antibiotic & antiseptic use in periodontal therapy
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7/21/2019 Antibiotic & Antiseptic Use in Periodontal Therapy
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Antibiotic & Antiseptic
Use in PeriodontalTherapyDr Sushil Kaur
BDS MDSc (Perio) DClinDent (Perio
FRACDS (Perio)
Dr.Betul Rahman
BDS, PhD.
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Introduction• Microbial aetiolog
(Bacteria !ithin "ental #la$ue bio%ilm)
• Bacteria essential but insu%%icient %or "e&elo#ment o%
#erio"ontitis
• 'ost susce#tibilit "estructi&e immunoin%lammator
res#onse to subgingi&al #la$ue bacteria
ingi&itis Perio"ontitis
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Microbial Aetiology
• *&er + s#ecies in subgingi&al %lora
• *nl a %e! s#ecies clearl associate" !ith #erio"ontitis
• Aggregatibacter actinomcetecomitans (A.a)
• Por#hromonas gingi&alis (P.g)
• -anerella %orsthensis (-.%)
• -re#onema "enticola (-.")
('a%%aee / Socrans0 122341225)
• Man s#ecies still uni"enti%ie"
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Periodontal Disease – Control ??
• Control host res#onse mo"i%ing %actors
• 6limination o% #la$ue retenti&e %actors
• Disru#tion an" re"uction o% #la$ue bio%ilm
• Shi%t o% microbial %lora com#osition
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Limitations o Treatment
• 7ocal anatom Root conca&ities, groo&es an"
%urcations
• Bacterial in&asion o% gingi&al tissue
• 8nabilit to "isru#t bio%ilm an" su##ressbacteria to a le&el com#atible !ith the host
• Re"uce" treatment outcome associate"
!ith ele&ate" #erio"onto#athogen le&els
• Ma e9#erience ongoing #erio"ontal
brea0"o!n
:ee" %or a"uncti&e thera#;
Antibiotic thera#;
Sstemic or local "eli&er;
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Antibiotic therapy
• :atural or snthetic organic
substances that can inhibit or 0ill
selecti&e microorganisms
• Multi<million "ollar in"ustr
• 8n 1225, o&er 1.= billion >SD !as
s#ent on #romotion
• 8n the >SA, o&er 1 million
0ilograms o% antibiotics are
#rescribe" %or human use annuall
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!acterial "esistance
• Antibiotic use a #rimar %actor
• 8ntrinsic, mutational or ac$uire"
• Selection o% resistant s#ecies
Methicillin Resistant Sta#hlococcus aureus (MRSA)
?ancomcin Resistant Sta#hlococcus aureus (?RSA)
@hat "oesnt 0ill them ma0es them stronger
Periodontal !acterial "esistance• ram &e s#ecies (Pre&otella) #ro"uce <lactamases
• <lactamases "etecte" in #erio"ontal #oc0ets
• -etraccline resistance
• Resistance associate" !ith increase" antibiotic use
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!acterial "esistance in Dentistry
• Dentistr < a##ro9imatel 1E o% all antibiotic
#rescri#tions • Poor #rescribing contributing to bacterial resistance
• Recent sur&e suggests
3GE o% "entists #rescribe"
!ithout a "iagnosis HE o% "entists #rescribe"
"ue to time #ressures
!acterial "esistance – Pre#ention
• Iu"icious use o% antibiotics• Selection o%
A##ro#riate clinical scenario %or antibiotic use
A##ro#riate agent %or each clinical scenario
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$% Antibiotics ha#e the potential tocause harm
• Allergies an" '#ersensiti&ities
1=E o% all "rug relate" a"&erse e&ents
#resenting to the 6mergenc
De#artment Commonl Penicillin
Allergic reactions to Penicillin ranges
%rom .GE to 1E among the general
#o#ulation Ana#hla9is ris0 .3<.11E
Fatal ana#hla9is ris0 .JE
Can "e&elo# at an e9#osure to "rug
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• A"&erse Reactions
:ausea an" Diarrhoea• *##ortunistic in%ections
Pseu"omembranous colitis
Can"i"osis
• Drug interactions ar%arin
Alcohol
• -o9icit -eratogenic e%%ects
Breast%ee"ing
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% Antibiotics should be used in limitedclinical situations
• Pro#hla9is or -hera#
• Pro#hla9is
8mmunosu##resse" in"i&i"uals 8n%ecti&e 6n"ocar"itis
• 8n"ications shoul" be consi"ere" in light o% recentl
u#"ate" gui"elines
(8n%ecti&e 6n"ocar"itis Pro#hla9is 69#ert rou#, J5) (Dal et al. J5) Pre&ention o% #osto#erati&e in%ection;;;
8m#ro&e #erio"ontal regenerati&e outcome;;;
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Pre#ention o postoperati#e inection• Antibiotics #rescribe" o%ten %or #erio"ontal an" im#lant surger
• Rate o% #osto#erati&e in%ection lo!
1E < +E• :o a"&antage "emonstrate" in re"ucing
#osto#erati&e in%ection a%ter
ingi&ectom
*sseous resecti&e surger Mucogingi&al surger
*sseous gra%ting
• Re"uce" in%ection rate !hen C'L use"
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Implant surgery :o "i%%erence in #osto#erati&e in%ection rates
Role in re"uction o% im#lant %ailure contro&ersial
• 8m#ro&e" sur&i&al (J39 higher)
• :o "i%%erence in sur&i&al
• Recent stu"ies suggest
a single #reo#erati&e antibiotic "ose more a##ro#riate
Similar in%ection or sur&i&al rates !hen com#are" to #re<an" #osto#erati&e regimen
• Cochrane re&ie! b 6s#osito et al.,(J5b)Metaanalsiso% J RC-
• Bene%it o% #osto#erati&e antibiotics unclear • Jg o% Amo9icillin 1hr #reo#erati&el
Signi%icantl re"uce" earl im#lant %ailures
:o e%%ect on #osto#erati&e in%ection
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Implant surgeryConsiderations or antibiotic prescription'
Patient %actors
7e&el o% ase#sis
Com#licate" or #rolonge" #roce"ure
Bone gra%ting
*#erator e9#erience (+ im#lants)
Chlorhe9i"ine mouthrinses re"uce" in%ection an" im#lant%ailure
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Periodontal regeneration
Microbial colonisation o% membrane
associate" !ith re"uce" CA7 gain
Most stu"ies ha&e inclu"e" sstemic
antibiotics "uring the %irst an"4or secon"
!ee0 o% membrane #lacement
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Periodontal regeneration
8m#ro&e" clinical outcomes !ith e<P-F6 membranes
in #atients using sstemic antibiotics com#are" to
#atients not recei&ing antibiotics
• Amo9icillin !ith Cla&ulanic Aci" (Augmentin)
:o "i%%erence in clinical outcomes !ith Bioresorbable
membranes• Amo9icillin N Metroni"aOole
Stu"ies using 6m"ogain ha&e utilise" a"uncti&e
antibiotics
:o a""itional bene%its !ith a"uncti&e Amo9icillin an" Metroni"aOole
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• Antibiotics shoul" not be use" ust in case
• :o in"ication %or routine #erio"ontal surger
• :o in"ication %or #erio"ontal regeneration !ith6m"ogain
• 7imite" e&i"ence %or #erio"ontal regeneration!ith membranes
• 7imite" e&i"ence %or routine im#lant surger
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Therapy :ecrotising >lcerati&e ingi&itis (:>)
Perio"ontal abscess
Perio"ontitis;;;;
• May be useul in'
7ocalise"4eneralise" Aggressi&e #erio"ontitis
Re%ractor "isease
• (reatest impro#ements in sites )*mm
• Minimal beneit in chronic periodontitis
Res#on"s !ell !ith con&entional #erio"ontalthera#
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+% Antibiotics used as an ad,unct- notreplacement in periodontal therapy• Subgingi&al #la$ue bio%ilm
– Diverse microbial community
– Exists outside of host
– Barrier to diusion
– Increased antibiotic resistance
• 'igh gingi&al cre&icular %lui" (CF) le&els re$uire" %orbio%ilm #enetration
• Sstemic antibiotics alone– GCF levels may not penetrate biolm
– Does not remove plaue retentive factors such assub!in!ival calculus
Current e#idence suggests that the use o
antibiotics alone are ineecti#e in the treatment
o periodontitis
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• A"unct to subgingi&al "ebri"ement 8mme"iatel a%ter initial #hase
At re<e&aluation #hase
• Qualit o% subgingi&al "ebri"ement a%%ects treatment
outcome
• Poorer outcome !hen #er%orme" b stu"ents or less
e9#erience" clinicians
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.% Dierent agents or dierent situations
-etracclines
Metroni"aOole Amo9icillin4Metroni"aOole
AOithromcin
• 8m#ortant thera#eutic consi"erationsMe"ical status an" concomitant me"ications
7i0el microbial s#ecies7ac0 an eas to use, cost e%%ecti&e microbiological test
:ot all aetiological s#ecies i"enti%ie"
7imite" antibiotic agents a&ailable
Most regimens remain largel em#irical
7imite" e&i"ence %or o#timal "osage an" "uration
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"eractory Periodontitis• Polmicrobial (A.a, P.g, -.%, P.i, Stre#.)
• Consi"erations :umber o% unres#onsi&e sites
'ost res#onse
Presence o% mo"i%ing %actors
69ten"e" antibiotic "uration in smo0ers
• Metronida/ole (*bligate anaerobes,A.a,gram &e) J<3mg t"s + "as
HG+mg4J+mg t"s + "as
• A/ithromycin
+mg once "ail H "as
7imite" e&i"ence Bene%it in "ee# sites an" smo0ers
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Aggressi#e Periodontitis
Localised Aggressi#e
• A.a im#licate"
• -etracclines
-etraccline 'Cl J+mg $"s13 "as
• A.a not su##resse" at all
sites
Resistance ?ariable CF concentration
(eneralised Aggressi#e
• Polmicrobial
(P.g, -.% N4< A.a)
• -etracclines 7imite" or no e%%ect
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Aggressi#e Periodontitis
• Amo0icillin1Metronida/ole
J+<+mg4J<3mg t"s + "as
• A/ithromycin
+mg once "ail H "as
6arl e&i"ence #romising
Localised Aggressi#e (eneralised Aggressi#e
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A/ithromycin
• Macroli"e
• Fe! a"&erse e%%ects
• i"e antimicrobial s#ectrum
" Aerobic an" anaerobic bacteria" 6%%ecti&e against
A.actinomcetemcomitans an" P.gingi&alis
• 'igh #erio"ontal tissue concentrations
%or + "as a%ter a"ministration• 8m#ro&e" #atient com#liance
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(eneralised Aggressi#ePeriodontitis
BaselineBaseline
# months post treatment# months post treatment
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Localised Aggressi#ePeriodontitis
BaselineBaseline
$% months post treatment$% months post treatment
% months post% months post
treatmenttreatment
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2% Antibiotics can result in re
inection1recolonisation
• A.a, P.g, -.%, -."
• Recolonisation
Su#ra an" subgingi&al #la$ue
Mucous membranes, tongue, tonsils
• Regular bio%ilm "isru#tion re$uire" "uring SP-
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Conclusions• Antibiotics are &aluable thera#eutic agents
• :ot magic bullets• i"es#rea" use bacterial resistance
• Clinicians nee" to be res#onsible %or sensible #rescribing
• 7imite" clinical scenarios
• :ot an e9cuse %or #oor surgical techni$ue• Ris0s o% com#lications ma be greater than the ris0 o%
#osto#erati&e in%ection occurring
• Ris0 small at a #atient le&el but signi%icant ris0 at
#o#ulation le&el %or #re&entable a"&erse e&ents
• Diagnosis im#ortant
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• :ot an e9cuse %or ina"e$uate "ebri"ement
• A"unct to re"uce le&el4com#osition o% bacteria to
one com#atible !ith host
• 8m#ortance o% host res#onse an" mo"i%ing%actors
• Most regimens largel em#irical
• Further stu"ies re$uire" to #ro&i"e gui"elines
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Chemical Pla3ue Control
Mouthrinses
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Pla3ue control
• -oothbrushing
• hen goo" oral hgiene is #ractice",
mechanical toothbrushing can remo&e #la$ue
e%%ecti&el
• Moti&ation ten"s to "ecline o&er time
• 8n in"ustrialise" countries, the a&erage #erson
brushes %or less than one minute• Combination o% mechanical an" chemical oral
hgiene a##ear to o%%er some bene%its
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The concept o chemical pla3ue control
• -he nee" to %urther im#ro&e #la$ue remo&al %orms the basis o%
@chemical #la$ue control• Pre&ention o% gingi&itis is base" on the assum#tion that gingi&itis
is the #recursor o% #erio"ontitis
So ho! o%ten "oes gingi&itis #rogress to periodontitis&
• Poor #re"ictor %or %uture #erio"ontitis• -he #ro#ortion o% gingi&al lesions that con&ert to #erio"ontitis is
currentl un0no!n• -he %actors that cause the con&ersion are not !ell un"erstoo"• -he most con&incing e&i"ence that gingi&itis "o not #rogress to
#erio"ontitis comes %rom e#i"emiological stu"ies on untreate"#o#ulations in China, Kena, an" :igeria.
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45A467 III
• >S :ational 'ealth an" :utrition 69amination Sur&e (Alban"ar et al .12224 JJ)
• H 515 subects to re#resent J3G million >S #o#ulationFor a"ults (H<2rs) !ith = teeth
• +%$8 ad#ance periodontitis• 2.+E mo"erate #erio"ontitis• J1.5E mil" #erio"ontitis• =+.+E no #erio"ontitis
• A"ults =rs an" ol"er in SA, le&el o% #erio"ontitis broa"l similarto :orth America (Sla"e / S#encer 122+)
• (enerally agreed that se#ere generali/edperiodontitis aects 29$28 o the population
• (AAP J+).
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Chemical pla3ue control agents':irst- second- third generation
$% :irst9generation' "o not e9hibit an signi%icantsubstanti&it (onl minutes)
% 7econd9generation antimicrobial agents highsubstanti&it (hours)
+% Third9generation' mo"erate substanti&it (hours)
• 7econd9generation antimicrobialagents are still the agents o choice(Consensus re#ort Jn" 6uro#ean or0sho# on Perio"ontolog 122=)
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• First generation agents can 0ill bacteria on contact,
but ha&e limite" abilities to e9ert an e%%ect on the oral
%lora a%ter e9#ectoration (e.g. cetl#ri"inium chlori"ean" sanguinarine),
• Secon" generation agents ha&e an imme"iate
antibacterial e%%ect an" more im#ortantl, ha&e a#rolonge" e%%ect on the oral %lora (e.g. chlorhe9i"ine).
• -hir"<generation agents are characteriOe" b an
abilit to inhibit or "isru#t the %ormation o% #la$ue
!hile ha&ing no "emonstrable e%%ect on bacteria.
(-he mor#holinoethanol "eri&ati&e<"elmo#inol)
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Mouthrinse
• Mouthrinses generall contain three basicingre"ients
• Alcohol < to enhance %la&our im#act an"solubiliOe the %la&our an" some acti&eingre"ients also acts as a #reser&ati&e.
• 7uractants 9 "ual %unction to assist in theremo&al o% "ebris %rom the mouth an" #ro&i"eantibacterial e%%ects ai" in solubilisation o%
%la&our an" some acti&e ingre"ients.• :la#ouring agents 9 #ro&i"e some breath<%reshening #ro#erties.
( t d t t l
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(roups o agents used to controlpla3ue and1or gingi#itis
• 1. Bisbiguani"e antise#tics• J. Quaternar ammonium com#oun"s
• H. 6ssential oils (6*)
• 3. :atural #ro"ucts• +. *9genating agents
• =. Amine alcohols
• G. *ther
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Chlorhe0idine ;C5<=
• Bisbiguani"e antise#tics• C'L is the most stu"ie" an"e%%ecti&e antise#tic in thiscategor
• De&elo#e" in the 123s in6nglan"
• Cationic antise#tic• Broa" s#ectrum antimicrobial• A%ter J ears o% use b the
"ental #ro%ession, C'L isrecogniOe" as the (>LD stan"ar" against !hich otheranti#la$ue an" gingi&itisagents are measure"
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The mechanism o C5< eect
-he anti#la$ue e%%ect o% C'L can be h#othesiOe"as
• An bacteria a"hering to the tooth sur%ace are
either 0ille" (bacterici"al e%%ect) or are #re&ente"%rom multi#ling (bacteriostatic e%%ect)
• -he #ersistent, bacteriostatic e%%ect o% C'L is!hat ma0es C'L the gol" stan"ar"
>ptimi ing the se o
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>ptimi/ing the use ochlorhe0idine
• C'L shoul" not be use"
be%ore, or imme"iatel
a%ter using tooth#aste (or
else it !ill re"uce the e%%ecti&e "eli&er
o% C'L to the tooth sur%ace in an
acti&e %orm)
• 7imit inta0e o% %oo"s an"
be&erages "uring
treatment !ith C'L,
es#eciall ust a%ter use!ith C'L
t i
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uaternary ammoniumcompounds
• Cetl#ri"inium chlori"e (CPC)• CPC mouthrinses ha&e been mar0ete" inthe >SA since 123
• Cationic in nature.
• CPC is use" in a !i"e range o% antise#ticmouthrinses• CPC has a broa" s#ectrum antimicrobial
acti&it• Substanti&it is less than C'L T H hours
(Roberts / A"" 1251)• 7ittle e&i"ence o% an bene%its to im#ro&e
gingi&itis
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7ide eects o CPC• CPC shares some o its side eects as C5<• -ooth staining• Calculus %ormation• Burning sensation• :o clinical trials su##ort the use o% CPC as an anti<
#la$ue or anti<gingi&itis agent
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6ssential oils ;6>=
• A##ro&e" in 125G in America
• Contain J #henol<relate"essential oils
• -hmol .=3E,6ucal#tol .2JE• @Listerine is a
breakthrough against plaque and it’s the onlymouthrinse that can breakthrough plaque and kill thebacteria.” - ana"&ertisement %or 7isterine
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5o@ does Listerine @or?
• Microorganisms are 0ille" b "isru#ting their cell !alls an" binhibiting their enOme acti&it
• Pre&ents bacteria %rom aggregating, an" slo!s bacterial#roli%eration
• Re"uces bacterial loa"
• A recent sstematic re&ie! on essential oils conclu"e"Bhen used as an ad,unct to unsuper#ised oralhygiene- 6> pro#ides an additional beneit @ithregard to pla3ue and gingi#itis reduction ascompared to a placebo or control mouthrinse
• Some stu"ies suggest as an alternati&e to C'L (PiOOo et
al. J5)
• Com#are" to C'L, e%%icac o% 7isterine isin%erior (Paras0e&as J+ Stoe0en et al . JG)
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7aety o Listerine
• 7ong<term use sa%e (al0er et al. 1252)
• Concern has been raise" about the associationo% long<term use o% a high<#ercentage alcohol<
content mouthrinse !ith oral cancer (6lmore / 'or!itO122+)
• :o e&i"ence o% cancer (Cole et al. JH inn et al. J1 Carretero
PelaeO et al . J3)
• Possibilit o% #ro"ucing #athological change
shoul" be borne in min" !hen consi"ering long<term use o% a mouth!ash o&er a li%etime (Paras0e&as
J+)
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4atural products
• 'erb an" #lant #ro"ucts ha&e been use" %orman ears i% not centuries
• -he bloo" root #lant Sanguinaria
cana"ensis #ro&i"es an al0aloi" e9tract
calle" @sanguinarine• -he #ro"uct is incor#orate" in mouthrinse
%ormulations / !ith Oinc chlori"e (salts) to
enhance the anti<#la$ue e%%ect (!hich ma0es it
"i%%icult to e&aluate the e%%icac o% sanguinarine alone)
• 7imite" bene%it (e&en !hen combine" !ith Oinc) (Quirnen et al . 122)
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>0ygenating agents
• 'J*J
• Most commonl use"
in cases o% A:>
an" #ericoronitis
• 7imite" e&i"ence
a&ailable to suggest
use as anantigingi&itis or
anti#la$ue agent
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Amine alcohols
• Consi"erable #romise as anti#la$ue agents• *cta#inol !as %irst stu"ie", !ith"ra!n %or to9icologicreasons
• Delmo#inol %ollo!e" at .1E an" .JEconcentrations in mouth!ashes
• Man si"e e%%ects ha&e been re#orte" tooth"iscolouration transient numbness o% the mucosasuch as the tongue taste "isturbance an" burningsensations in the mouth
• hen com#are" to C'L, e%%ecti&eness !as %arbelo! C'L (7ang et al. 1225)
• :o #ro"ucts o% Delmo#inol are a&ailable
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>ther antiseptics
• Man other agents ha&e been stu"ie" but most ha&ebeen %oun" to ha&e little or no e%%ect clinicall
• Po&i"one io"ine at 1E has a
substanti&it o% onl 1 hour (A"" / right 12G5)
minimal #la$ue inhibitor acti&it (A"" et al.
12GG) or action in acute in%ections (A"" / 7le!eln
12G5) As a rinse, has #otential to a%%ect throi" %unction(ra et al. 12GG)
Can mouthrinses treat
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Can mouthrinses treatperiodontitis??
• -he use o% mouthrinses is increasing, es#eciall asa"uncts to the "ail mechanical oral hgiene (:etuschil,
JH) • @Mouthrinsing %aile" to achie&e an signi%icant
#enetration o% #oc0ets (Pitcher et al. 125)
• -he lac0 o% #enetration ma ha&e been "ue to the
#resence o% subgingi&al calculus or o% a ban" o% tightl
a"a#te" #oc0et e#ithelium imme"iatel coronal to the
e#ithelial attachment (:e!man 12G=)
• Conclusion that mouth!ash "oes not a%%ect
subgingi&al #la$ue ;FlUtra et al. 12GJ)
I di ti
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Indications or use omouthrinse as an ad,unct
1. A%ter surgical #roce"ures
% 8n me"icall com#romise" #atients those
recei&ing chemothera# or ra"iothera#
an" bone marro! trans#lant #atients
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Conclusion
• C'L is the *7D stan"ar" %or mouthrinse• C'L mouth!ash "oes not a%%ect subgingi&al
#la$ue "ue to the lac0 o% subgingi&al#enetration
• 7imite" use in treatment o% #erio"ontitis
• Mouthrinses ha&e a role in gingi&itis #re&ention,but consi"ering gingi&itis "oes not necessaril
#rogress to #erio"ontitis, !e nee" to $uestion!hether the use o% chemical agents %or thegeneral #o#ulation is reall necessar
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