Prevention of Periodontal Disease – 2 Chemical Plaque Control

Prevention of Periodontal Disease – 2Chemical 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

Chemical Plaque Control • 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) Damages permeability barriers Coagulation of macromolecules in cytoplasm CHX X X 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) • Curasept0.12% 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 • Brown staining of teeth/fillings difficult to remove result of dietary pigments adhering to tooth surface Tooth Dietary stains Bacteria

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

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

Listerine • Active 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 • 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 • 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 Sanguinariacanadensis (Bloodroot) • plaque inhibitory effect less than CHX • Mouthwash is more effective than toothpaste • Gingivitis prevention is questionable.

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 • 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 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

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

Mouthrinserecommendation forprosthodontic 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 fororthodontic 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

Prevention of Periodontal Disease – 2 Chemical Plaque Control