This document discusses chemical plaque control agents. It begins with an introduction and overview of the concept and history of chemical plaque control. It then covers the rationale, approaches, and methods for evaluating antiplaque agents. Ideal properties and groups of agents used are described, including bisbiguanides like chlorhexidine, which are considered the most effective second generation agents. Recent advances and future trends in chemical plaque control agents are also mentioned.

1. Chemical
plaque
control
GUIDED BY
Dr.V.R.Balaji MDS
11
G.Kalaivani
3 rdyr pg

2. 2
content
Introduction
Concept of chemical plaque control
History
Rationale of Antiplaque agents
Approaches to Antiplaque agents
Methods to evaluate Antiplaque agents
Ideal properties of Antiplaque agents
Groups of agents used in antiplaque agents
Recent advances
Future trends
Conclusions
References

3. 3
INTRODUCTION:
Chemical plaque control
definitive edge
over mechanical plaque control,
in that access to the areas beyond the preview of mechanical
plaque control therapy
provides an effective plaque control.

4. 4

5. 5
plaque

6. 6
The formation of plaque on a tooth surface is a dynamic and ordered
process, commencing with the attachment of primary plaque-forming
bacteria.
The attachment of these organisms appears essential for initiating the
sequence of attachment of other organisms such that, with time, the
mass and complexity of the plaque increases.
Plaque control, which prevents plaque achieving the critical point where
gingival health deteriorates, will stop gingivitis.
Plaque inhibition has, therefore, targeted plaque formation at particular
points – bacterial attachment, bacterial proliferation, and plaque
maturation.

7. 7

8. 8
•The terminology “oral hygiene products” is recent
•6000 years, that formulation and recipes existed to
benefit oral and dental health (Fischman 1997).
•Ebers Papyrus 1500 BC -recipes for tooth powders
and mouth rinses
•Alcohol-based mouth rinses -the Romans and
included white wine and beer.
•Urine, as a mouth rinse
•Use of stale urine- Cantabri and others in Spain
•Use of fresh urine-Fauchard (1670-1761) of France.

9. 9
19 th centuries:
•Use of essential oils in the form of
mouth rinse, later with addition of
antimicrobial or antiseptics agents to
the tooth paste and mouth rinse
developed.

10. 10
RATIONALE FOR
CHEMICAL
PLAQUE
CONTROL:

11. 11
prevent
gingivitis periodontitis

12. 12
The concept of chemical plaque
control may be justified
overcoming
inadequacies of
mechanical cleaning.

13. 13
APPROACHES TO
CHEMICAL
PLAQUE
CONTROL:

14. 14
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 control quantitatively and
qualitatively.
.

15. 15
The action of the chemicals could
fit into four categories:
1. Antiadhesive
2. Antimicrobial
3. Plaque removal
4. Antipathogenic.

16. 16
Antiadhesive
act at the pellicle surface to prevent the initial attachment of the
primary plaque-forming bacteria.
•prevent the attachment and development of a variety of biofilms and are
usually described as antifouling agents.
•Prevention of extrinsic stain.
Toxic
Not under research

17. 17
Antimicrobial
inhibition of bacterial attachment and bacterial
proliferation/division.

18. 18
Plaque removal
act in an identical manner to a toothbrush and remove bacteria from
the tooth surface, is an attractive proposition.
“the chemical toothbrush”.
Contained in mouthrinse,dentifices etc
Very effective

19. 19
Antipathogenic.
agent could have an effect on plaque
microorganisms, which might inhibit the
expression of their pathogencity without
necessarily destroying the microorganisms-
Cummins 1992
I.e. alter the pathogeniticity of plaque.

20. 20
METHODS IN VITRO OR IN
VIVO
TO EVALUATE ORAL HYGIENE
PRODUCTS:

21. 21
ANTIMICROBIAL TESTS :
•measures of minimum inhibitory concentration
•and kill curves using bacterial strains or fresh isolates
Factors considered:
•Unless the active agent has a peculiar profile
for certain bacteria, the detergent effect
may hide the activity of the active ingredient.
•Substantivity appears to be a crucial property
of effective antimicrobial antiplaque agents.

22. 22
Other in vitro tests:
Stain removal,
detrimental actions, such as abrasivity.
Probably as a function of pH some types of mouth
rinse and toothpaste have the potential to erode
tooth tissue- Addy et al.
Stain control is perhaps more easily modeled,
particularly using forced staining methods
involving chlorhexidine - Addy et al in 1991
evidence

23. 23
In vivo method:
Parallel, randomized control method
to be done

24. 24
Clinical significance can be assessed as
follows:
Benchmark efficacy: -effect similar to other
established products;
Positive efficacy: -effect similar to or greater
than the most effective formulation to date;
Disease efficacy: effect on a causative factor
that reduces a disease or condition;
Proportional efficacy: achieving a previously
agreed proportional reduction in a parameter
compared with control.

25. 25
A major feature of scientific research, particularly in
clinical trials, is the use of controls
Placebo control: one without any expected
activity against the condition under investigation;
Minus active ingredient control: one that is
identical to the test product or formulation
without the active agent or agents;
Benchmark control: a product already in use by
the public or an agent already evaluated; and
Positive control: an accepted effective
formulation or the most effective formulation
available to date

26. 26
Among plaque control agents,
chlorhexidine
has tended to be considered a
positive control or gold standard
by which to compare other
chemicals-
Addy et al and Kornman 1986.

27. 27
IDEAL PROPERTIES OF ANTIPLAQUE
AGENTS:
Elimination of pathogenic bacteria
prevent development of resistant bacteria
exhibit substantivity
safety
reduction in plaque and gingivitis
no staining or alteration of taste
easy to use and inexpensive
no systemic effect

28. 28
CRITERIA FOR USAGE OF
ANTIMICROBIALS:
Substantivity: The ability of an agent to be bound to
the pellicle and tooth surface and to be released over an
extended period of time with the retention of its potency.
Stability: chemical breakdown or modification may
occur during storage, especially at elevated temperatures.
Penetrability: For a drug to be effective, it must be
able to penetrate deep into the formed plaque matrix.
Toxic safety: any agent used for prevention or
treatment of oral diseases must have low toxicity.

29. 29
AGENTS FOR
CHEMICAL PLAQUE
CONTROL
Kornman, 1986; Mandel, 1988

30. 30
Antibiotics: penicillin, vancomycin
Enzymes: proteases, lipase, dextranase
Bisbiguanides: chlorhexidine, alexidine
Quaternary ammonium compounds: cetylpyridinium chloride,
benzalkonium chloride
Phenols and essential oils: thymol, triclosan
Natural products: sanguinarine
Fluorides: sodium fluoride, stannous F
Metal salts: tin, zinc, copper
Oxygenating agents: Hydrogen peroxide
Detergents: sodium lauryl sulfate
Amine alcohols: octapinol, delmopinol.

31. 31
ANTISEPTIC AGENT: Newbrun 1985

32. 32
DEPENDING ON THE
ANTIMICROBIAL
EFFICIENCY
AND
RELATIVE
SUBSTANTITIVITY.
Generation of anti-plaque
agents: Kornman 1986

33. 33
CHEMICAL PLAQUE
CONTROL AGENTS
FIRST GENERATION
Eg: antibiotics, phenol,quarternary
ammonium compounds & sanguinarine
SECOND GENERATION
Eg: Bisbiguanides,(chlorhexidine)
THIRD GENERATION
Eg: delmopinol

34. 34
FIRST GENERATION
AGENTS:
•1st generation: decreases plaque
scores by 20-50%,
• but efficacy is decreased by
poor retention in the mouth.
•E.g. antibiotics, phenols etc.

35. PHENOLS
AND
ESSENTIAL OIL:
plaque inhibitory
anti-inflammatory action
• anti oxidative activity
(Firalti et al al 1994)
exert non specific antibacterial action
dependent upon ability of drug to
penetrate lipid component of cell
walls of gram negative bacteria
inhibit neutrophil chemotaxis, generation
of neutrophil superoxide ion and
production of prostaglandin synthetase-
Charles et al 2004.

36. 36
Positive facts
6 month study - Compared with CHX – demonstrated equivalent effects on plaque &
gingivitis without inherent side effects of chx.
Because of low pH of product (4.3) – in vitro & in situ – erosion of dentine & enamel
but less than orange juice (Addy et al 1991, Pontefract et al 2001).
Phenolic compounds are also known to act as scavengers of oxygen-free-radicals (Kuehl
et al)
Goodson (1985) has recently pointed out that most phenolic compounds have anti-
inflammatory and prostaglandin synthetase inhibitor activity which can occur at
concentration lower than that for antibacterial activity.
Combining essential oils with CPC attempted – promising results (Hunter et al 1994).

37. 37
TRICLOSAN
•Phenol derivative –employed by Lister in 1867
(Eley 1998)
•Is synthetic and ionic
•Used as a topical antimicrobial agent
•Broad spectrum of action including both gram
positive and gram negative bacteria
•It also includes mycobacterium spores and
Candida species.

38. 38
Mechanism of action:
Triclosan
Act on cytoplasmic membrane
Induce leakage of cellular constitutes
Bacteriolysis and cell death

39. 39
AVAILABILITY
tooth paste and mouthrinse
Concentrations (0.2%) and dose (20 mg twice per day), triclosan has
moderate plaque-inhibitory action and antimicrobial substantivity of around
5 hours (Jenkins et al. 1991)
Listerine is an over the counter phenol preparation containing thymol,
eucalyptol, methyl salicylate, benzoic acid and boric acid in hydro alcoholic
vehicle
Some patients find an initial burning sensation and bitter taste, occasional
straining is evident
Become the first over-the-counter mouth rinse to be accepted by the
Council of Dental Therapeutics for its help in controlling plaque and
gingivitis.

40. 40
Ciancio et al demonstrated the value of
twice-daily use in the maintenance of
dental implants compared with a control
mouth rinse.
Ciancio has further reported that use of an essential oil
mouthwash as a subgingival irrigation prior to scaling greatly
reduced anaerobic and aerobic bacterial populations associated
with bacteremia and that pre-procedural rinsing
The favorable results for a mouth rinse containing
phenolic essential oils at inhibiting plaque and reducing
gingival inflammation have more recently led to its
evaluation for use as a post-surgical rinse- Laspia et al

41. 41
.
Zinc salts:
•plaque inhibitor was first described by Hanke in 1940
•Astringent
•Zinc citrate has been combined
with ionic antimicrobial triclosan in toothpaste form,
•significant anticalculus activity.
•Zinc salts may be of value at reducing volatile sulfu
compounds associated with oral malodor (Rosing et al 2002).
METALLIC IONS

42. 42
Tin salts:
• Inhibit plaque formation
•Svatun et al 1977 showed mechanism of
action of tin is through their ability to bind to
teichoic acid present on cell wall of gram
positive organisms changing surface charge
causing decreased adsorption of cells to teeth.

43. 43
Disadvantage of metal salts:
•Metallic taste
•Dryness of mouth
•Yellowish brown discoloration of teeth and tongue
Stannous fluoride mouth rinses:
•Difficult to formulate – stability problems –
hydrolysis in presence of water anhydrous
gel & toothpaste (Beiswanger et al 1995,
Perlich et al 1995)
•Human studies confirmed that
antibacterial action of stannous fluoride
was more due to tin ions although they
have synergistic effect (Andreas et al
1974).

44. 44
3. QUARTERNARYAMMONIUM
COMPOUNDS
•Cationic antiseptics & surface active agents
•Effective against gram positive organisms
Mechanism of action
•Positively charged molecule reacts with negatively charged cell
membrane phosphates and thereby disrupts the bacterial cell wall
structure
E.g.: Benzanthonium chloride, Benzalleonium chloride and
cetylpyridinium chloride.

45. 4
5
CETYLPYRIDINIUMCHLORIDE (CPC):
•used as agents for plaque inhibition
cationic
•CPC at 0.05% conc used in wide variety of
antiseptic mouth rinse products.
Substantivity of cetylpyridinium chloride is only 3– 5
hours (Roberts & Addy 1981).
Efficacy of CPC – increased by doubling frequency
of rinsing to 4 times per day (Bonsvoll & Gjermo
1978) – increased side effects & affect compliance

46. 46
Side effects:
•Brownish discoloration of teeth
•Recurrent apthous type ulceration of oral mucosa.
•Mouth rinses combining CPC with CHX – studies
done – compare well with CHX (Quirynen et al
2001, 2005) – cannot be assessed – whether CPC
actually contributes to activity of chx
•Slow release system & lozenges to deliver cps – no
greater plaque inhibition than CPC rinse &
significantly < chx rinse (Vanderkerchove et al
1995).

47. 47

48. 48
SANGUINARINE:
benzophenanthredine alkaloid derived from
Sanguinaria Canadensis.
It is most effective against gram –ve organisms
Properties:
•Used in mouth rinse
•Adverse effects:
•Mouth rinses shown to increase likelihood of
oral precancerous lesions ten-fold even after
cessation of use

49. 49
•Topically delivered tea tree oil
- suggested to be of value in
reducing gingival inflammation
(Sookoulis & Hirsch 2004).

50. 50
PROPOLIS
•natural resinous material produced by honey bees
•More than 300 components have been found in
propolis, mainly composed of phenolic
compounds (e.g., flavonoids, aromatic
compounds), terpenes, and essential oil. Flavonoids
and cinnamic acid.
•antimicrobial properties,
•the use of it as
• a mouthwash is questionable-
•Murray et al 1997.

51. 51
LIPPIA SIDOIDES
•mouthwash
•northeast of Brazil.
•as a topical antiseptic agent for skin and mucosa
surface and also for throat infections.
•essential oil -thymol and carvacrol and other
substances, such as felandreno, cariofileno, p-cimeno,
and mirceno.
•Studies indicated that these major components had
shown potent antimicrobial activity against fungi and
bacteria and reduced the severity of gingivitis and
bacterial plaque- Rodrigues IS et al.

52. 52
ALOE VERA EXTRACT
•Aloe vera gel consists of 98 to 99% water
and the remaining 1 to 2% of active compounds.
•aloin, aloeemodin, aloemannan, acemannan, aloeride,
naftoquinones, methylchromones, flavonoids, saponin,
sterols, amino acids, and vitamins.
• A randomized controlled study using 100% aloe vera
extract showed significant reduction in plaque
formation with no reported side effects.
•The antimicrobial effect of aloe vera has been
demonstrated earlier in an in vitro study.

53. 53

54. 54
•Due to bacterial resistance problems the use
of antibiotics has been reduced.
•Despite evidence for efficacy – systemic
antimicrobials used in past (as topical/ systemic)
are Penicillin, Vancomycin, Erythromycin) for
preventing caries & gingivitis.
•Not be used as preventive agents.
•Risk-to-benefit ratio is high (Slots & Rams
1990; Addy & Martin 2003).

55. 55
SECOND GENERATION
AGENTS:
• More effectively retained by oral
tissues and slow release properties
provide reduction in plaque scores
between 70 and 90%
• E.g.: Bisbiguanides.

56. 56
BISBIGUANIDES
•Considered to most effective
antiplaque agents.
•Second generation agents
•exhibiting substantivity
•broad antimicrobial properties.

57. 57
CHLORHEXIDINE
the gold standard.
Developed in 1940s by Imperial
Chemical Industries England -
marketed in 1954 – as antiseptic for
skin wounds.
Available in 3 forms:
•digluconate,
•acetate &
•hydrochloride salts

58. 58
Structure:
•Symmetrical molecule
• Four chlorophenyl rings & two biguanide groups
connected by central hexamethylene bridge.
• Compound is strong base & dicationic > pH 3.5, with
two positive charges on either side of hexamethylene
bridge .

59. 59
properties
antimicrobial
Antiplaque
agents
substantivity

60. 60
Antimicrobial
Bacteriostatic
At low
concentration
Bacteriocidal
At high concentration
Bacterial cell wall (-ve charge)
Reacts with +ve charged chlorhexidine
molecule
CHX binds to inner membrane
phospholipids & increase
permeability
Vital elements leak out & this
effect is reversible

62. 62
ANTI PLAQUE ACTION:
Rolla & Melsen postulated it prevents formation of
acquired pellicle. Blocks the acidic group of
salivary glycoprotein’s which reduces their
adsorption to hydroxyapatite.
Reduces the ability of bacteria to bind to tooth
surface.
Adsorption of CHX to bacterial capsule or
glycocalyx and prevents them binding on to tooth
surface.
CHX competes for Ca ions which are required for
agglutination of plaque.

63. 63
•CHX due to its dicationic nature binds to
enamel pellicle or tooth surface and salivary
proteins.
•This adsorbed CHX is released of a period
of time.
Substantivity
•Binds different surfaces within the mouth (teeth and mucosa) and also to the pellicle and
saliva;
•for example, after a single rinse with chlorhexidine, the saliva itself exhibits antibacterial
activity for up to 5 hours, whereas persistence at the oral surfaces has been shown to
suppress salivary bacterial counts for over 12 hours

64. 64
Metabolism:
• Does not penetrate oral epithelium (Lindhe et
al 1970).
• If accidentally swallowed – bind to mucosal
surface of alimentary canal - is poorly absorbed
& all of swallowed dose excreted in feces.

65. 65
Oral retention of chlorhexidine:
clinical data
•Efficacy with respect to other drugs.
•persistent bacteriostatic action lasting > 12 hours
(Schiott et al 1970)
•When mouth rinse of 10 ml of 0.2% chlorhexidine is
done for 1 min app- 30% drug is retained in mouth
(Gjermo 1975).
•Reasons:
•Radio-labeled studies suggest slow release of
antiseptic from surfaces (Bonesvoll et al. 1974)
(Gjermo et al. 1974)
Calcium ions from saliva are able to displace it from
binding sites

66. 66
Optimizing use of chlorhexidine:
•Does not distinguish between bacterial protein &
other proteins found within mature plaque so
extraneous protein must first be removed
professionally.
•Prevents plaque formation; its mode of action does
not allow it to remove plaque efficiently.
•May react with anionic surfactants present in
formulations reducing its activity.
•Should not be used before/ immediately after
toothpaste; interaction anionic surfactants will reduce
effective delivery to tooth surface in active form

67. 67
ADVERSE EFFECTS OF
CHLORHEXIDINE:-
Flotra et al. 1971
1. Brown discoloration of teeth & some
restorative materials & dorsum of tongue.
Occurs with all products –
rinse, gel, toothpastes, sprays
(Erikson et al 1985, Addy &
Moran 1995, Watts & Addy
2001)

68. 68
Proposed mechanisms for
chlorhexidine staining:
•Degradation of CHX molecule to release
parachloraniline.
•Catalysis of Maillard reactions.
•Protein denaturation with metal sulfide formation.
•Precipitation of anionic dietary chromogens
splitting sulphide bridges to produce free
sulpydryl groups , latter then reacts with iron
or tin ions to produce brown and yellow
pigmented products (Ellingsten et al 1882)
•Chlorhexidine reacts with ketones and
aldehydes in dietary breakdown or intermediary
products to form insoluble colored compounds
( Nordho 1971)

69. 69
Anti-discoloration system
(ADS)
 was launched=Europe
A clinical study supporting to show reduced
staining had significant drawbacks in design and
presentation (Bernadi et al. 2004).
A laboratory study found no difference in staining
potential (Addy et al. 2005).

70. 70
Plaque regrowth study showed significantly reduced plaque
inhibition for the ADS rinse (Arweiler et al. 2006).
“If it does not stain it does not work”.

71. 71
Taste perturbation where salt taste
appears to be affected (Lang et al.
1988).

72. 72
Oral mucosal erosion - idiosyncratic reaction and
concentration dependent.
Dilution of 0.2% formulation to 0.1%, but rinsing
with whole volume to maintain dose, usually
alleviates problem.
Erosions are rarely seen with 0.12% rinse products
used at 15 ml volume.
ISP 2012

73. 73
Unilateral or bilateral parotid swelling
extremely rare - negative pressure &
aspiration into duct.

74. 74
Enhanced supragingival calculus formation –
may be due to precipitation of salivary proteins
on to tooth surface –
increasing pellicle thickness &/or precipitation
of inorganic salts on to or into pellicle layer

75. 75
CHLORHEXIDINE
PRODUCTS
•Mode of delivery of CHX:
• mouth rinse, gels, tooth paste,
dental floss, and tooth picks.

76. 76
Mouth rinses:
• Aqueous solutions of 0.2% chlorhexidine –
•twice daily rinse in Europe in 1970s
• 0.1% - less efficacious (Jenkins et al 1989).
• In US - 0.12% - but to maintain optimum 20 mg
doses derived from 10 ml of 0.2% rinses -
recommended as 15 ml rinse (18 mg dose).
• Segreto et al 1986 reported equal efficacy for
0.2% & 0.12% rinses when used at appropriate
similar doses
0.2%
0.12%
0.05%

77. 77
Gel
• 1% chlorhexidine gel product is available and can
be delivered on a toothbrush or in trays.
• Distribution by toothbrush – poor (Saxen et al 1976)
• Tray delivery system - effective against plaque &
gingivitis in handicapped individuals (Francis et al.
1987).
• 0.2% and 0.12% chlorhexidine gels have become
available

78. 78
Sprays:
• 0.1% & 0.2% commercially available.
• Small doses of approximately 1–2 mg delivered to
all tooth surfaces produces similar plaque inhibition
to rinse with 0.2% mouth rinses (Kalaga et al. 1989)
• Useful for physically and mentally handicapped
groups-Francis et al 1987, Kalaga et al 1989).

79. 79
Toothpaste:
• Yates et al 1993
• Difficult to formulate into toothpaste
• Variable outcomes for benefits to plaque &
gingivitis
• 1% chlorhexidine toothpaste with & without
fluoride – found superior to control product for
prevention of plaque and gingivitis in a 6-
month home use study
• Stain scores were increased
supragingival calculus formation

80. varnish

81. 81
CLINICAL USES
• Adjunct to oral hygiene & professional
prophylaxis
• Post oral surgery including periodontal surgery
or root planing
• For patients with jaw fixation
• Oral hygiene and gingival health benefits in
mentally & physically handicapped
• Medically compromised individuals
predisposed to oral infections
•Removable and fixed orthodontic appliance
•Recurrent oral ulcers
•Denture stomatitis
•Oral malodor
High-risk caries patients

82. 82
PERIOCHIP
(Dexcel Pharmaceuticals, Israel)
orange brown, biodegradable, rectangular chip
rounded at one end that has an active ingredient
of chlorhexidine gluconate (2.5 mg) that is
released into the pocket over a period of 7 to 10
days.
suppress the pocket flora for up to 10- 11 weeks
post application.
approved by the FDA as an adjunct to SRP
procedures for the reduction of probing pocket
depth or as part of a routine periodontal
maintenance program.

83. 83
The recommendation for use adjunctive to
SRP involves isolation of the periodontal
pocket of 5 mm or more.
Drying the surrounding area, and grasping the
Periochip with a forceps and inserting the chip
into the pocket to its maximum depth
The chip can be maneuvered further into
position with a plastic instrument.

84. 84
THIRD GENERATION AGENTS
(Addy et al 2007)
•Characterized by an ability to inhibit or
disrupt formation of plaque while having
no demonstrable effect on bacteria
E.g.: amine alcohols

85. 85
AMINE ALCOHOLS
do not truly fit into antimicrobial/ antiseptic
category
• Low surface tension and lipophillic, hydrophilic
property can affect plaque growth without affecting
ecological balance
•Octopinol - first to be
shown effective as
antiplaque agent –
•withdrawn for toxicological
reasons
Delmopinol at 0.1% & 0.2% mouth
rinses – shown to be effective against
plaque & gingivitis in short term
long term home use studies.
(Collaert et al 1992, Claydon et al
1996, Hase et al 1998, Lang et al
1998)

86. 86
Side effects:
Tooth discoloration - less and easily removed
Transient numbness of tongue
Burning sensations in mouth (Claydon et al 1996,
Hase et al 1998, Lang et al 1998)
Positive facts
• Effectiveness of delmopinol, coupled with its
qualitatively and quantitatively greatly reduced
potential for tooth staining compared with
chlorhexidine (Lang et al. 1998) makes this
compound potentially an attractive alternative to
chlorhexidine for plaque control.

87. 87
OTHERS:
SALIFLUOR:
A salicylanide with both antibacterial and anti-inflammatory
properties.
• Studied for its effects of plaque inhibition and retardation of
onset of gingivitis (Furuichi et al. 1996).
• Initial 4 day plaque regrowth studies & 14- day gingivitis
studies have suggested equivalent efficacy to 0.12%
chlorhexidine mouth rinse (Furuichi et al. 1996)
• Despite this – long term studies yet to be carried out

88. 88
ACIDIFIED SODIUM
CHLORITE
• Yates et al 1997
• Sodium chlorite is reacted with acid to produce
chlorous acid,
which then liberates oxidant species which has
antimicrobial benefits.
105 experimental formulations shown to be as good
as chlorhexidine against plaque regrowth and
showed same substantivity.
• Side effects: Low pH of formulations cause dental
erosion
• To date no commercial products are available

89. 89
ENZYMES:
1st group – not truly antimicrobial agents, more
plaque removal agents- potential to disrupt early
plaque matrix, dislodge bacteria from the tooth
surface.
• In late 1960s & early 1970s –
dextranase, mutanase & various proteases –
thought major breakthrough in dental plaque
control
•
Had poor substantivity & unpleasant local side
effects like mucosal erosion .

90. 90
Dextranase:
DEXTRAN
high-molecular-weight polysaccharide synthesized
by Streptococcus mutans.
Action:
microbial community development and
proliferation, hence improving dental plaque’s
structural integrity.
Degradation of dextran by dextranase has
been found to be one of the approaches to
remove dental plaque and prevent further
caries.

91. 91
Bacterial dextranase-marine origin
that are high salt tolerant and stable
temperature 35.5°C,
oral use- Khalikova E et al , Jiao
YL et al 2014.
fungal dextranase are reported to
show higher optimal temperature in
the range 50 to 60°C; hence, they
might not be effective in oral use.
Commercially available

92. 92
2nd group:
Glucose oxidase, amyloglucosidase enhanced host
defense mechanism - glucose oxidase &
amyloglucosidase
• Catalyzed conversion of endogenous & exogenous
thiocyanate to hypothiocyanite via salivary
lactoperoxydase system
• Hypothiocyanite produces inhibitory effects upon
oral bacteria, particularly streptococci by interfering
with their metabolism
• Toothpaste containing enzymes & thiocyanate but
no convincing long-term studies of efficacy

93. 93
OXYGENATING
AGENTS:
Disinfectants - Hydrogen peroxide –
supragingival plaque control.
Peroxyborate – acute ulcerative gingivitis.
(Wade 1966)
cleansing action- effervescence
Undesirable tissue changes

94. 94
POVIDONE IODINE:
1811, Bernard Courtois – Iodine
1880, Devaine – Bactericidal efficacy
Late 1960s – Povidone iodine
Mechanism:
affinity for the cell membrane, thereby delivering
free iodine directly to the bacterial cell surface.
It has a broad spectrum of activity against bacteria,
fungi, protozoa, and viruses.

95. 95
The mouthwash has been shown to be effective in
reducing plaque and gingivitis and may be a useful
adjunct to routine oral hygiene.
Absorption of significant levels of iodine through the
oral mucosa may make this compound unsatisfactory for
prolonged use in the oral cavity-Fergusson et al.
Side effects
Staining teeth/ tissues
Thyroid dysfunction
Allergic to iodine
Pregnant & lactating mother

96. 96
DISCLOSING AGENTS:
•liquid, tablet or lozenge from which contains a dye or other coloring
agents.
•used for identifying bacterial plaque
•When applied to the teeth, the agents imparts its colour to soft deposits
but can be rinsed easily from clean tooth surface.
IDEAL PROPERTIES:
•Intensity of colour
•Duration of intensity
•Taste
•Irritation to mucous membrane
•Diffusibility
•Astringent and antiseptic property

97. 97
Agents used for disclosing plaque
1.Iodine preparations
•Skinners iodine solution
•Diluted tincture of iodine
2.Mercurochrome preparations
•Mercurochrome solution
•Flavored mercurochrome disclosing
solution
3.Bismarck brown
4.Mebromin
5.Erythrosine
6.Fast green
7.Fluoresin
8.Two tone solutions

98. newer

100. 100

101. 101
.
.
Mouth rinse
antiplaque,
antigingivitis, antitartar
and antisensitivity
properties
American Dental
Association recognizes
that mouthrinse
containing chlorhexidine
and the Listerine formula
is effective in controlling
plaque and gingivitis-
Mandel 1988.
chlorhexidine, triclosan,
cetylpyridinium chloride
and essential oils -due to
their proven
effectiveness and safety
and general lack of
sensory negatives such
as bitterness

102. 102
DENTRIFICES:
The main functions of toothpaste (in conjunction with
tooth-brushing) are:
•minimizing build-up of plaque
•strengthening teeth against caries
•cleaning the teeth by removing stain
•removing food debris
•Freshening the mouth.
Brushing must be carried out regularly, correctly and
for a sufficient length of time (at least one minute
twice a day) to be effective.
Three minutes is probably the minimum for fully
effective plaque removal.

103. Gum prevention tooth paste

104. 104
Anticalculus agents
Calculus control is effected by
agents such as soluble
pyrophosphates and zinc
citrate –Mandel et al 1995

105. 105
RECENT DEVELOPMENT OF
ANTIPLAQUE AGENTS
sugar-free chewing gum
on plaque and clinical
parameters of gingival
inflammation:
chlorhexidine tetrapalmitate
(CHXTP):
•Results showed CHXTP salt –low
tendency to stain
•Addition of polyvinylpyrrolidone
allowed CHXTP to be
retained longer in mouth
Renato FM et al

106. 106
green tea catechin
mouthwash
Grape seed extract (GSE) &
amine fluoride (Fluorinol)
combination – significant
antiplaque & important
antioxidant capacity
A synergistic
chlorhexidine/
chitosan combination for
improved antiplaque
strategies
Azadirachta indica
leaf extract gel

107. 107
FUTURE CHALLENGES IN CHEMICAL
PLAQUE CONTROL
Probiotics- aims to achieve
biological plaque control by
eliminating pathogenic
bacteria
Vaccination against
oral biofilm
Plant /natural
products
Ozone
irrigation

108. 108
CONCLUSION:
• In past 50 years – various antiplaque
agents have been formulated.
• Still Chlorhexidine remains
gold standard by which other
agents are standardized.
• Delmopinol & Chitosan also shows
promising prospects

109. 109
Home message
Chlorhexidine
Addy et al
substantivity

110. 110
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Aug;100(8):3130-38.
4. Addy.M. Clinical indications for use of chemical plaque control
agents. Periodontology 2000, Vol. 15, , 52- 54 128.
5. Yates R, Jenkins S, Newcombe R, Wade W, Moran J, Addy M. A
6-month home usage trial of a 1% chlorhexidine toothpaste. J
Clin Periodontol. 1993; 20:130-8.
6. Mohammed HN, MortezaT, Majid RM, Ali F, Fateme F, Mona
M et al. Comparative study of 0.2% and 0.12% digluconate
chlorhexidine mouth rinses on the level of dental staining and
gingival indices. Dent Res J (Isfahan). 2012 May-Jun; 9: 305-8.
References

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•Hase JC, Attstrom R, Edwardsson S, Kelty E, Kisch J. 6- month use of
0.2% delmopinol hydrochloride in comparison with 0.2% chlorhexidine
digluconate and placebo. J Clin Periodontol. 1998;25:746-53.
•M Raveendra Pai, Leelavathi D Acharya, N Udupa. Evaluation of
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•EM Decker, C Von Ohle, R Weiger, I Wiech, M Brecx. A synergistic
chlorhexidine/ chitosan combination for improved antiplaque strategies.
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•PC Baehni, Y Takeuchi. Anti-plaque agents in the prevention of biofilm-
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•JM Tanzer, AM Slee, B Kamay, ER Scheer. In vitro evaluation of three
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effectiveness of green tea catechin mouthwash with chlorhexidine
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112. 112