Dr. AnumalaDepartment of Oral Health

� Mouth rinses� Toothpastes� Chewing Gum� Lozenges

1. Bisguanide

2. Quaternary Ammonium Compounds

3. Phenolic Antiseptics

4. Hexetidine

5. Povidone Iodine

6. Triclosan

7. Delmopinol

8. Salifluor

9. Metal Ions

10. Natural Products

11. Oxygenating Agents

� Kills a wide range of microorganisms by damaging cell wall

� Bisguanide antiseptics that possess anti-plaque activity are:

� Chlorhexidine

� Alexidine

� Octenidine

� Digluconate of chlorhexidine is a synthetic broad-spectrum antimicrobial agent

� Effective against gram +ve and –ve bacteria including aerobes and anaerobes, yeasts and fungi

� Action: increases cellular membrane permeability followed by coagulation of the cytoplasmic

macromolecules

� Reduces bacterial adherence by binding to the bacterial outer membrane

� According to research 0.2% chx will prevent experimental gingivitis after withdrawal of oral hygiene

� However chx is more effective in preventing plaque accumulation on a clean tooth surface than in reducing preexisting plaque deposits

� Chx is able to inhibit plaque formation in a clean mouth but will not significantly reduce plaque in an untreated mouth

� Therefore, it should not be given to patients before necessary periodontal treatment

� Substantivity of Chx

� Substantivity: ability of drugs to adsorb onto and bind to soft and hard tissues

� This ability of chx allows it to maintain effective concentrations for long periods of time and which makes it suitable for inhibition of plaque formation

� Safety of Chx

� Excreted through feces

� Poorly absorbed by GIT

� Low toxicity

� Clinical Use

� Formulations:▪ Mouth Rinses:

▪ 0.2% chlorhexidine 10mL per rinse (Corsodyl)

▪ 0.12% chlorhexidine 15mL per rinse (Peridex)

� Can be combined with fluoride in rinses to provide anti-plaque and anti-cariogenic effect:▪ 0.12% chlorhexidine with 100ppm fluoride

▪ 0.05% chlorhexidine with 0.05% sodium fluoride

� It is difficult to incorporate chlorhexidine into toothpastes and gels because of the binding of chx to components in toothpaste

� Chx can also be incorporated into a sugar-free chewing gum

▪ Contains 20mg of chx

▪ E.g. Fertin A/S, Vejle

� Side Effects of Chx

� Unpleasant taste

� Alters taste sensation

� Stains teeth (pts should avoid tea, coffee and red wine)

� Encourages supragingival calculus formation

� Stains restorations (margins and surfaces of composites and GIC)

� Rare Side Effects:▪ Mucosal erosion

▪ Parotid swelling

� have moderate plaque inhibitory activity

� Greater oral retention and equivalent antibacterial activity to chx

� Less effective in inhibiting plaque and preventing gingivitis

� Reason: rapidly desorbs from oral mucosa

� Example of QAC is cetylpyridinium chloride (CPC)

� Most effective in 0.1% formulations

� Available as CPC rinses and CPC lozenges (Cepacol)

� Causes staining

� Used either alone or in combination in mouth rinses or lozenges

� Has moderate plaque inhibiting effects and some anti-inflammatory effects in reducing gingivitis

� E.g. is Listerine, which is an essential oil/phenolic mouthwash

� Its lack of profound plaque inhibitory effect is because of poor oral retention

� Thus, Listerine has moderate effect on plaque re-growth and some anti-inflammatory effect which may reduce the severity of gingivitis

� Has some plaque inhibitory activity

� Oral retention: 1 – 3 hours, which accounts for the low plaque inhibitory effects

� Concentrations >0.1% can cause oral ulceration

� Combining zinc with hexetidine improves its plaque inhibiting activity

� Product: Oraldene

� No significant activity when used as 1% mouthwash

� Absorption of significant levels through oral mucosa makes it unsatisfactory for prolong use in oral cavity

� Can cause iodine sensitivity

� Either full strength or equal parts of povidone iodine and water is used for subgingival irrigation.

� Non-ionic antiseptic

� Has moderate plaque inhibitory effects

� Usually used in combination with zinc to increase oral retention

� Extent of plaque inhibitory effects seems to be dependent upon presence of co-polymers to increase retention

� Acts as an anti-inflammatory agent in mouth rinses and toothpastes

� Inhibits cyclo-oygenease and lipooxygenase thus reducing prostaglandins and leukotrienes

� Anti-inflammatory effect of depends on its ability to penetrate into gingival tissues and this is dependent upon the nature of solvent (s) in mouthwash formulation

� Triclosan has also been added to a number of experimental and commercial toothpastes with and without zinc and these appear to produce moderate inhibition of plaque formation

� Brushing with a Triclosan toothpaste reduces gingival inflammation

� Effective formulations:

� Triclosan/ Copolymer

� Triclosan/ Zinc Citrate

� Has plaque inhibiting effects:� Interferes with plaque matrix formation and reduction of bacterial adherence

� This causes plaque to be more loosely adherent to tooth making it easier to be removed by mechanical cleaning, therefore its suitable for a pre-brush rinse

� Formulations: 0.1% and 0.2%

� Has plaque inhibiting effects:

� Interferes with plaque matrix formation and reduction of bacterial adherence

� This causes plaque to be more loosely adherent to tooth making it easier to be removed by mechanical cleaning, therefore its suitable for a pre-brush rinse

� Possesses anti-inflammatory effects

� Mediates its plaque inhibitory and anti-inflammation effects without causing a major shift in bacterial populations apart from the reductions in dextran-producing streptococci

� Side effects:

� Transient numbness of tongue

� Tooth and tongue staining

� Taste disturbances

� Mucosal soreness

� Erosion

� Is a salicylanide which has anti-bacterial and inflammatory properties

� Mechanism of action not fully understood

� Experimentally 0.12% is as effective as 0.12% chlorhexidine

� Clinically more studies needed before it can be released for clinical use

� Zinc, copper, and tin possess plaque inhibitory effect

� Copper and tin: causes staining

� Fluoride compounds such as stannous fluoride and amine fluoride have plaque inhibitory effect due to stannous ion and the surface-active amine portions

� Zinc is retained by dental plaque and inhibits its regrowth without disrupting oral ecology

� Zinc has additive or synergistic effect with hexetidine, Triclosan and sanguinarine

1. Sanguinarine2. Propolis

� Contains iminium ion which is responsible for its activity

� Is retained in plaque for several hours after use and is poorly absorbed by GIT

� Mode of action: inhibition of glycolysis with assistance from zinc

� Is an effective plaque inhibitory agent but less effective than chlorhexidine

� Prevents development of gingivitis

� Mouthwash is more effective plaque inhibitory agent than toothpaste due to binding of other components in toothpaste to the chemically reactive site of the sanguinarine molecule

� Has an antiseptic, anti-inflammatory, antimycotic and bacteriostatic effect

� Not effective as mouthwash

� Some benefits in toothpastes, effective against some periodontal pathogens

� Examples:� Hydrogen peroxide

� Buffered sodium peroxyborate

� Peroxycarbonate

� Inhibits anaerobic bacteria

� As obligate anaerobes are important in the development of gingivitis and periodontitis, these effects are useful

� Many mouthwashes contain significant quantities of alcohol, which leads to a number of possible disadvantages:

� If accidentally swallowed by young children it can cause alcohol toxicity

� Can increase the incidence of oral and pharyngeal cancer

� Increases alcohol content of exhaled breathe and thus could change the readings of the police breathe test

� Reduces hardness of composite and hybrid-resin restorations

1. To replace mechanical toothbrushing when it is not possible in the following situations:

� After oral or periodontal surgery and during healing period

� After intermaxillary fixation used to treat jaw fractures or following cosmetic surgery

� With acute oral mucosal or gingival infections when pain and soreness prevents mechanical oral hygiene

� For mentally or physically challenged pts who are unable to brush:▪ However, these pts may not be able to use a mouthwash so swabbing the gingival margins by a care giver may be the only option

▪ Long-term use of effective agents has the major disadvantage of causing tooth staining

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 planning when the gingivae maybe sore for a few days. Use of mouthwash is usually only necessary for about 3 days in this situation

� Following scaling when there is cervical hypersensitivity due to exposed root surfaces. Its use needs to be combined with measures to treat the hypersensitivity since duration for use of mouthwash should not exceed 2 weeks to avoid staining. Amount of staining varies between patients

� Following scaling in situations where the patients’ 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 suitable antibacterial agent which does not cause significant staining in a toothpaste or pre-brush rinse