plaque disclosing agents

PLAQUE DISCLOSING

AGENTS

CONTENTSI. DEFINITION OF PLAQUE

II. DENTAL PLAQUE: A HOST-ASSOCIATED BIOFILM

III. SIGNIFICANCE OF PLAQUE IN DEVELOPMENT OF PERIODONTAL DISEASE

IV. IDENTIFICATION OF DENTAL PLAQUE

V. DEFINITION OF DISCLOSING AGENT

VI. HISTORY

VII. UTILITY

VIII. IDEAL PROPERTIES

IX. COMPOSITION

X. MECHANISM OF ACTION

XI. DYES USED AS DISCLOSING AGENT

XII. METHOD OF APPLICATION

XIII. APPLIED ASPECTS

XIV. CONCLUSION

XV. REFERENCES2

1. WHO (1978):

Dental plaque is defined as a specific but highly variable

structural entity resulting from sequential colonization

and growth of micro organisms on the surfaces of teeth

and restoration consisting of micro organisms of various

strains and species are embedded in the extra cellular

matrix, composed of bacterial metabolic products and

substance from serum, saliva and blood.

3

I. DEFINITION OF DENTAL PLAQUE

2. Bradshaw and Marsh (1999):

Dental plaque is a microbial biofilm, a diverse microbial

community found on the tooth surface embedded in a

matrix of polymers of bacterial and salivary origin.

4Dumitrescu AL. Etiology and Pathogenesis of Periodontal disease: Springer –

Verlag Berlin Heidelberg, 2010.

II. DENTAL PLAQUE: A HOST-ASSOCIATED BIOFILM

Dental plaque is a host-associated biofilm. The significance of the biofilm environment has been increasingly recognized because the environment itself may alter properties of microorganisms. The biofilm community is initially formed through bacterial interactions with the tooth and then through physical and physiologic interactions among different species within the microbial mass. Furthermore, the bacteria found in the plaque biofilm are strongly influenced by external environmental factors that may be host mediated.

5Newman et al. Carranza’s Clinical Periodontology. ed.3. W.B. Saunders Co.2002.

Macroscopically,

Classified as Supragingival & Subgingival plaque, based on its position of the tooth surface.

Marginal plaque – The supragingival plaque in direct contact with the gingival margin. Holds prime importance in the development of gingivitis.


III. SIGNIFICANCE OF PLAQUE IN DEVELOPMENT OF PERIODONTAL DISEASE

• Once the biofilm has formed, the species composition at a

site is characterized by a degree of stability or balance

among the component species, despite regular minor

environmental stresses following, for example, periodic oral

hygiene, food intake or diurnal changes in saliva flow.

Importantly, this stability (termed microbial homeostasis) is

not due to any biological indifference among the resident

organisms, but is due to a dynamic balance imposed by

numerous microbial interactions.


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• Bacteria respond to environmental change, and,

microbial homeostasis can break down if a key

parameter exceeds the threshold that is compatible

with community stability.

• A consequence of homeostasis breakdown is re-

organization of the structure and composition of the

microbial community, with previous species that

were only minor components becoming more

competitive under the new conditions, and, as a

result, more dominant. Such a change in community

composition and activity can predispose a site to

disease.

Newman et al. Carranza’s Clinical Periodontology. ed.3. W.B. Saunders Co.2002.

IV. IDENTIFICATION OF DENTAL PLAQUE

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• Elimination of bacterial plaque from tooth surfaces is

essential for maintaining dental health (Loe et al 1965,

1971, Lovdal et al 1958, 1961, Suomi et al 1969, 1971,

Greene and Vermillion 1971).

• It is often difficult, however, to convince patients about the

importance of performing thorough oral hygiene.

• Patient motivation, therefore, represents an important

aspect in improving oral hygiene.

Lang et al 1972. A fluorescent plaque disclosing agent. J. Periodont.Res. 7: 59-

67.

The use of agents which stain and disclose bacterial plaque in situ is generally thought to enhance motivation by enabling the patient to detect deposits on the teeth and to control the efficacy of his oral hygiene techniques.

Home care aids: 1. Tooth brushing methods

2. Dentifrices(ShoPlaq , PlaqueHD)

may contain plaque disclosing agent that permits dental plaque observation.

Staining of bacterial plaque aids in efficient plaque removal teaches the significance of plaque in periodontal disease.

Shefali Sharma 2010. Plaque Disclosing Agent – A Review. J Adv Dental Research.2[1]:1-3 10

Raybin (1943):

A disclosing agent is a solution which when applied on the tooth, makes visible by staining roughness and foreign matter on the tooth.

World English Dictionary:

A disclosing agent is a dye in liquid or tablet form that colors something, especially the teeth to show plaque.

V. DEFINITION OF DISCLOSING AGENT

11Shefali Sharma 2010. Plaque Disclosing Agent – A Review. J Adv Dental Research.2[1]:1-3

VI. HISTORY

1. Skinner in 1914: First disclosing solution

(Skinner’s iodine solution). Patients' teeth

were disclosed with this solution to

demonstrate "soft accumulations" which

had to be removed by the patient at home.

2. Berwick in 1920: Combination of Brilliant

green – crystal violet.

3. Easlick in 1935: Bismark brown.

4. Raybin in 1943: Gentian violet (non-iodine

dye)e

Cohen et al 1972. A Comparison of Bacterial Plaque Disclosants in Periodontal Disease. J Periodonol.43[6]: 333-338.

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VII. UTILITY OF DISCLOSING AGENT

a. Diagnosing the dental plaque.

b. Personalized patient instruction and motivation.

c. Self- evaluation by the patient.

d. To evaluate the effectiveness of oral hygiene

maintenance.

e. Preparation of plaque indices.


1. Taste: i. Patient comfort.ii. Flavored.iii. Should encourage patient co-operation.

2. Intensity of color:i. Evident contrast to differentiate from surrounding

environment.

3. Duration of Intensity: Retentive – The color should not rinse off with ordinary rinsing methods for the period of time required to complete the instructions or clinical examination.

4. Non-irritating to oral mucosa.

5. Non-allergic.

6. Antiseptic property.

VIII. IDEAL PROPERTIES


7. The dye must be capable of adequately

penetrating the plaque deposit.

8. Selective staining efficacy.

9. Water-soluble.

15Skaggs et al.,1991. Plaque Disclosing Compositions. United States Patent: 1-7

IX. COMPOSITION

Pertains to combinations of dyes-

I. FDC Red No. 3(Erythrosin) and FDC Blue No. 1;

II. FD&C Blue No. 2;

III. FD&C Green No.5;

IV. FD&C Blue No. 1 and D&C Yellow No. 5;

V. D. & C. Yellow No. 8 (Fluorescein);

VI. FD&C Red No. 3 and FD&C Green No. 3;

VII. FD&C Red No. 3 and Hercules Green Shade 3;

VIII.FD&C Red No. 40, or Allura Red (0.05%-10%);

IX. FD&C Red No. 22 (eocine)

16Skaggs et al.,1991. Plaque Disclosing Compositions. United States Patent: 1-7

i. Disclosing agents work by changing the color of dental plaque so that it contrasts with the white tooth surface.

ii. Dental plaque has the ability to retain a large number of dye substances which can be used for disclosing purposes. This property is related to interaction, because of the polarity difference between the components of plaque and dyes(Gallagher et al, 1977). The particles are bound to the surface by electrostatic interaction(proteins) and hydrogen bonds(polysaccharides).

Chetrus and Ion 2013. Dental Plaque – classification, formation, and identification.

International Journal of Medical Dentistry.3[2]:139-143.

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X. MECHANISM OF ACTION

2. Mercurochrome preparations

3. Bismark brown

1. Iodine preparations

5. Erythrosin

4. Merbromin

6. Fast green

8. Two tone solution

9. Basic fuchsin

10. Three tone gel

7. Fluorescein

XI. DYES USED AS DISCLOSING AGENTS


1. Iodine preparations

Iodine crystals – 3.3%Potassium iodide – 16%

Zinc iodide -10%Distilled water – 16%

Skinner’s iodine solution

Tincture of iodine – 21%

Distilled water – 15%

Diluted tincture of iodine

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Plaque deeply brown or black.

Inflamed gingiva dark areas.

Discoloration disappears in a few minutes.

Advantages :

Low cost.

Clinical photography.

Disadvantages :

Patients allergic to iodine.

Objectionable taste.

I. Iodine based solutions

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2. Mercurochrome preparations

Mercurochrome – 1.5%

Distilled water – 30%

Mercuroc-hrome

solution – 5%

Mercurochrome – 13.5 gmDistilled water – 3 ml

Oil of peppermint – 3 drops

Flavoured mercuroch

r-ome solution

21

3. Bismark Brown (Easlick’s disclosing solution)

Bismark brown – 3 gm Glycerin – 120 ml

Ethyl alcohol – 10 ml

Anise (flavor) – 1 drop

22

4. Merbromin

Merbromin NF – 450 mg Oil of peppermint – 1 drop Distilled water – 100

ml

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5. Erythrosin

Based on purpose

1. By Rinsing

2. For Direct topical application

3. Tablet or Wafers

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1. By Rinsing

F.D & C. Red No. 3 or No. 28 – 6 gm

Alcohol - 10 ml

Distilled water - 100 ml

Peppermint Oil - 2 drops

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2. For Direct topical application

Erythrosine – 0.8 gm

Alcohol - 10 ml

Distilled water - 100 ml

Peppermint Oil - 2 drops

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3. Tablet or Wafers

F.D & C. Red No. 3 – 15 gm

Sodium chloride – 0.747%

Sodium sucaryl – 0.747%

Calcium stearate – 0.995%

White oil – 1.124%

Flavoring agent – 2.239%

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However, with regular use of the FDC Red No. 3 tablet, it

became abundantly clear that the “pleasing shade of red”

adversely affected the utility of wafer. The plaque

interproximally and at the gingival margin, especially in

the posterior areas, could not easily be seen because of

poor contrast between the gingiva and the stained plaque.

Accordingly, the use of a red disclosing dye reveals that

red is the wrong color since plaque that has been stained

red is extremely difficult to see due to poor contrast with

the oral tissues, especially in the back areas of the mouth

and between the teeth. It should be noted that it is these

precise areas which are the most prevalent sites of caries

and periodontal disease.

Block et al 1973. Dental Plaque Disclosing Agent. United States Patent:1-6.

ADVANTAGES OF ERYTHROSIN RED

1. Fades in brief time.

2. Does not stain dental equipment or clothing

permanently.

3. Does not stain composite type restoratives

permanently.

4. Does not have any known possible effects that

iodine or mercury stains possess.

29

6. Fast Green F. D. & C. Green No. 3 – 5%

7. Fluoroscein F.D. & C. Yellow No. 8. Used with special ultraviolet light source to make the

agents visible.

30

PLAK – LITE:John Forrest 1981 The apparatus consists of a small mains operated lamp

gives off white light

through a dichrotic filter

Introducing 2 drops of Fluorescein – based solution

in patient’s mouth

Patient is asked to swish

Affinity for plaque by the indicator fluid

The light makes it visible as a

greenish yellow glow.31

Following application of the Plak-Lite® solution, the fluorescence remained unchanged for 20 minutes following which it began to fade, and after 2 hours, the fluorescence was completely absent.

The Plak-Lite® system consists of a fluorescent disclosing agent and a light source to make the agent visible. The solution has a light absorbency which lies within the frequencies of 2000-5400 A. The highest peak is at 4800 A and two lower peaks appear at 3250 A and 2900 A (Fig. 1).

The Plak-Lite® lamp transmits light in the frequency range 4200-5600 A.

32Lang et al.,1972. A fluorescent plaque disclosing agent. J. periodont Res.7: 59-67.

8. Two Tone solution• F. D. & C. Green No. 3• F. D. & C. Red No.3• Thicker (older) plaque stains Blue.• Thinner (newer) plaque stains Red.

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The central blue-staining mass would show a bacterial population and degree of organization that would be typical of old plaque, while the red peripheral zone would show the characteristics of newly formed plaque.

The red staining may have been due to the uptake of dye by the structureless cuticle or mucoprotein layer which forms on the enamel surface prior to plaque formation.

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35

Blue plaque - clinicaland microscopic features Red plaques

Considerably greater thickness than red plaque.

Extreme thinness - to the extent that sometimesit was hard to obtain sufficient material for examination.

High degree of architectural organization. Cocci,

Low density of organisms.

Rods and/or filaments arranged in parallel rowsforming fan-shaped patterns. Filaments intertwined forming a mesh work.

No evidence of any orderly architecture.

Motility — present in some blue plaques.

No motility.

Spiral organisms and vibrios. No filaments, spiral organisms or vibrios.

Block et al 1973. Dental Plaque Disclosing Agent. United States Patent:1-6.

36

9. Basic Fuchsin• 6 gm• Ethyl alcohol 100 ml - 95 %• Used by adding 2 drops to distilled water in a

dappen dish.

XII. METHODS OF APPLICATION

1. Solution for direct application:

i. Retracting the cheeks and tongue.

ii. Air drying the teeth.

iii. Carrying the solution in cotton pellet or swabs and applying it on the crowns of teeth.

iv. The patient is directed to spread the solution over all surfaces of teeth.

v. The distribution is examined and patient is instructed to rinse off.

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3. Rinsing

i. Few drops of concentrated preparation

ii. Water is added to dilution

iii. Swish and rinse for 1 minute

iv. Examining all the tooth surfaces.

4. Tablets or Wafers

i. After chewing, tablets or wafers are to be swished for around 30 – 60 seconds and then rinsed off.

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EFFECT

Clean tooth surface do not absorb the colouring agent.

The pellicle and bacterial plaque, if present, absorbs

the agent and are thus, disclosed.

Pellicle stains Relatively thin, clear covering.

Bacterial plaque Darker, thicker and more opaque.

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1. GC Plaque Indicator Kit(Now out of assortment and is replaced by GC Tri Plaque ID Gel)

APPLIED ASPECTS

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2. GC Tri Plaque ID Gel

Unique three tone plaque disclosing gel that identifies new, mature and acid producing biofilms.

41

Differentiates among fresh plaque, mature plaque (more than 48 hours old) and strong acid-producing plaque by colour to aid in patient oral hygiene education.

42

Ingredients:

1. Glycerol – 10 – 20%

2. Sucrose – 5 – 10%

3. Ethyl alcohol – 1 – 5%

4. Sodium carboxyl methyl cellulose– 1 – 5%

43

DIRECTIONS FOR USE

1. Apply GC Tri Plaque ID Gel onto the tooth surfaces using a suitable instrument (microbrush, swab or tooth brush).

44

2. Dispense gel into a dish if applying on multiple tooth surfaces. Following this, the patient is instructed to lightly rinse their mouth with water.

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3. Plaque identification by observing the color of gel.

46

a) A pink or red colour fresh plaque accumulation. b) A blue or purple colour 48hr old mature plaque. c) A light blue colour mature and strong acid-producing plaque.

47

2. Patient is instructed about proper tooth cleaning and thereby remove any remaining plaque and disclosing gel.

CONTRAINDICATION:Patients sensitive or allergic to benzoate preservatives.

48

3. The use of a Disclosing Agent During Resective Periodontal Surgery for Improved Removal of Biofilm

Aim: To clinically evaluate the scaling effectiveness during osseous resective surgery and the potential aid of a disclosing agent during this procedure. The influence on the scaling results induced by the operator awareness of a final supervision was also analyzed.

The surgical treatments – Apically positioned flap with respective osseous surgery – were performed.

49Montevecchi et al.2012. The Open Dentistry Journal(6):46-50.

50

N = 20 N = 20

Operator was informed about the planned post-treatment chromatic

examination by a supervisor. Operator was not previously informed

about the examination.

The chromatic examination was performed using the Phloxine B

disclosing agent. It was applied in a passive manner using sterile swabs

onto the exposed roots, left in situ for 10 seconds and then washed out for an

equal time.

The examination phase was performed just before suturing the flaps.

Teeth % with residual biofilm = (No. of treated teeth with atleast one stained area/total number of

treated teeth)*100

A second chromatic examination was performed to verify the use of

disclosing agent in improving the scaling results.

The stains were cleaned away & flaps were sutured.

A significant reduction (80%, p=0.0001) of the PI score between the first and the second chromatic examination was observed.

Distribution and number (%) of dental areas with identified deposits were:

Palatal areas (31%); Distal areas (29.5%); Mesial areas (21.9%); Vestibular areas (17.6%).

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Chromatic Examination

Mean PI(%) ± Standard Error

First 48.58 ± 3.88

Second 9.71 ± 0.78

This finding, associated to the observation that at the first

chromatic examination, the distal and lingual areas

remained more frequently unclean than the vestibular

areas – Suggestive of Accessibility and Visibility are

important limiting factors in determining the quality of

the cleansing outcome.

Interestingly, the use of a disclosing agent during

periodontal resective surgery seems to be instead

effective in improving the scaling and root planing results.

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XIV. CONCLUSION This study shows that a total removal of root deposits

during an osseous resective surgery is never obtained with conventional instrumentation.

Clinical limitations and visual deficiency could be primarily responsible of the present results. In order to overcome these obstacles, the use of a plaque disclosing agent during resective surgeries seems to be effective.

Through this observation, the post-operative clinical parameters remain to be assessed in order to evaluate the attainable advantages that affect both recovery phases and long-term periodontal health.

Such observations would constitute an interesting starting point for future experimental studies on this subject.

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XV. REFERENCES1. Newman et al. Carranza’s Clinical Periodontology. ed.3. W.B. Saunders

Co.2002.2. Dumitrescu AL. Etiology and Pathogenesis of Periodontal disease:

Springer – Verlag Berlin Heidelberg, 2010.3. Lang et al 1972. A fluorescent plaque disclosing agent. J. Periodont.Res.

7: 59-67.4. Shefali Sharma 2010. Plaque Disclosing Agent – A Review. J Adv Dental

Research.2[1]:1-35. Cohen et al 1972. A Comparison of Bacterial Plaque Disclosants in

Periodontal Disease. J Periodonol.43[6]: 333-338.6. Skaggs et al.,1991. Plaque Disclosing Compositions. United States

Patent: 1-7.7. Chetrus and Ion 2013. Dental Plaque – classification, formation, and

identification. International Journal of Medical Dentistry.3[2]:139-143.8. Block et al 1973. Dental Plaque Disclosing Agent. United States Patent:1-

6.9. Lang et al.,1972. A fluorescent plaque disclosing agent. J. periodont

Res.7: 59-67.10. Montevecchi et al.2012. The use of a Disclosing Agent During Resective

Periodontal Surgery for Improved Removal of Biofilm. The Open Dentistry Journal(6):46-50.

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plaque disclosing agents

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