Prevention of Periodontal Disease

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Prevention of Periodontal Disease 2Chemical
Plaque Control

• Dr. Omar Alkaradsheh

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Aims

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

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Chemical Plaque Control

• Supragingival plaque control
• Mechanism of action
• Prevention of colonization of enamel
• Removal of attached organisms
• Antimicrobials

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Chemical Plaque Control

1. Bisguanide antiseptics Chlorhexidine
2. Quaternary ammonium compounds
3. Phenolic antiseptics
4. Metal ions
5. Natural products
6. Oxygenating agents

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Bisguanide - Chlorhexidine (CHX)
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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

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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
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chlorhexidinefacts.com
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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

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How is CHX administered?

• Mouthrinse
• 0.2 (Corsodyl)
• 0.12 (Peridex)
• Toothpaste/Gel
• Spray
• Chewing gum

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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

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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)

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

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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

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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

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Is CHX safe?

• poorly absorbed by the GIT - displays very low
  toxicity
• No carcinogenic or teratogenic effects have been
  found following long-term use

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Side effects

• Brown staining of teeth/fillings
• difficult to remove
• result of dietary pigments adhering to tooth
  surface

Tooth
Dietary stains
Bacteria
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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

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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

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Chemical Plaque Control

1. Bisguanide antiseptics Chlorhexidine
2. Quaternary ammonium compounds
3. Phenolic antiseptics
4. Metal ions
5. Natural products
6. Oxygenating agents

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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
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Chemical Plaque Control

1. Bisguanide antiseptics Chlorhexidine
2. Quaternary ammonium compounds
3. Phenolic antiseptics
4. Metal ions
5. Natural products
6. Oxygenating agents

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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

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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

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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)

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Chemical Plaque Control

1. Bisguanide antiseptics Chlorhexidine
2. Quaternary ammonium compounds
3. Phenolic antiseptics
4. Metal ions
5. Natural products
6. Oxygenating agents

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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

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Chemical Plaque Control

1. Bisguanide antiseptics Chlorhexidine
2. Quaternary ammonium compounds
3. Phenolic antiseptics
4. Metal ions
5. Natural products
6. Oxygenating agents

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Natural products - Sanguinarine

• Root of Sanguinaria canadensis (Bloodroot)
• plaque inhibitory effect less than CHX
• Mouthwash is more effective than toothpaste
• Gingivitis prevention is questionable.

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Chemical Plaque Control

1. Bisguanide antiseptics Chlorhexidine
2. Quaternary ammonium compounds
3. Phenolic antiseptics
4. Metal ions
5. Natural products
6. Oxygenating agents

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Oxygenating agents

• Hydrogen peroxide, sodium peroxyborate
• Mouthrinses
• Inhibit obligate anaerobes
• Some retardation in plaque growth
• Further investigation is needed

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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

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Bottom line

• Chlorhexidine most effective chemical agent

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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

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1. Replacing Toothbrushing

• After oral/periodontal therapy and during the
  healing period
• Intermaxillary fixation

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1. Replacing Toothbrushing

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

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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

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2. With Toothbrushing

• Following scaling in situations where the
  patients oral hygiene remains inadequate
• Need to remedy situation quickly
• duration of the CHX mouthwash use should not gt2
  weeks
• Antibacterial agent that does not cause
  significant staining in a toothpaste or pre-brush
  rinse - TRICLOSAN

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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

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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

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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.

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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)

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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.

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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
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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

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Mouthrinse recommendation 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

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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

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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

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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

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Chemical plaque control in special needs patients
No-spell Beaker
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Thank you