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
1.
Prevention of colonization
of enamel
2.
Removal of attached
organisms
3.
Antimicrobials
Chemical Plaque Control
1.
2.
3.
4.
5.
6.
Bisguanide antiseptics – Chlorhexidine
Quaternary ammonium compounds
Phenolic antiseptics
Metal ions
Natural products
Oxygenating agents
Bisguanide - Chlorhexidine (CHX)
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
How does CHX work?
Positive charged CHX binds to


Bacterial cell wall
Oral surfaces (hydroxyapatite
tooth enamel)
CHX
X
X
Damages permeability barriers
Coagulation of macromolecules
in cytoplasm
XXX
XXX
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
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
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)


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
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
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
1.
Brown staining of
teeth/fillings
difficult to remove
result of dietary pigments
adhering to tooth surface
+
Tooth
CHX
+
Dietary
Bacteria
stains
Side effects (cont)
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
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
Chemical Plaque Control
1.
2.
3.
4.
5.
6.
Bisguanide antiseptics – Chlorhexidine
Quaternary ammonium compounds
Phenolic antiseptics
Metal ions
Natural products
Oxygenating agents
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
Chemical Plaque Control
1.
2.
3.
4.
5.
6.
Bisguanide antiseptics – Chlorhexidine
Quaternary ammonium compounds
Phenolic antiseptics
Metal ions
Natural products
Oxygenating agents
Listerine

Active ingredients



Inactive ingredients




Phenol-related essential oils
(thymol and eucalyptol)
Menthol and methyl salicylate
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

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)
Chemical Plaque Control
1.
2.
3.
4.
5.
6.
Bisguanide antiseptics – Chlorhexidine
Quaternary ammonium compounds
Phenolic antiseptics
Metal ions
Natural products
Oxygenating agents
Metal ions

Zinc



additive effect with other antiseptics
Attaches to dental tissue and inhibits
regrowth of plaque
Copper and Tin – local side effects of
staining
Chemical Plaque Control
1.
2.
3.
4.
5.
6.
Bisguanide antiseptics – Chlorhexidine
Quaternary ammonium compounds
Phenolic antiseptics
Metal ions
Natural products
Oxygenating agents
Natural products - Sanguinarine




Root of Sanguinaria
canadensis (Bloodroot)
plaque inhibitory effect less
than CHX
Mouthwash is more
effective than toothpaste
Gingivitis prevention is
questionable.
Chemical Plaque Control
1.
2.
3.
4.
5.
6.
Bisguanide antiseptics – Chlorhexidine
Quaternary ammonium compounds
Phenolic antiseptics
Metal ions
Natural products
Oxygenating agents
Oxygenating agents
Hydrogen peroxide, sodium peroxyborate




Mouthrinses
Inhibit obligate anaerobes
Some retardation in plaque growth
Further investigation is needed
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
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
1. Replacing Toothbrushing
A.
B.
After oral/periodontal therapy
and during the healing period
Intermaxillary fixation
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. 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 prebrush 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
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.
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!!!
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
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
Neely 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
special needs patients
“No-spell”
Beaker
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