“DETERMINATION OF EFFICACY OF ANTIPLAQUE AGENTS - A CLINICAL TRIAL”
A research project by:
Dr.Muhammad Wasif Haq,
Dr.Mehwish Batool,
Dr.Syed Hammad Ahsan.
Introduction
• Plaque control & prevention still stand as a
challenge for modern day dentistry.
• Adequate plaque control related to optimal
oral health & reduction in pathologies e.g.
Gingivitis, Periodontitis, Caries and Periimplantitis.
• Tooth brushing in conjunction to mouthwashes
reported to impart superior plaque control.
Introduction
•
•
•
•
•
•
Antiplaque agents:
The common antiplaque agents used are:
Chlorhexidine.
Fluoride.
Chlorhexidine + Fluoride.
Cetylpyridinium Chloride + Fluoride.
Introduction
• Chlorhexidine:
• Cationic, bacteriostatic & bactericidal agent.
• Inhibits bacterial Glucosyltransferase, causes
cytoplasmic precipitation & bacterial cell wall
disruption.
• Inhibitor of Matrix metalloproteinases, proinflammatory cytokines, interleukins & salivary
Cathepsin C.
Introduction
• Fluoride:
• Anionic, bacteriostatic & bactericidal agent.
• Remineralizes tooth structure, formation of
acid resistant and larger Fluoroapatite crystals.
• Inhibits Glucosyltransferase, Enolase, Glucose
uptake & utilization.
• Inhibits salivary Cathepsin C.
Introduction
• Cetylpyridinium Chloride:
• Bactericidal, quartenary ammonium
compound.
• Inhibits metabolic pathways, denatures
bacterial proteins & damages cell wall.
• Bioaccumulation in dental plaque.
Introduction
• Matter of debate:
• Inconclusive results on combination of
Chlorhexidine with Fluoride.
• Some report synergistic interaction while others
report negative interaction.
• Very few studies have evaluated the
combination of Cetylpyridinium Chloride with
Fluoride.
Aims & Objectives
• Primary aim to determine efficacy of
antiplaque agents:
• Chlorhexidine.
• Sodium Monofluorophosphate.
• Chlorhexidine + Sodium
Monofluorophospahte.
• Cetylpyridinium Chloride + Sodium Fluoride.
Materials & Methods
• A 5 day study conducted at L.C.M.D. Karachi.
• Informed consent was taken.
• Random allocation into 4 test groups & 1
control group ( 6 subjects/group).
• Plaque levels estimated prior to & at the
completion of the study using Turesky et al
modification of Quigley Hein plaque index.
Materials & Methods
• Inclusion criteria:
18-50 years.
Complete dentition till 2nd Molar in all the four
quadrants.
Exclusion criteria:
Any teeth with active dental caries or signs of
periodontal involvement .
Subjects with any systemic disease or using
medication.
Undergoing orthodontic treatment.
Subjects wearing prosthetic appliances.
Materials & Methods
• Participants instructed to:
• Brush teeth1 time (1 minute)with Fluoride
toothpaste.
• Mouthwash (5 ml with 10 ml water) 2 times (30
Seconds).
• Control group brushed teeth with water.
• Follow routine dietary habits.
• One way ANOVA & Bonferroni test for Multiple
Comparisions applied.
Materials & Methods
Name of group
Number of subjects
Active ingredients
Group 1
6
0.2% Chlorhexidine gluconate.
Group 2
6
0.05% Sodium
Monofluorophosphate
Group 3
6
0.12% Chlorhexidine gluconate &
0.05% Sodium Fluoride.
Group 4
6
0.05% Cetylpyridinium Chloride &
0.05% Sodium Fluoride.
Control
6
Water.
Results
Group
Pre-test
Post-test
Reduction
Significance
Group 1
11.89
11.0
0.89
p=0.032
Group 2
11.22
10.59
0.27
p=0.146
Group 3
13.37
13.41
-0.04
p=0.271
Group 4
13.36
12.34
1.02
p=0.023
Control
11.61
14.23
2.62
-
Discussion
• Compared to control group, all study groups
decreased plaque levels.
• Statistically significant difference only in
Chlorhexidine (group 1) & Cetylpyridinium
Chloride + Fluoride(group 4)compared to
control group (p < 0.05).
• Only Chlorhexidine & Fluoride combination did
not decrease plaque levels.
Discussion
Plaque inhibitory action
• Group 4 (Cetylpyridinium Chloride & Sodium
Fluoride)
• Group 1 (Chlorhexidine)
• Group 2 (Sodium Monofluorophosphate)
• Group 3 (Chlorhexidine and Sodium
Flouride))
• Control Group (Water)
Discussion
• Cetylpyridinium Chloride + Fluoride seems to
offer best anti plaque activity,more effective
than Chlorhexidine or Chlorhexidine with
Fluoride.
• Increasing Fluoride concentration did not offer
increased antiplaque effect.
• Synergistic effect reported for Chlorhexidine
with Fluoride not observed in this study.
Discussion
• New Research Challenges:
• Few or no side effects.
• Chlorhexidine : Stains, taste alteration,
supragingival calculus,cytotoxic to
odontoblasts, fibroblasts & osteoblasts.
• Sodium Fluoride: Cytotoxicity to fibroblasts, oral
mucosal cells & odnotoblasts.
• Cetylpyridinium Chloride: Staining.
• Toothpaste compatible mouthwashes.
Limitations
• Small sample size.
• Inability to eliminate tooth brushing.
• Possibility of lack of compliance & nonuniformity of diet.
• Alternatively experiments utilizing antimicrobial
isolates on teeth of laboratory animals &
assessing inhibitory effect of antiplaque agents
on microbial colonies could provide better
results.
Conclusion
• Antiplauque effect : Cetylpyridinium Chloride +
Sodium Fluoride> Chlorhexidine> Sodium
Monofluorophosphate.
• Chlorhexidine + Sodium Fluoride combination
did not reduce plaque levels.
• Increasing Fluoride concentration did not
improve antiplaque effect.
Special Thanks
• Our courteous thanks to:
• Teachers:
Dr. Naheed Najmi (L.C.M.D., Karachi).
Dr.Asif Hussain(L.C.M.D., Karachi).
Dr.Nadeem Chand (L.C.M.D., Karachi).
Team Members:
Dr.Mehwish Batool.
Dr.Syed Hammad Ahsan.
• All the participants of the study.
References
•
de Freitas CS, Diniz HF, Gomes JB, Sinisterra RD, Cortés ME.Evaluation
of the substantivity of chlorhexidine in association with sodium
fluoride in vitro. Pesqui Odontol Bras. 2003 Jan-Mar;17(1):78-81
•
Feres M, Gursky LC, Faveri M, Tsuzuki CO, Figueiredo LC.Clinical and
microbiological benefits of strict supragingival plaque control as part
of the active phase of periodontal therapy. J Clin Periodontol. 2009
Oct;36(10):857-67
•
Tyldesley. Oral Medicine. In: Tyldesley. Therapy.5th edition. Karachi:
Oxford University press, 2007, pp25
•
A. D. Russell. Chlorhexidine: Antibacterial Action and Bacterial
Resistance. Infection. 1986 Sep-Oct; 14(5):212-5
•
Mitchell DA, Mitchell L. Oxford handbook of clinical dentistry.In David
A.Mitchell, Laura Mitchell:Periodontology. 4th ed. Karachi: Oxford
University Press, 2005:pp 202
References
• Guha-Chowdhury N, Clark AG, Sissons CH.Inhibition of purified
enolases from oral bacteria by fluoride.Oral Microbiol
Immunol. 1997 Apr;12(2):91-7.
• Shani S, Friedman M, Steinberg D.The anticariogenic effect of
amine fluorides on Streptococcus sobrinus and
glucosyltransferase in biofilms.Caries Res. 2000 MayJun;34(3):260-7.
• Sturevant’s. Art and science of Operative Dentistry. In:
Theodore M. Roberson, Thomas F. Lundeen. Cariology : The
lesion, Etiology, prevention and control. 4th edition.
Philadelphia : Mosby, 2002, pp 110-3
• Dabrowska E, Letko M, Roszkowska-Jakimiec W, Letko R,
Jamiolkowski J.Effect of fluoride preparations on the activity of
human salivary cathepsin C.Rocz Akad Med Bialymst. 2005;50
Suppl 1:160-2.
HUMBLE THANKS