prevention of periodontal disease – 2 chemical plaque control dr. omar alkaradsheh
TRANSCRIPT
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
Chemical Plaque ControlChemical Plaque Control
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
Chemical Plaque ControlChemical Plaque Control
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
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
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)
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
Chemical Plaque ControlChemical Plaque Control
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
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
+
Chemical Plaque ControlChemical Plaque Control
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
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)
Chemical Plaque ControlChemical Plaque Control
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
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
Chemical Plaque ControlChemical Plaque Control
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
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..
Chemical Plaque ControlChemical Plaque Control
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
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