Prevention of Periodontal Disease – 2 Chemical Plaque Control

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

Aims Mechanism of chemical plaque control Types of chemical agents
Indications of chemical plaque control

Chemical Plaque Control
Supragingival plaque control Mechanism of action Prevention of colonization of enamel Removal of attached organisms Antimicrobials Not to replace any mechanical method of plaque removal Antimicrobial and plaque inhibitory agents in mouthwashes or toothpastes, used to inhibit bacterial plaque formation and thus to prevent or resolve chronic gingivitis, can only affect supragingival plaque. They should be clearly distinguished from agents directed against subgingival plaque which may be used to treat chronic periodontitis and which need to gain access to the periodontal pocket in sufficient concentration to produce their effect. A number of antimicrobial agents have been studies in their effect on supragingival plaque formation They can be divided into bisguanide antiseptics, quaternary ammonium antiseptics, phenolic antiseptics, other antiseptics, oxygenating agents, metal ions and natural products.1

Bisguanide antiseptics – Chlorhexidine Quaternary ammonium compounds Phenolic antiseptics Metal ions Natural products Oxygenating agents

Bisguanide - Chlorhexidine (CHX)
Marketed initially for disinfection of skin and mucous membranes and used in medicine and srugery as presurgical skin preparation and remains used in this way todayMarketed as disinfectant for skin and mucous membranes (1953’s) Introduced in dentistry for presurgical disinfection of the mouth (1960’s)

Chlorhexidine (CHX) Used in the form of chlorhexidine digluconate
Broad-spectrum bactericidal against Gram positive and Gram negative bacteria yeasts and fungi Mechanism immediate antibacterial prolonged effect – for several hours Both bacteriostatic and bacteriocidal Synthetic antimicrobial agent

How does CHX work? Positive charged CHX binds to
Bacterial cell wall Oral surfaces (hydroxyapatite tooth enamel) Damages permeability barriers Coagulation of macromolecules in cytoplasm CHX X X XXX XXX It has been shown that a 0.2% chlorhexidine gluconate mouthrinse will prevent the development of experimental gingivitis after the withdrawal of oral hygiene procedures.1,8 It has thus been shown to be both a highly effective anti-plaque agent. However, when used as an adjunct to normal oral hygiene measures, variable results are achieved, suggesting that chlorhexidine is more effective in preventing plaque accumulation on a clean tooth surface than in reducing pre-existing plaque deposits. Chlorhexidine is thus able to inhibit plaque formation in a clean Positive charged CHX binds to Bacterial cell wall Oral surfaces Hydroxyapatite tooth enamel Organic pellicle covering tooth surface Mucous membrane Salivary protein mouth but will not significantly reduce plaque in an untreated mouth. For these reasons chlorhexidine mouthwash should never be given to patients before the necessary periodontal treatment has been carried out and then should only be used for the specific rea increase in cellular membrane permeability followed by coagulation of the cytoplasmic macromolecules. Besdies acting immediately on oral bacteria it is retaoned on the tooth surface to exert a prolonged bactericidal effect and when concentration falls a bacteriostatic effect for several hours The major role in dental plaque inibition is result of local antibacterial activity of CHX bound to tooth sruface compoents (CHX is able to inhibit plaque formation in a clean mouth but will not significantly reduce plaque in an untreated mouth Due to its positive molecular charge, chlorhexidine readily reacts with the negatively charged cell surface of micro-organisms, thereby destroying the integrity of the cell membrane. Chlorhexidine is effective against Gram-positive and Gram-negative bacteria including aerobes and anaerobes in addition to viruses and fungi. The antimicrobial activity of chlorhexidine has led to it being used for years as dentistry's first choice for an anti-plaque agent. The anti-plaque properties of chlorhexidine are unrivalled by other compounds and its effects are stronger and of greater longevity than other antiseptics with similar antibacterial activity5. Bacterial cell

chlorhexidinefacts.com

CHX highly effective anti-plaque agent
more effective in preventing plaque accumulation on a clean tooth surface Little or no effect on established plaque and established gingivitis where subgingival plaque has already formed . more effective in preventing plaque accumulation on a clean tooth surface than in reducing pre-existing plaque deposits Little or no effect on established plaque and established gingivitis where subgingival plaque has already formed Chlorhexidine is thus able to inhibit plaque formation in a clean mouth but will not significantly reduce plaque in an untreated mouth. A healthy mouth in a subject with excellent oral hygiene. The teeth are free of visible plaque. It would be possible to maintain this healthy periodontal state by the use of an effective anti-plaque mouthwash such as chlorhexidine if this subject were unable to brush their teeth for a short period for any reason For these reasons chlorhexidine mouthwash should never be given to patients before the necessary periodontal treatment has been carried out and then should only be used for the specific reasons

How is CHX administered?
Mouthrinse 0.2% (Corsodyl) 0.12% (Peridex) Toothpaste/Gel Spray Chewing gum

Chlorhexidine Antiplaque effects are dose related (not concentration related) Optimum daily dose = 18 – 20 mg 0.2% CHX 10ml 2x daily = 20mg 0.12% CHX 15ml 2x daily = 18mg Optimum plaque control is achieved by using a mothwash with a divided daily dose of mg

CHX Toothpaste/Gels Toothpaste ingredients inactivate CHX
1% formulations similar to MW (Jenkins et al., 1993) Gels (1%) – no detergents or abrasives – reduces patient acceptance (staining) remove anionic detergents – modest reductions in plaque and gingivitis It is more difficult to incorporate chlorhexidine into toothpastes and gels because of the binding of chlorhexidine to components in the toothpaste. This reduces its activity by decreasing the number of active cationic sites.18 However, some formulations have been achieved which avoid this problem. In comparing the effect of potential anti-plaque ingredients in toothpastes, the plaque inhibitory effects of the other ingredients need to be taken into account. In this regard, it has been shown that commercial toothpastes containing various formulations of fluoride all reduce the rate of plaque regrowth compared with water in a 4-day study.19 Gels however can be applied to trays to teeth of severely handicapped patients when conventional cleaning is not possible – but still awkward technique

Kin Gingival Paste (0.12% CHX), (0.22% SF)
Curasept 0.12% Chlorhexidine Toothpaste

CHX Spray More popular than mouthwash or gels for use in handicapped patients Research shows that when used by parents less effective than gels in trays Applied to the teeth by a dentist under optimal conditions – good results So if patient has professional support a spray application has some advantages over traditional methods (mouthwash gels)

CHX Gum CHX molecules are unbound (20mg CHX diacetate)
anti-plaque effect similar to 0.2% CHX mouthwash Tooth staining was seen but intensity less with the gum Good method in long-term users GUM - Chlorhexidine has also been incorporated into a sugar-free chewing gum (Fertin A/S, Vejle, Denmark), and in this form the chlorhexidine molecule remains unbound. The chewing gum contains 20 mg of chlorhexidine diacetate and this has been compared with the effects of a 0.2% chlorhexidine mouthwash and a placebo gum in a clinical study.21 The 151 subjects were divided into three groups, one using the chlorhexidine gum, one 0.2% chlorhexidine mouthwash and one a placebo gum. These groups were tested for their anti-plaque effects after 4 and 8 weeks. The subjects using the gum chewed two pieces twice per day for 10 minutes and mouthwash subjects rinsed twice per day for 1 minute. There were significant and similar anti-plaque effects from the use of the chlorhexidine gum and mouthwash, and these were not seen with the placebo gum. Tooth staining was seen both with the chlorhexidine gum and mouthwash but the intensity and extent of stain was less with the gum. In a similar study, the use of chlorhexidine gum has also been found to reduce plaque levels significantly more than the use of xylitol and sorbitol gums.22 Therefore, the use of chlorhexidine gum could be a good method of using chlorhexidine in longer term users.

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 effects Brown staining of teeth/fillings difficult to remove
result of dietary pigments adhering to tooth surface Tooth it produces brown staing of teeth and also composite and glass ionomer restorations which is very difficult to remove usually requiring scaling – ultrasonic scaler can remove the stain It is important for these reasons to advise patients using chlorhexidine mouthwash to avoid the intake of tea, coffee and red wine for the duration of its use. One should also severely restrict its use in patients with visible anterior composite and glassionomer restorations. Staining may also effect the tongue and mucous membranes So CHX formulations that do not stain are ineffective at plaque formation as the cationic group of the molecule which should react with bacteria has reacted with something else in the formulation and is therefore unavailable It is also worth stating that chlorhexidine formulations which do not stain are ineffective in inhibiting plaque. This is because the second cationic group of the molecule has reacted with something in the formulation making it unavailable for either a beneficial bactericidal effect or the unwanted staining effect. This has been shown clearly in a comparison of a number of commercial chlorhexididine mouthwashes which differed in their content of binding additives. Those which effectively bound up the chlorhexidine did not produce staining but also lacked an anti-plaque effect.25,26 Mouthwashes with this reduced effect include French Eludril. The formula of British Eludril has now been changed to prevent the binding of chlorhexidine. As a result this product is now effective and causes tooth staining similar to the other effective products. Dietary stains Bacteria

Side effects (cont) suppresses acidogenic plaque bacteria Raises pH
2. Supragingival calculus formation suppresses acidogenic plaque bacteria Raises pH ppt of calcium and phosphate 1 +2 = dose-dependent cannot be reduced without loss of antiplaque effects Suppresses plaque bacteria and raises the ph so leads to precicipation of calcium and phosphate. Although CHX is nontoxic –

Side effects (cont) 3. Taste disturbances 4. Mucosal desquamation 3 and 4 can be decreased by reducing the conc. and using a larger volume to maintain clinical efficacy 5. Parotid swelling ? Mechanical obstruction of the duct Taste disturbances may last for several hours after use Desquamative lesions occur for in a small number of people – with the CHX making membranes vuleneralbe to mechanic trauma or to the cytotoxic effects of the chemicals Few cases of parotid swelling has occurred – clinical features suggest mechanical obstruction of the duct

Quaternary ammonium compounds
Cetylprydinium chloride (CPC) Moderate plaque inhibitory activity Less effective than CHX monocationic CPC pre-brushing mouthrinse has not been found to have an additional beneficial antiplaque effect Have been marketed as lozenges (CEPACOL) but cause marked staining + CPC Quaternary ammonium compounds such as cetylpyridinium chloride (CPC) have moderate plaque inhibitory activity.31,32 Although they have greater initial oral retention and equivalent antibacterial activity to chlorhexidine, they are less effective in inhibiting plaque and preventing gingivitis. One reason for this may be that these compounds are rapidly desorbed from the oral mucosa.11,33,34 It has also been found that the antibacterial properties of these compounds are considerably reduced once adsorbed onto a surface and this may be related to the monocationic nature of these compounds. The cationic groups of each molecule bind to receptors on the mucosa producing the mucosal retention but because of the monocationic nature of these molecules this process leaves few unattached sites available for its antibacterial function. A CPC pre-brushing mouthrinse used as an adjunct to mechanical oral hygiene has not been found to have an additional beneficial effect on plaque accumulation.35

Listerine Active ingredients Inactive ingredients
Phenol-related essential oils (thymol and eucalyptol) Menthol and methyl salicylate Inactive ingredients Water Alcohol (26%) Less effective than CHX Side effects – bitter taste, staining

Phenolic compounds (cont)
Triclosan Soaps, deodorants Mouthwash reduce plaque accumulation but to a much lesser extent than CHX dependent upon the presence of co-polymers in the formulation to increase oral retention (Gantrez) anti-inflammatory effect triclosan mouthwashes reduce plaque accumulation but to a much lesser extent than chlorhexidine. However, the extent of their plaque inhibitory effect seems to be dependent upon the presence of co-polymers in the formulation to increase oral retention of triclosan. Any effects of triclosan on gingivitis levels are probably due to its anti-inflammatory effect. The anti-inflammatory effect of triclosan also depends upon its ability to penetrate into the gingival tissues and this is in turn dependent upon the nature of the solvent( s) in the mouthwash formulation. Brushing with fluoride toothpaste is better than brushing with water alone in removing plaque – due to antimicrobial effect of fluoride and detergents and abrasives in toothpaste Recently Chemical agents have been added to toothpastes to enahcne the removal of plaque These formulations provide significant reductions in plaque and improvemt in gingival health when compared with fluoride toothpaste alone (Volpe et al., 1996) There recomeend the use of toothpaste which contain triclosa with either copolymer or zinc citrate to improvlelevels of plaque control and periodontal health

Triclosan Added to toothpaste - effect is improved by
Copolymer (Gantrez) to enhance retention in the mouth OR Zinc citrate to provide additional antibacterial activity Provide significant reduction in plaque and improvement in gingival health when compared with fluoride toothpaste alone (Volpe et al., 1996)

Metal ions Zinc Copper and Tin – local side effects of staining
additive effect with other antiseptics Attaches to dental tissue and inhibits regrowth of plaque Copper and Tin – local side effects of staining

Natural products - Sanguinarine
Root of Sanguinaria canadensis (Bloodroot) plaque inhibitory effect less than CHX Mouthwash is more effective than toothpaste Gingivitis prevention is questionable. Plant extractTOXIC - Do not ingest! The root contains several alkaloids, most notably sanguinarine, which has shown antiseptic, anesthetic and anticancer activity. American Indians used the root for rhuematism, asthma, bronchitis, lung ailments, laryngyitis and fevers. The red-orange juice from the root was applied to warts, used as a dye and a decorative skin stain. Bachelors of the Ponca tribe used it as a love charm, by applying it to their palms and shaking hands with the woman they wanted to marry. Within 5 or 6 days, the girl would be willing. Unable to prevent gingivitis

Oxygenating agents Hydrogen peroxide, sodium peroxyborate Mouthrinses
Inhibit obligate anaerobes Some retardation in plaque growth Further investigation is needed Oxygenating agents such as hydrogen peroxide, and buffered sodium peroxyborate and peroxycarbonate in mouthrinses have a beneficial effect on acute ulcerative gingivitis, probably by inhibiting anaerobic bacteria.116 As obligate anaerobes are important in the development of gingivitis and periodontitis, these effects could be useful. The information relating to the value of these agents in suppressing supragingival plaque formation is limited although some retardation of plaque growth has been noted with the use of oxygenating mouthwashes.117 In view of the importance of obligate anaerobic bacteria in the development of gingivitis and periodontitis these compounds deserve further investigation.1

Alcohol containing mouthwashes
Accidental swallowing by children Link with oral and pharyngeal cancer ??? Reduce the hardness of composite and hybrid-resin restorations related to % alcohol content of mouthwash Many mouthwashes contain significant quantities of alcohol and this may have a number of possible disadvantages. Firstly, it is important that they are not accidentally swallowed particularly by young children. In this regard, alcohol toxicity from this source has been reported.118,119 Secondly, because of the known links between alcohol consumption plus tobacco smoking, and oral and pharyngeal cancer, it has been suggested that the frequent use of alcohol-containing mouthwashes might increase the incidence of this form of cancer. However, the evidence for this appears to be very weak, mainly because the statistical tests applied to test the strength of association are effected by the confounding effects of known aetiological factors such as tobacco smoking and alcohol consumption in the subjects studied.120–123 Thirdly, it has been suggested that the use of alcoholcontaining mouthwashes may increase the alcohol content of exhaled breath and could thus change the readings of the police breath test.124 However, this effect was found to be transient. Finally, alcohol-containing mouthwashes have been shown to reduce the hardness of composite and hybrid-resin restorations and these effects seem to relate to the percentage alcohol content of the mouthwash.125 It has also been found that composite resins soaked in alcohol-containing mouthwashes gain more weight that those soaked in alcohol-free mouthwashes.126 This suggests that some component of mouthwash, probably alcohol, is absorbed into the resin and may be responsible for the softening effect. However, one study has found that either alcohol-containing or alcohol-free mouthwashes reduced the hardness of composite resin and glass ionomer cement.127 In addition, it has been found that alcohol-containing mouthwashes may alter the colour of some hybrid composite resins.128

Chlorhexidine most effective chemical agent
Bottom line Chlorhexidine most effective chemical agent

Indications of chemical plaque control
1. To replace toothbrushing when this is not possible 2. As an adjunct to toothbrushing in situations when this may be painful or inadequate . To replace mechanical toothbrushing when this is not possible in the following situations: •

1. Replacing Toothbrushing
After oral/periodontal therapy and during the healing period Intermaxillary fixation Chlorhexidine mouthwash may also be used during periods of intermaxillary fixation following the treatment of fractures or skeletal surgery when effective oral hygiene is not possible lingually and interdentally. During this period patients should also be seen regularly for professional cleaning by a dentist or hygienist to limit staining. After oral or periodontal surgery and during the healing period (fig. 4) • After intermaxillary fixation used to treat jaw fractures or following cosmetic jaw surgery • With acute oral mucosal or gingival infections when pain and soreness prevents mechanical oral hygiene • For mentally or physically-handicapped patients who are unable to brush their teeth themselves. However, these patients may also not be able to use a mouthwash so that swabbing the gingival margins by a care worker may be the only option. This may not necessarily be easier for the care worker to carry out than brushing. The long-term use of effective agents has the major disadvantage of causing tooth staining.

1. Replacing Toothbrushing
c. Acute oral mucosal or gingival infections D. Mentally or physically-handicapped patients who are unable to brush their teeth themselves

2. With Toothbrushing Following subgingival scaling/root planing when the gingivae may be sore (used for ~3 days) Following scaling - cervical hypersensitivity due to exposed root surface 2 As an adjunct to normal mechanical oral hygiene in situations where this may be compromised by discomfort or inadequacies: • Following subgingival scaling and root planing when the gingivae may be sore for a few days. The use of a mouthwash is usually only necessary for about 3 days in this situation. • Following scaling when there is cervical hypersensitivity due to exposed root surface. Its use needs to be combined with measures to treat the hypersensitivity since the duration for the use of the mouthwash should usually not exceed 2 weeks to avoid tooth staining. However patients vary considerably in the amount of staining they experience and some may have staining within a few days and others show little after 1 month’s use. • Following scaling in situations where the patient’s oral hygiene remains inadequate. The inadequacy needs to be remedied quickly since the duration of the mouthwash use should not exceed 2 weeks in order to avoid staining. It would be better to have a suitable antibacterial agent which does not cause significant staining in a toothpaste or pre-brush rinse, such as triclosan, for this purpose in view of the above restriction.

2. With Toothbrushing Following scaling in situations where the patient’s oral hygiene remains inadequate Need to remedy situation quickly duration of the CHX mouthwash use should not >2 weeks Antibacterial agent that does not cause significant staining in a toothpaste or pre-brush rinse - TRICLOSAN

Assess 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 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 chlorhexidine These are mouthwashes with good substantivity and antibacterial spectrum and thus have good anti-plaque effects. The only agents with these properties are the bisguanides, the best of which is chlorhexidine. These can be used to replace mechanical cleaning methods for short periods when this is not possible. The main drawback of the bisguanides is staining which is strongly linked to their substantivity. It precludes their prolonged use. Commercial chlorhexidine mouthwashes which do not produce staining are inactive usually because the active chlorhexidine molecules have been bound to another constituent of the mouthwash. Two other agents, salifluor and delmopinol, either achieve or come close to achieving these properties but probably by rather different mechanisms to chlorhexidine.

Group 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. These are agents with little or no substantivity but with a good antibacterial spectrum. Therefore, they have plaque inhibitory effects but lack true anti-plaque effects. They thus cannot be used to replace toothbrushing but can be used as adjuvants to mechanical cleaning.

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) These are antiseptic mouthwashes that have be shown to have antibacterial effects in vitro but in clinical studies have been shown to have either varying plaque inhibitory effects from moderate to low or no statistical difference from the negative control. These include hexetidine (Oraldene), povidone iodine, oxygenating agents and the natural product sanguinarine (Veadent) which is a benzophenanthridine alkaloid. These would have limited or no adjuvant effects when combined with mechanical cleaning and therefore cannot be recommended for this purpose.

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 stick
Mechanical effect of fibers Release of antibacterial chemicals against Periodontal pathogens Cariogenic bacteria Antiplaque effect similar to 0.2% CHX mouthwash Salvadora persica Various explanations for the cleansing ecacy of the miswak have been o.ered, including: (i) the mechanical e.ects of its ®bers, (ii) the release of bene®cial chemicals by the miswak or (iii) a combi- nation of both (i) and (ii) (8). When a miswak is used for teeth and oral cleaning, it is held by one hand in a pen-like grip and the brush-end is used with an up-and-down or rolling motion (27, 28). A two-®nger and a ®ve-®nger grip technique have also been described (29). The miswak is generally used for a longer period of time than a toothbrush (25), the cleaning is usually implemented for 5 to 10 min each time (7), and the plant ®bers remove plaque and simultaneously massage the gum. Unlike a modern toothbrush, the bristles of the miswak are situated along the long axis of its handle. Conse- quently, the facial surfaces of the teeth can be reached more easily than the lingual surfaces or the interdental spaces (25). Reduced lingual access was considered a drawback of the miswak by Carl & Zambon (1). So far, published studies on the in vivo cleansing ecacy of the miswak have been scarce and such in vitro studies are missing. Eid et al. (25) reported that the majority of miswak users appl Fig. 2. Mouth cleaning with a chewing stick usually involves the brushing of teeth, gums and tongue. When cleaning is completed, the chewing stick is removed or may be left in the mouth for some additional time. Some in vitro studies have shown that S. persica extracts inhibited growth of various oral aerobic and anaerobeic bacteria, and C. albicans (76, 78). Inhibition of in vitro plaque formation, growth and acid production of various cariogenic bacteria by such extracts have also been demonstrated (15).

Miswak Recommended by WHO as alternative oral hygiene method
Proper use Pen grip Rolling or up and down movement Massage the gum and tooth surfaces Longer time than brushing – 5 to 10 min

Mouthrinse recommendation for prosthodontic patients
High risk for plaque accumulation additional measures Side effects on the prosthesis CHX for short-term periods EOs for long-term periods. Cortelli et al.,2014

Mouthrinse recommendation for orthodontic patients
Use of oral antiseptics by orthodontic subjects may be beneficial in controlling plaque and gingivitis. CHX showed the best results in reducing plaque and gingivitis CHX for short-term periods EOs for long-term periods. Nogueira et al.,2014

Literature Essential oil mouthwash (EO) may be equivalent to chlorhexidine (CHX) for long-term control of gingival inflammation but CHX appears to perform better than EO in plaque control. Neely 2012 EO less staining 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 special needs patients
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Prevention of Periodontal Disease – 2 Chemical Plaque Control

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