Chemical Plaque Biofilm Control Methods

KANNURDENTALCOLLEGE
DEPARTMENTOFPERIODONTICS
SEMINARON:
CHEMICAL PLAQUE BIOFILM CONTROL
BY,
RAHUL K
180020362

CONTENTS
Introduction
Plaque : definition
History
Chemical plaque biofilm control with oral rinses
Ideal properties of plaque control agents
Classification
Antimicrobial agents
Disclosing agents
Frequency of plaque biofilm control
Patient motivation and education
Conclusion

INTRODUCTION
◦ Dental plaque is defined clinically as a structured resilient , yellow greyish
substance that adheres tenaciously to the intra oral hard surfaces including
removable and fixed restoration .
◦ The tough extra cellular matrix makes it impossible to remove plaque by rinsing or
with the use of sprays .
◦ “ Plaque Control ” is the removal of microbial plaque and the prevention of its
accumulation on the teeth and adjacent gingival tissues. Besides, it also deals with
prevention of calculus formation.

HISTORY
◦ In 1965,Loe et al conducted the classic study demonstrating the relationship between microbial plaque
biofilm accumulation and the development of experimental gingivitis in humans
◦ Subjects in the study stopped brushing and other plaque biofilm control procedures , resulting in the
development of gingivitis in every person within 7-21 days.
◦ The composition of the biofilm bacteria also shifted so that more virulent gram negative organisms
predominated , and all these changes were shown to be reversible within 7 days.

◦ Good supragingival biofilm control has also been shown to affect the growth and composition of
subgingival plaque so that it favours a healthier microflora and reduces calculus formation.
◦ Carefully performed daily home plaque biofilm control combined with frequent professionally
delivered plaque biofilm and calculus removal reduces the amount of supragingival biofilm;
decreases the total number of microorganisms in moderately deep pockets including furcation areas ;
and greatly reduces the quantity of periodontal pathogens .

RATIONALE
◦ Microbial biofilm growth occurs within hours and it must be completely removed at least once every 48
hours in experimental setting with periodontally healthy subjects to prevent inflammation .
◦ The American Dental Association recommends that individuals brush twice per day and use floss or other
interdental cleaners once per day to effectively remove microbial plaque biofilms and prevent gingivitis .

◦ Periodontal lesions are predominantly found in interdental locations , so toothbrushing alone is not sufficient to
control gingival and periodontal diseases .
◦ It has been demonstrated in healthy subjects that plaque biofilm formation begins on the interproximal surfaces
where the toothbrush does not reach.
◦ Masses of biofilm first develop in the molar and premolar areas, followed by the proximal surfaces of the
anterior teeth and the facial surfaces of the molars and premolars. Lingual surfaces accumulate the least amount
of biofilm.

◦ Patients consistently leave more plaque biofilm on the posterior teeth than the anterior teeth, with
interproximal surfaces retaining the highest amounts of biofilm, exactly the places in which periodontal
infections begin.
◦ In addition, periodontal patients have increased susceptibility to disease, complex defects in gingival
architecture, and long exposed root surfaces to clean, compounding the difficulty of doing a thorough
job of cleaning.
• Daily plaque biofilm control permits each patient to assume responsibility for oral health every day.
Without it, optimal oral health through periodontal treatment cannot be attained or preserved. Elements
of biofilm control include mechanical cleaning and chemical adjuncts.

CHEMICAL PLAQUE BIOFILM CONTROL WITH
ORAL RINSES
◦ Chemical inhibitors of plaque biofilm and calculus that are incorporated in mouthwashes or dentifrices
play important roles in controlling microbial biofilms
◦ . Fluorides delivered through toothpastes and mouth rinses are essential for caries control. Many products
are available as adjunctive agents to mechanical techniques. These medicaments, as with any drug,
should be recommended and prescribed according to the needs of individual patients.
◦ Mouthwash, mouth rinse, oral rinse, or mouth bath is a liquid which is held in the mouth passively or
swirled around the mouth by contraction of the perioral muscles and/or movement of the head, and
gargled .

IDEAL PROPERTIES OF PLAQUE CONTROL AGENTS
◦ An ideal chemical plaque control agent should possess the properties of:
 Substantivity (ability of agent to bind to tissue surfaces and be released over
time)
 Penetrability (ability to penetrate deeply into the biofilm) and
Selectivity (ability to affect specific bacteria in a mixed population).
◦ The extent of stability of the active agent in the presence of salivary and/or
bacterial enzymes, its solubility into the oral environment, its adequate
bioavailability; its accessibility to the site of action and the ionic interactions
between agent and receptor sites are other important factors which affect delivery
to, and clearance of the plaque control agents from the oral cavity.

First generation chemical plaque
control agents
Second generation chemical plaque
control agents
Third generation chemical
plaque control agents
CLASSIFICATION OF CHEMICAL PLAQUE CONTROLAGENTS

ANTIMICROBIAL AGENTS
Some of the antimicrobial agents are discussed below :
1.Chlorhexidine Rinse
◦ The agent that has shown the most positive antibacterial results to date is chlorhexidine, a Di guanido hexane with
pronounced antiseptic properties.
◦ Several other clinical investigations confirmed the initial finding that two daily rinses with 10 mL of a 0.2%
aqueous solution of chlorhexidine di gluconate almost completely inhibited the development of dental plaque,
calculus, and gingivitis in the human model for experimental gingivitis.
◦ Clinical studies of several months’ duration have reported plaque reductions of 45–61% and, more importantly,
gingivitis reductions of 27–67%.

• The 0.12% chlorhexidine Di gluconate preparation available in the United States for
reducing plaque and gingivitis has been shown to be equally effective as the higher-
concentration product. It has a broad antimicrobial spectrum. At low concentrations it
causes leakage of intracellular potassium and reduction in bacterial acid production .
◦ At higher concentrations it is able to induce bacterial cell wall disruption and coagulation
of the cytoplasmic constituents.
◦ It also inhibits enzymes involved in bacterial adhesion, bacterial growth and metabolism.

◦ Approximately 30% of the chlorhexidine applied is retained in the oral soft tissues, which serve as a reservoir for slow
release of the agent over extended periods of time.
◦ Localized, reversible side effects to chlorhexidine use may occur, primarily brown staining of the teeth, tongue, and
silicate and resin restorations and transient impairment of taste perception.
◦ Chlorhexidine has very low systemic toxic activity in humans, has not produced any appreciable resistance of oral
microorganisms, and has not been associated with teratogenic alterations.

2.Chlorhexidine Gluconate(0.2%)
◦ Chlorhexidine gluconate is a cationic bis biguanide which is effective against an array of
microorganisms , including gram positive and gram negative organisms ,fungi , yeast and viruses.
◦ Chlorhexidine exhibits both antiplaque and antibacterial properties.
Mechanism of action
◦ The superior antiplaque activity of chlorhexidine is due to its property of sustained availability-
‘substantivity’
◦ This involves a reservoir of chlorhexidine ,slowly dissolving from all oral surfaces , resulting in the
“bacteriostatic mileu” in the oral cavity

◦ Chlorhexidine shows different effects at different concentrations
◦ It is bacteriostatic at low concentrations and bactericidal at higher concentrations
◦ After a single rinse with chlorhexidine , saliva itself antibacterial activity for about 5 hours and
suppresses salivary bacterial counts for over 12 hours.
◦ Following several rinses of chlorhexidine , saliva ,the number of aerobic and anaerobic species of saliva
can be reduced by 80-90%.
◦ Chlorhexidine has also been found to be a potent antifungal agent in the oral cavity.

◦ Chlorhexidine inhibits plaque by:
Preventing pellicle formation by blocking acidic groups on salivary glycoproteins thereby reducing
glycoprotein adsorption on to the tooth surface.
Preventing adsorption of bacterial cell wall onto the tooth surface by binding to the bacteria.
Preventing binding of mature plaque by precipitating agglutination factors in the saliva and displacing
calcium from the plaque matrix
• Chlorhexidine should not be used before/immediately after using a tooth paste as interaction with anionic
surfactants found within the formulations , will reduce effective delivery of chlorhexidine in an active
form.

• Adverse effects of chlorhexidine
Brownish staining of teeth on restorations.
Loss of taste sensation
Rarely hypersensitivity to chlorhexidine has been reported
Stenosis of the parotid duct has also been reported

3. Nonprescription Essential Oil rinse
◦ One of the most extensively used and researched mouth rinse, Listerine (named after Lister), is a
combination of phenol-related essential ions, thymol and eucalyptol, mixed with menthol and methyl
salicylate in a hydroalcoholic base.
◦ It is anti inflammatory and has the ability to suppress odori genic bacteria.
◦ The nonionized molecules cause inactivation of essential enzymes at low concentrations and disruption
of cell proteins at high concentrations.

4.Heavy metal ions
◦ Divalent metal ions possess antiplaque potential as a result of their ability to bind plaque components via
electrostatic forces, thereby altering the surface charge and adherence potential of bacteria.
◦ They are able to displace calcium ions from the pellicle and bacterial surfaces, have antiglycolytic effect, and reduce
pathogenicity of established plaque by suppressing plaque acidogenicity .
5.Quaternary ammonium compounds
◦ These cationic antiseptics interact with plaque in a manner similar to that of Chlorhexidine, but are less effective
because of their rapid clearance from the oral cavity.

6.Sanguinarine
◦ A mixture of benzophenanthridine alkaloids, this extract of the bloodroot plant Sanguinaria Canadensis is
effective against both gram-positive and gram-negative bacteria.
◦ Its ability to interfere with the steps in bacterial cell wall synthesis may be responsible for its antimicrobial
activities.
7.Hexetidine
◦ A synthetic hexahydro pyridine with mechanism of action similar to chlorhexidine. However, it has little
antiplaque effect at clinically acceptable concentrations. Higher concentrations are associated with
corresponding increase in frequency of desquamative lesions.

8.Triclosan
◦ This is a nonionic, broad spectrum antimicrobial agent, currently being incorporated into dentifrices and mouth
rinses because of its high retentivity in the oral cavity and hence a positive, linear dose-response antiplaque and
anti gingivitis effect.
◦ Its anti inflammatory effect can be attributed to its ability to inhibit both cyclo-oxygenase and lipoxygenase,
thereby retarding prostaglandin and leukotriene production.
◦ Total (Colgate Oral Pharmaceuticals Inc. Canton, Mass.) contains triclosan and Gantrez (a copolymer of
polyvinyl methyl and maleic acid) and is the first dentifrice sold in the USA to receive the ADA’s Seal of
Acceptance for the reduction of plaque and gingivitis

9.Enzymes
• Peroxidases have been added to mouth rinses and dentifrices to ensure presence of sufficient hydrogen
peroxide to control proliferation of plaque bacteria.
10.Octenidine dihydrochloride
◦ It has high antimicrobial activity together with good tolerability. It provides anti-bacterial and anti-fungal
activity during oral rinsing which is maintained between rinsing.
◦ It is a positively charged compound that exerts its bactericidal action by binding to the negatively charged
bacterial cell membranes as well as to the soft and hard tissue surfaces of the oral cavity.

◦ It has both lipophilic and hydrophilic properties, allowing it to embed in the phospholipid
bilayer, disrupting the regular distribution of phospholipids, and attacking the enzyme
systems. This causes the cell wall to lose integrity and leak cytoplasmic contents.
◦ It also has a high affinity for cardiolipin, which is a lipid only present in bacterial cell
membranes, and is therefore lethal only to bacterial cells, leaving human tissue and
epithelium unaffected.
◦ Octenidine dihydrochloride is a potential alternative to chlorhexidine.

11.Delmopinol
◦ This is a substituted amino-alcohol, which disrupts the bacterial matrix formation, thereby interfering
with bacterial attachment.
◦ This surface-modifying agent is less effective than chlorhexidine on established gingivitis patients.
Transient anesthesia of the dorsum of the tongue, mucosal soreness, taste disturbances and erosions are
the various side effects attributed to this compound.

DISCLOSING AGENTS
◦ Removal of plaque at regular intervals is critical for oral health maintenance. However, plaque is
relatively invisible to the naked eye. Therein comes the role of Plaque Disclosing Agents, which are
agents capable of staining bacterial biofilms on the surfaces of teeth, tongue, and gingiva, making it
visible for easy detection and removal.
◦ They play a vital role in patient motivation and education; help the clinicians in determining the plaque
indices; and also help the researcher in evaluating the effectiveness of plaque control devices.

FIG. :Effect of a disclosing agent. A, Unstained, the
teeth look clean, but close inspection shows subtle signs of
gingivitis. B, Plaque shows as dark-red particulate matter
when stained with a disclosing dye. It is useful to demonstrate
toothbrushing in the patient’s mouth with the teeth disclosed
and plaque visible.

◦ Various dyes that have been utilized to detect plaque are:
 Skinners Iodine solution (formerly widely used, unacceptable taste, high incidence of allergic reactions)
Fast green
 Erythrosine (most widely used, stains the plaque area red, but may also stain the soft tissues)
 Mercurochrome preparations
Bismark Brown
 Merbromin
Basic Fuchsin
 Phloxine B plus Patent Blue (Two-tone dye, stains older/mature plaque blue and newer/immature plaque
pink/red, does not stain the soft tissues)
Fluorescein (fluoresces yellow–green under UV light, expensive, does not stain the soft tissues, but a
special light is required to visualize the stained plaque).

◦ Disclosing agents are available as solutions or wafers commercially.
◦ Solutions are applied to the teeth as concentrates on cotton swabs or diluted as rinses.
◦ Wafers are crushed between the teeth and swished around the mouth for a few seconds and then spit
out.
◦ Either form can be used for plaque biofilm control instruction in the office and dispensed for home
use to aid periodontal patients in evaluating the effectiveness of their oral hygiene routines.

FREQUENCY OF PLAQUE BIOFILM REMOVAL
◦ In the controlled and supervised environment of clinical research, where well-trained individuals remove all visible plaque
biofilm, gingival health can be maintained by one thorough cleaning with brush, floss, and toothpicks every 24 to 48 hours.
◦ However, this is not true with most patients. The average daily home care routine lasts less than 2 minutes and removes
only 40% of plaque biofilm.
◦ It has been reported that improved plaque biofilm removal and therefore improved periodontal health are associated with
increasing the frequency of brushing to twice per day.
◦ Cleaning three or more times per day does not appear to improve periodontal conditions further. Clinical experience has
also indicated that more important than the number of times the patient practices oral hygiene during a given day is
effective target hygiene, meaning thorough plaque biofilm removal at the proper location. One could be cleaning several
times a day, but if the target areas are missed, plaque biofilm will persist in these critical areas.

PATIENT MOTIVATION AND EDUCATION
◦ In periodontal therapy, plaque biofilm control has two important purposes: to minimize gingival inflammation and
to prevent the recurrence or progression of periodontal diseases and caries.
◦ Daily mechanical removal of plaque biofilm by the patient, including the use of appropriate antimicrobial agents, is
the only practical means for improving oral health on a long-term basis.
◦ The process requires interest on the part of the patient and education and instruction from the dentist, followed by
encouragement and reinforcement. Keeping records of patient performance facilitates this process. The given
figure provides an example of a plaque biofilm control record that permits repeated measures and comparison over
time.

FIG: The plaque control record can be an effective
motivator for patients. This form permits easy comparison
of
scores over time. Source: (Courtesy: Dean John D.B.
Featherstone, University of California, San Francisco School of
Dentistry, San Francisco)

MOTIVATION FOR EFFECTIVE PLAQUE BIOFILM CONTROL
◦ Motivating patients to perform effective plaque biofilm control is one of the most
critical and difficult elements of long-term success in periodontal therapy.
◦ It requires both commitment by the patient to change daily habits and regular return
visits for maintenance and reinforcement. The scope of this compliance problem is
immense.
◦ It has been shown that patients stop using interproximal cleaning aids after a very short
time.

• Heasman et al followed 100 patients treated for moderate to severe periodontal
disease and taught to use one or more interdental cleaning aids. It was found that only
20% used the aids after 6 months. Of those who had started using three devices, one
third had stopped all interdental cleaning at 6 months; the others used one or two of
the aids.
• The situation is no better when looking at patient willingness to return for office
visits. In one study of 1280 patients, most of whom had periodontal surgery in
multiple sites after intensive scaling, root planning, and home care instruction, 25%
never returned for a follow-up visit; only 40% returned regularly. Wilson et al
reported that 67% of periodontal patients were noncompliant with return visits in a
20-year retrospective of a private periodontal practice.

◦ Adopting new habits and returning for office visits is not an impossible task.
◦ To be successful, the patient
(1) must be receptive and understand the concepts of pathogenesis, treatment, and prevention of periodontal disease;
(2) must be willing to change the habits of a lifetime; and
(3) must be able to adjust personal beliefs, practices, and values to accommodate new regimens.
◦ Manual skills must be developed to establish an effective plaque biofilm control regimen. In addition, the patient must
understand the dentist’s critical role in treating and maintaining periodontal health. If not, long-term success of treatment is m
less likely.

EDUCATION AND SCORING SYSTEMS
◦ Many patients prefer to believe that treatment is a passive process, so it is incumbent on the dentist to educate and
reinforce to each patient their personal role in long-term success of therapy.
◦ Our health conscious society is an advantage with regard to patient education. Most patients know what gingivitis
is because they have heard about it on television or read about it in magazines or on the web. They are willing to
spend time and money to try new products such as toothbrushes and mouth rinses.

◦ Patients must also be informed that periodic assessment and debridement of the teeth in the dental office are
required to prevent recurrence of periodontal diseases and identify problems that may arise.
◦ These procedures work best when combined with an individualized oral hygiene regimen practiced daily at home.
Therefore time spent in the dental office teaching the patient how to perform microbial plaque biofilm control
procedures is central to care.
◦ Patients sometimes have the concept that “cleanings” every few months are sufficient for calculus and biofilm
removal and disease control.
◦ Only the combination of regular office visits with conscientious home care has been shown to significantly reduce
gingivitis and loss of supporting periodontal tissues over the long term.

◦ Periodontal patients should be shown how periodontal disease has manifested in their own mouth.
◦ Stained plaque biofilm, the bleeding of inflamed gingiva, and demonstrations of the periodontal probe inserted
into pockets are impressive demonstrations of the presence of pathogens and symptoms of disease.
◦ It also is of educational value to patients to have their oral cleanliness and periodontal condition recorded
periodically so that improvements in performance can be used for positive reinforcement.
◦ The plaque biofilm control record index, bleeding points index and their significance in patient education and
motivation are discussed in detail online.

INSTRUCTION AND DEMONSTRATION
◦ Patients can reduce the incidence of plaque biofilm and gingivitis with repeated instruction and
encouragement much more effectively than with self-acquired oral hygiene habits. However,
instruction in how to clean teeth must be more than a cursory chairside demonstration on the use
of a toothbrush.
◦ It is a painstaking procedure that requires patient participation, careful supervision with correction
of mistakes, and reinforcement during return visits, until the patient achieves the necessary
proficiency.
◦ Any strategy for introducing plaque biofilm control to the periodontal patient includes several
elements. At the first instruction visit, the patient should be given a new toothbrush, an interdental
cleaner, and a disclosing agent. The patient’s plaque biofilm should be disclosed otherwise it is
difficult for the patient to see .

◦ Polished dental restorations do not take up the stain, but the oral mucosa and the lips may retain
it for up to several hours.
◦ Use petroleum jelly to keep the dye off the patient’s lips.
◦ For these patients, the location and true color of the plaque biofilm can be demonstrated with the
rubber tip.
◦ Once the plaque biofilm is demonstrated, the clinician can proceed with the hygiene instruction
in the patient’s mouth .

◦ The rubber tip is used to demonstrate the plaque biofilm located at the gingival margin, which is the
target area.
◦ The nondisclosed plaque biofilm is almost the same color as the teeth, which impresses and
educates the patient about the reason for not recognizing biofilm in the past.
◦ Toothbrushing should also be demonstrated in the patient’s mouth while he or she observes with a
hand mirror. The patient then repeats the procedure with the clinician giving assistance, correction,
and positive reinforcement.

◦ Repeat the demonstration and instruction with dental floss and other interdental cleaning aids
according to the patient’s needs. Depending on the patient’s skill and understanding of the technique,
instruction on interdental hygiene may be postponed until the patient is able to manipulate the
toothbrush properly. The rubber tip is an excellent instrument to demonstrate plaque biofilm, but it is
also used to clean the interdental area. The rubber tip is placed interdentally, and the plaque biofilm
is removed with a scooping motion.
◦ Encourage patients to clean the teeth thoroughly at least once a day. Be sure to inform them that
home care procedures on a full dentition take 5–10 min, and for complex periodontal cases, home
care procedures may take 30 min.

◦ The patient should set aside a convenient time and place in the daily schedule to perform the procedures reliably
every day.
◦ Subsequent instruction visits should be used to reinforce or modify previous instructions, periodically recording the
state of gingival health and amount of plaque biofilm.
◦ Some strategies simply do not work. Waiting until the end of the appointment, for example, when the patient is sore,
exhausted, and possibly anesthetized is not conducive to learning. Failing to provide positive reinforcement, handing
the patient too many tools, and relying only on pamphlets and printed material to provide education are likely to
result in an insufficient or ineffective instruction process.

RECOMMENDATIONS
The following list provides some strategies that will assist you in educating and motivating your
patients:
Provide encouragement.
Demonstrate how devices work, and allow the patient to practice with them.
Provide samples so that the patient does not have to stop and buy products on the way home; the
patient may not follow through with the purchase.
Show improvements at subsequent appointments, even if they are modest.
Use positive reinforcement; threats are not effective.

CONCLUSION
◦ All patients require the regular use of a toothbrush, either manual or electric, at least once per day. The brushing
method should emphasize access to the gingival margins (dento– gingival junction) of all accessible tooth
surfaces, referred to as targeted hygiene, and extension as far onto the proximal surfaces as possible.
◦ Dental floss should be used in all interdental spaces that are filled with gingiva Interdental aids such as
interproximal brushes, wooden tips, rubber tips, or toothpicks should be used in all areas where the toothbrush
and floss techniques cannot adequately remove the plaque biofilm. This includes large embrasure spaces and
furcation areas as well as the mesial surface of the maxillary first bicuspid, which presents a concavity on the
root surface near the cemento enamel junction.
◦ Daily at-home subgingival irrigation is useful for reduction of inflammation and maintenance for patients with
residual deep pockets and those who struggle with mechanical interproximal cleaning devices. The effectiveness
of irrigation is enhanced by the addition of a chlorhexidine or essential oil rinse as an irrigant.

◦ Caries control requires the daily use of a dentifrice with low concentration fluoride. Topical oral rinses and gels with
higher concentrations of fluoride should be used if the patient demonstrates caries risk, and chlorhexidine rinses
should be used in a caries risk management program for patients at high risk for caries.
◦ Chemical antimicrobial agents, such as chlorhexidine and essential oils, can be used to disinfect the patient’s mouth
and control infection. These oral rinses may be continued indefinitely. Staining of teeth and taste alteration are side
effects that may limit the use of these products.
◦ Reinforcement of daily plaque biofilm control practices and routine visits to the dental office for maintenance care
are essential to successful microbial plaque biofilm control and the long-term success of therapy.

REFERENCES
◦ Newman and Carranza’s
CLINICAL
PERIODONTOLOGY(Third
south Asia edition)
• Essentials of Public Health
Dentistry-Soben Peter(6th edition)

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