chewing stickstick

Mechanical effect of Mechanical effect of fibers fibers

Release of antibacterial Release of antibacterial chemicals againstchemicals against Periodontal pathogensPeriodontal pathogens Cariogenic bacteriaCariogenic bacteria

Antiplaque effect similar Antiplaque effect similar to 0.2% CHX mouthwashto 0.2% CHX mouthwash

Salvadora Salvadora persicapersica

MiswakMiswak

Recommended by WHO as Recommended by WHO as alternative oral hygiene methodalternative oral hygiene method

Proper useProper use

Pen gripPen grip Rolling or up and down movementRolling or up and down movement Massage the gum and tooth surfacesMassage the gum and tooth surfaces Longer time than brushing – Longer time than brushing – 5 to 10 min5 to 10 min

Mouthrinse Mouthrinse recommendation forrecommendation for

prosthodontic patientsprosthodontic patients High risk for plaque accumulationHigh risk for plaque accumulation additional measuresadditional measures Side effects on the prosthesisSide effects on the prosthesis

CHX for short-term periods CHX for short-term periods EOs for long-term periods.EOs for long-term periods.

Cortelli et al.,2014Cortelli et al.,2014

Mouthrinse Mouthrinse recommendation forrecommendation fororthodontic patientsorthodontic patients

Use of oral antiseptics by orthodontic subjects Use of oral antiseptics by orthodontic subjects may be beneficial in controlling plaque and may be beneficial in controlling plaque and gingivitis.gingivitis.

CHX showed the best results in reducing plaque CHX showed the best results in reducing plaque and gingivitisand gingivitis

CHX for short-term periods CHX for short-term periods EOs for long-term periods.EOs for long-term periods.

Nogueira et al.,2014Nogueira et al.,2014

LiteratureLiterature

Essential oil mouthwash Essential oil mouthwash (EO) (EO) may be may be equivalent equivalent to to chlorhexidine chlorhexidine (CHX) (CHX) for long-term control of for long-term control of gingival gingival inflammation inflammation but CHX appears to perform better than EO but CHX appears to perform better than EO in in plaque controlplaque control..

Neely 2012Neely 2012 EO less stainingEO less staining

Neely 2012Neely 2012

The alcohol-free CHX rinse was as effective as the one containing alcohol in controlling plaque and reducing gingival inflammation.

Todkar et al. 2012

Maintaining and recovering soft tissue health around dental

implants

”There was weak evidence that antibacterial mouthrinses are effective in reducing plaque and marginal bleeding around implants”

Grusovin et al. 2010

Chemical plaque control in Chemical plaque control in special needs patientsspecial needs patients

“No-spell” Beaker

Thank youThank you

Prevention of Periodontal Disease – 2 Chemical Plaque Control Dr. Omar Alkaradsheh.

Documents

established plaque

chx spray

plaque accumulation

subgingival plaque

chx work

gum slide

chlorhexidine toothpaste

bacteriocidal slide