“DETERMINATION OF EFFICACY OF ANTI-PLAQUE 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 Peri-implantitis.

• 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, pro-inflammatory 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.

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

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 & non-

uniformity 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 May-Jun;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.

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