CHEMICAL PLAQUE CONTROL

CONTENTS
• Introduction
• Historical Background
• Approaches to Chemical Plaque Control
• Chemical Plaque Control Agents
• Classification of Chemical Agents according to their
Antimicrobial Effect and Substantivity
• Chlorhexidine
• Povidone Iodine
 Introduction
• Periodontal disease is highly prevalent and can affect up to 90% of
the world population.
• Since then control of biofilm accumulation on the teeth has been
the key to periodontal disease prevention. Toothbrushes and the
use of dental floss and other devices to remove bacterial plaque
from the teeth are the most common ways of removing biofilm.
Despite its important role in the control of periodontal disease,
mechanical plaque control is not properly practiced by most
individuals.
• A systemic review of the effectiveness of self-performed
mechanical plaque removal in objects with periodontal disease
concluded that it had limitations. So the adjunctive use of
chemical plaque control might beneficial.
 APPROACHES TO CHEMICAL PLAQUE CONTROL

Mechanical cleaning aims to regularly remove sufficient microorganisms to leave a “healthy

plaque” present, which cannot induce gingival inflammation. Chemical agents, on the other
hand, could influence plaque quantitatively and qualitatively via several processes.
The action of the chemicals could fit into four categories:

1.Anti-adhesive
2.Antimicrobial
3.Plaque removal
4.Antipathogenic

ANTIADHESIVE AGENTS:
Antiadhesive agents would act at the pellicle surface to prevent the initial attachment of the
primary plaque-forming bacteria. Such adhesive agents should have to be preventive in their
effects, acting most effectively on an initially clean tooth surface. Adhesive agents do exist
and are used in the industry, domestically, and in the environment. Such chemicals prevent
the attachment and the development of a variety of biofilms and are usually described as
antifouling agents. Unfortunately, the chemicals found in such applications are either too
toxic for oral use or ineffective against dental bacteria plaques.
eg: Anionic polymers.
ANTIMICROBIAL AGENTS:

Antimicrobial agents could inhibit plaque formation through one of the two mechanisms
alone or combined. The first is bacteriostatic which includes inhibition of bacterial
proliferation.
These agents could exert their effects either at the pellicle-coated tooth surface before the
primary plaque formers attach or after attachment but before the division of these bacteria.

The second effect is bactericidal where the antimicrobial agent destroys all of the
microorganisms either attaching or already attached to the tooth surface.

The antimicrobial agents probably exert both bactericidal effects followed by a

bacteriostatic action of variable duration.
PLAQUE REMOVAL AGENTS:

The idea of employing a chemical agent in a mouth rinse is expected to reach all tooth
surfaces effectively which is similar to a toothbrush that removes bacteria from a tooth
surface. For this reason, chemical plaque removal agents are also referred to as “the
chemical toothbrush”.eg; hypochlorites and enzymes.

ANTIPATHOGENIC AGENTS:

It is theoretically possible that an agent could affect plaque microorganisms, which might
inhibit the expression of the pathogenicity without necessarily destroying the
microorganisms. At present such an approach within the oral cavity for either gingivitis
or caries is still under research.
VEHICLES FOR THE DELIVERY OF CHEMICAL AGENTS:

The carriage of chemical agents into the mouth for supragingival plaque control includes a
small but varied range of vehicles

1. Toothpaste(Dentifrices)
2. Mouth rinses
3. Spray
4. Irrigators
5. Varnishes

TOOTHPASTE:
The most commonly used vehicle for the carriage of the plaque control agent is
toothpaste. The ingredients present in the toothpaste have a role in either influencing the
consistency and stability of the product or its function . The major ingredients are as
follows
1. ABRASIVES:(20%-50%) It affects the consistency of the toothpaste and assists in the
control of extrinsic dental staining.
Examples include;
silica, alumina, dicalcium phosphate, and calcium carbonate either alone or more usually
today in combination.
2. DETERGENTS:(1%-3%) It imparts the foaming properties to the product. Moreover,
detergents may help dissolve active ingredients and the anionic detergent sodium lauryl
sulphate has both antimicrobial and plaque inhibitory properties.

3. THICKENERS:(1%-2%) Such as silica and gums, primarily influence the viscosity of the
products. Control the stability and constitency of the toothpaste.

4. SWEETENERS:(0%-2%) Such as saccharine.

5. HUMECTANTS:(20%-33%) Such as glycerine and sorbitol.

function: reduces the loss of moisture from the toothpaste.

6.FLAVORS:(0%-2%) Herbal flavors are more popular in the Indian

subcontinent.eg;peppermint,menthol,eucalyptus.

7. ACTIVES: Fluorides for caries prevention; triclosan and stannous fluoride for plaque
control;pyrophosphates,zinc citrate and zinc chloride which are anticalculus agents;
polyphosphates which are whitening agents; strontium and potassium salts which are
desensitizing agents

8. Preservatives: Alcohol , Benzoates , Dichlorinated phenols to Prevent bacterial growth

and Prolong shelf life.
Therapeutic agents:
Anti-caries agents
Fluoride,Xylitol, Calcium phosphate,Sodium bicarbonate

Anti-plaque agents-
Sodium Lauryl Sulfate (SLS),Triclosan,Metal-ions,Amyloglucosidase and Glucose
oxidase,Essential oils,Chlorhexidine.

Anti-calculus agents
Pyrophosphate sodiumhexametaphosphate)

Anti-dentine hypersensitive agents

Potassium salts

Anti-halitosis agents
Zinc(also have anticalculus and antibacterial properties)

Whitening agents
Abrasives
Dimethicone
Papain
Sodium bicarbonate
 MOUTHRINSES:
• Mouthrinses are usually less complex than toothpaste.

• They can be simple aqueous solutions with the addition of flavoring, coloring, and
preservatives such as sodium benzoate.

• Ethyl alcohol is commonly used both to stabilize certain active ingredients and to
improve the shelf life of the product. Several concerns have been expressed over
alcohol-containing mouth rinses.

• The proportion of alcohol is usually less than 10% but some rinses have more than 20%
alcohol.

• Some manufacturers are producing alcohol–free mouth rinses.

IDEAL REQUISITES OF MOUTHWASH
o Reduce plaque and gingivitis
o Prevent growth of pathogenic bacteria
o Prevent the development of resistant bacteria
o Compatible with oral tissues
o Not stain teeth/ after taste
o Exhibit good retentive properties.
o Inexpensive and easy to use
SPRAY: Chlorhexidine sprays were found particularly useful for plaque control in physically
and mentally handicapped .

IRRIGATORS: Irrigators were designed to spray water, under pressure, around the teeth. As
such they only removed debris, with little effects on plaque deposits (Frandenson 1986).

CHEWING GUM: Chewing gums are used to deliver a variety of agents for oral health
benefits. There appear to be significant benefits to dental health through the use of sugar-
free chewing gum. They can reduce occlusal plaque deposits but it is unlikely to be
beneficial in the prevention of fissure caries.

VARNISHES: Varnishes have been employed to deliver antiseptics including chlorhexidine,

but the purpose has been to prevent root caries rather than as a reservoir for plaque
control throughout the mouth
CLASSIFICATION OF CHEMICAL AGENTS ACCORDING TO THEIR ANTIMICROBIAL EFFECT
AND SUBSTANTIVITY:(KORNMAN -1986)

First generation antiplaque Second generation Third generation antiplaque

agents antiplaque agents agents

The plaque decrease is

They block microorganisms’
about 70-90% overall and is
This may reduce the plaque binding on or against the
better preserved than the
to 20-50%. tooth. In contrast to second
first generation.
They have low mouth generation chlorhexidine,
They demonstrate improved
retention. they have low retention
oral tissue retention and
capability.
slow release characteristics

E.g., Antibiotics, phenols,

quaternary ammonium E.g.,. Bisbiguanides
E.g., Delmopinol.
compounds and (chlorhexidine).
sanguanarine.
 PROPERTIES OF IDEAL CHEMICAL PLAQUE CONTROL AGENTS:

• Substantivity: Ability of the agent to bind to tissue surfaces and be

released over time.

• Penetrability: Ability to penetrate deeply into the biofilm.

• Selectivity: Ability to affect specific bacteria in a mixed population.

• Stability

• Solubility

• Adequate Bioavailability

• Accessibility to the site of action and the ionic interaction between agents
and receptor sites.
 TRICLOSAN

ACT ON CYTOPLASMIC MEMBRANE

INDUCE LEAKAGE OF CELLULAR CONSTITUTES

BACTERIOLYSIS
• Cetylpyridinium chloride is used in a wide variety of antiseptic
mouth rinse products, usually at a concentration of 0.05%.

• At oral pH, these antiseptics are monocationic and adsorb readily

and quantitatively, to a greater extent, than chlorhexidine to oral
surfaces.

• The substantivity of cetylpyridinium chloride however appears to

be only 3–5 hours due either to loss of activity once adsorbed or
rapid desorption( release of absorbs substance from a surface).

• Cetylpyridinium chloride in mouth rinses has some chemical

plaque-inhibitory action but evidence for gingivitis benefits is
equivocal, particularly when formulations are used alongside
toothbrushing with toothpaste.
• The efficacy of cetylpyridinium chloride can be increased by
doubling the frequency of rinsing to four times per day
(Bonsvoll & Gjermo 1978).

• But this increases local side effects, including tooth staining,

and would probably affect compliance.
 CHLORHEXIDINE
• The first definitive study on chlorhexidine was performed by Löe
and Schiott (1970).

• This study showed that rinsing for 60 seconds twice per day
with 10 ml of a 0.2% (20 mg dose) chlorhexidine gluconate
solution in the absence of normal tooth cleaning, inhibited
plaque regrowth and the development of gingivitis.

Forms
Chlorhexidine is available in various forms such as digluconate,
acetate and hydrochloride salts which are sparingly soluble in
water.
Structure:
Chlorhexidine is a cationic bisbiguanide.
The molecule is symmetric with two 4, chlorophenyl rings and
two biguanide groups connected by a central hexamethylene
chain.

CHX is a strong base and, at physiologic pH, is a large

dicationic molecule [1, 6-di (4- chlorophenyl-diguanido)
hexane] with two positive charges distributed over the
nitrogen atoms on either side of the hexamethylene bridge
 Introduction
• Chlorhexidine (CHX) is an antibacterial used for numerous
applications.

• It is a cationic polybiguanide (bisbiguanide) used primarily as its

salts, dihydrochloride, diacetate, and digluconate.

• Chlorhexidine is one of those drugs which are enlisted/included in

the World Health Organization's List of Essential Medicines, a list of
the most important drugs needed in a basic health system.

• At physiologic pH, chlorhexidine salts dissociate and release the

positively charged chlorhexidine cation.
•
• At low concentrations of chlorhexidine, this results in a
bacteriostatic effect; however, at relatively higher concentrations,
membrane disruption results in cell death.
• Chlorhexidine is active against Gram-positive and Gram-negative
organisms, facultative anaerobes, aerobes, and yeasts.
Chlorhexidine is particularly effective against Gram-positive
bacteria in concentrations ≥ 1 µg/l.

• Significantly higher concentrations (10 to more than 73 μg/ml)

are required for Gram-negative bacteria and fungi.
• It is one of the most efficient antiplaque agents. It has been
shown to have immediate bactericidal action and a prolonged
bacteriostatic action due to adsorption onto the pellicle-coated
enamel surface.
• If it is not deactivated, chlorhexidine lasts longer in the mouth
than other mouth rinses, which is partly why it is still considered
to be the most preferred antiplaque agent today.
INDICATIONS FOR CHLORHEXIDINE USE:

1. As an adjunct to mechanical oral hygiene, particularly in the oral

hygiene phase of periodontal treatment. Alternatives to a
mouthrinse could be a chlorohexidine spray, already found to be
useful in handicapped individuals.

2. Secondary prevention following oral surgical procedures, including

periodontal therapy. Considerable evidence reviewed on several
occasions indicates the value of chlorhexidine rinses after oral
surgery procedures, including after periodontal surgery and root
planing, gingivectomy.
3. In patients with intermaxillary fixation, chlorhexidine was shown to
significantly improve oral hygiene and reduce the bacterial load in
saliva.

4.For oral hygiene and gingival health benefits in the mentally and
physically handicapped.

5.High-risk caries patients: Chlorhexidine rinses or gels can reduce

considerably the Streptococcus mutants counts in individuals who
are caries prone.

6. Immediate pre-operative chlorhexidine rinsing and irrigation This

technique can be used immediately prior to operative treatment,
particularly when air polishing, ultrasonic scaling, or high-speed
instruments are to be used. Such pre-operative rinsing markedly
reduces the bacterial load and contamination of the operative area,
operator, and staff.
7.Oral malodor:
Rinsing with chlorhexidine as with other antiseptic mouth rinses
containing triclosan, and essential oils have been suggested to be of
value in reducing halitosis.

8.Denture stomatitis:
Chlorhexidine has been recommended in the treatment of Candida-
associated infections

9.Removable and fixed orthodontic appliance wearers:

Plaque control in the early stages of orthodontic appliance therapy
may be compromised and chlorhexidine can be prescribed for the
first 4–8 weeks.

10.Medically compromised individuals predisposed to oral infection

Adverse effects pertaining to oral cavity:

A. Staining:
• The most common being a brownish discoloration of the
teeth, some restorative materials, the mucosae and notably,
the dorsum of the tongue, decreasing patient compliance.
• The amount of staining seems to be dependent on the mode
of application, concentration, and presence of the potential
discoloring agents within the extraneous factors including diet.
B. Bitter taste/taste disturbance (dysgeusia):
Aqueous solutions of CHX have a very bitter taste leading to a
transient change in taste perception (dysgeusia).

C. Mucosal desquamation:
Desquamation and subsequent, ulcerations and erosions of the
oral mucosa in connection with mouth rinses with bisbiguanides
have been sporadically reported and have been explained by
precipitation of the mucin layer weakening its lubricating effect.
Erosions are rarely seen with 0.12% rinse products used at 15 ml
volume.
D.Unilateral or bilateral parotid swelling:
extremely rare occurrence with no plausible explanation.

E. Enhanced supragingival calculus formation:

his effect may be due to the precipitation of salivary proteins onto
the tooth surfaces, thereby increasing the pellicle thickness and/or
precipitation of inorganic salts onto the pellicle layer.
REFERENCES:

1)ADDY M, MORAN JM. clinical indications for the use of

chemical adjuncts to plaque control: chlorhexidine formulations.
periodontol 2000. 1997 oct;15:52-4.

2) DR. MEKHALA MUKHERJEE, et al. chemical plaque control .

3) Caranzza 13 edition

4) ESTHER M. WILKINS: clinical practice of the dental hygienist:

Twelfth edition.

5) Caranzza’s clinical periodontology: Second South Asia Edition