Classification of chemical antiplaque agents 1. FIRST GENERATION AGENTS Poor substantivity and thus used 4-6 times daily. Reduces plaque score by 20-50% Examples: Antibiotics like Penicillin, Erythromycin, Metronidazole 2. SECOND GENERATION AGENTS Reduce plaque score by 70-90% Used twice daily Example: Bisbiguanides, Chlorhexidine, Alexidine 3. THIRD GENERATION AGENTS Effective against specific periodontal pathogens Example: Delmopinol II. Vehicles for delivery of chemical agents a. Toothpastes b. Sprays c. Irrigators d. Chewing gums e. Mouthwashes (Listerine, Chlorhexidine, Triclosan, Fluorides, Hydrogen peroxides, Povidone iodine)

1. CHEMICAL PLAQUE
CONTROL

3. INDEX
1.Classification
2. Vehicles for delivery of chemical agents
• Toothpastes
• Sprays
• Irrigators
• Chewing gums
• Mouthwashes (Listerine, Chlorhexidine,
Triclosan, Fluorides, Hydrogen peroxides,
Povidone iodine)

4. PROPERTIESOF IDEALANTIPLAQUE AGENTS (BRAL
AND BROWNSTEIN1988)
Eliminate pathogenic bacteria only
Prevent development of resistant bacteria
Exhibit Substantivity
Safe to oral tissues
Significantly reduce plaque and calculus
Should not stain teeth or alter taste
Inexpensive
Easy to use
No adverse effects on teeth or dental materials

5. CLASSIFICATION

6. I. CLASSIFICATION BY
(LINDHE 1983)
FIRST GENERATION AGENTS
• Poor substantivity and thus used 4-6 times
daily.
• Reduces plaque score by 20-50%
Examples:
• Antibiotics
- Penicillin
- Erythromycin
- Metronidazole

8. SECOND GENERATION AGENTS
• Reduce plaque score by 70-90%
• Used twice daily
Example:
• Bisbiguanides
-Chlorhexidine
-Alexidine
• Bispyridines
-Octenidine

9. THIRD GENERATION AGENTS
• Effective against specific periodontal
pathogens
Example:
Delmopinol

10. II. CHEMICAL ANTIPLAQUE
AGENTS
• Antibiotics: Penicillin, Vancomycin, Kanamycin
• Bisbiguanide antiseptics: Chlorhexidine,
alexidine, Octenide
• Phenols and essential oils: Thymol, Triclosan,
Hexylresorcinol
• Natural products: Sanguinarine
• Quarternary ammonium compounds:
Cetylpyridinium chloride

11. • Oxygenating agents: hydrogen peroxide, sodium
perborate, sodium peroxycarbonate
• Detergents: sodium lauryl sulphate
• Enzymes: protease, lipase, dextranase, mutanase-
glucose oxidase
• Amine alcohol: octapinol, delmopinol
• Metal salts: tin, zinc, copper
• Fluorides: Sodium fluoride, Stannous fluoride,
Amine fluoride.

12. III. ACCORDING TO ACTION OF
ANTIPLAQUE AGENT— MANDEL
IN 1988
• ANTIADHESIVE
• ANTIMICROBIAL
• PLAQUE REMOVAL
• ANTIPATHOGENIC
• ENZYMES

13. VEHICLES FOR
DELIVERY OF
CHEMICAL AGENTS

14. VEHICLES FOR DELIVERY OF
CHEMICAL AGENTS
• TOOTHPASTE
• SPRAY
• IRRIGATORS
• CHEWING GUM
• VARNISHES
• MOUTHRINSES

15. TOOTHPASTE
A dentifrice is a substance used with a tooth brush for
purpose of cleaning the accessible surface of teeth and
removing dental plaque, materia alba and food debris
Basically, used for applying specific agents to tooth
surface for preventive or therapeutic purposes
It is derived from dens= [tooth]
 Fricare= [to rub] (WEBSTER’S)

16. WHY BRUSHING WITH TOOTHPASTE
IS IMPORTANT ??
Remove plaque, a sticky, harmful film of bacteria
that grows on your teeth that causes caries, gum
disease, and eventual tooth loss if not controlled.
Fluoride makes the entire tooth structure more
resistant to decay and promotes remineralization ,
which aids in repairing early decay before the
damage can even be seen.
Special ingredients in the dentifrice help to clean
and polish the teeth and remove stains over time.
Toothpastes help freshen breath and leave your
mouth with a clean feeling.

17. COMPOSITION
1. Polishing/ abrasive agents
• Ca carbonate
• Dicalcium phosphate dihydrate
• Alumina
• Silica
Functions
 Mild abrasive action aids in illuminating plaque
 Removes stained pellicle, restores natural luster,
enhances enamel whiteness

18. 2.Binding/ thickening agents
a. Water soluble agents
• Alginates, Sodium carboxy methyl cellulose etc
b. Water insoluble agents
• Colloidal silica, Magnesium aluminium salts etc
Functions
 Controls stability & constitency of tooth paste
3.Detergents/ surfactants
• Sodium lauryl sulfate
Functions
 Produces foam & removes food debris
 Antimicrobial property

19. 4. Humectants
• Sorbitol, glycerine, polyethylene glycol
Function
 reduces the loss of moisture from tooth paste
5. Flavoring agents
• Peppermint oil, spearmint oil, oil of
wintergreen
Function
 Render the product pleasant to use & leaves a
fresh taste in mouth after use

20. 6. Sweeteners and colouring agents
7. Antibacterial agents
8. Anti bacterial agents
• Triclosan, delmopinol, metallic ions & Zn-citrate trihydrate
9. Anticaries agents
• Na fluoride, stannous fluoride
10. Active agents-fluoride
11. Anticalculus agents(crystal growth inhibitors)
• Pyrophosphate, Zn citrate, Zn chloride
12. Desensitizing agents
• Sodium fluoride, potassium nitrate

21. • Anti-Caries / Cavity Protection
• Plaque & Gingivitis Prevention
• Tooth Whitening
• Sensitivity
• Tartar Control
• Fresh Breath
• For Children
THE DIFFERENT TYPES OF TOOTHPAS

22. Colgate Cavity Protection
• contains Sodium monofluorophosphate as the active
ingredient.
Colgate Simply White
• A whitening toothpaste that is "Clinically-proven to
whiten in 14 days". Its whitening ingredient is
hydrogen peroxide, which gradually bleaches the
teeth. It utilizes two separate chambers that contain
a whitening agent and a cleaning gel.

23. SPRAYS
• Sprays have the advantage of focusing
delivery on the required site.
• The dose is clearly reduced and for
antiseptics such as chlorhexidine, this has
taste advantages.
• When correctly applied chlorhexidine sprays
were as effective as mouthrinses for plaque
inhibition although there was no reduction in
staining (Francis et al. 1987, Kalaga et al.
1989). Chlorhexidine sprays were found
particularly useful for plaque control in
physically and mentally handicapped groups

24. IRRIGATORS
• Irrigators were designed to spray water, under
pressure, around the teeth. As such they only
removed debris, with little effect on plaque
deposits.
• Antiseptics and other chemical plaque control
agents, such as chlorhexidine, have been
added to the reservoir of such devices.
• Waterpik cordless advanced water flosser
available and can be used at home.

25. CHEWING GUMS
• There appear to be significant benefits to
dental health through the use of sugar-free
chewing gum.
• Unfortunately, chewing gums alone appear to
have little in the way of plaque control
benefits particularly at sites prone to
gingivitis
• Nonetheless, the vehicle has been used to
deliver chemical agents such as chlorhexidine
and, when used as an adjunct to normal
toothbrushing, reduced plaque and gingivitis
levels have been shown.

26. 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

27. MOUTHWASHES

28. LISTERINE

29. ANTIPLAQUE AGENTS
ACCEPTED BY FDA FOR
TREATMENT OF GINGIVITIS
1) CHLORHEXIDINE: Prescription drug
2) LISTERINE: Over the counter/Non prescription
drug.
• In September 1987, Listerine antiseptic mouthwash
was the first non prescription product to be
awarded the ADA council on Dental Therapeutic
seal of acceptance as an aid in controlling
supragingival dental plaque.
• The mouthwash has been named in the honour of
Dr. Joseph Lister, a pioneer in the field of antiseptic
surgery.

30. COMPOSITION
Ethanol-21.6% in flavoured product
• 26.9% in original gold Listerine antiseptic
Active ingredients:
• Menthol- 0.042%- local anaesthetic
• Thymol- 0.064%- antiseptic
• Methyl salicylate-0.060%-cleaning agent
• Eucalyptol-0.092%

31. BISBIGUANIDE
ANTISEPTICS
CHLORHEXIDINE

32. CHEMISTRY
• Chlorhexidine is a bis-biguanide formula with cationic
properties.
• Effective against gram +ve, gram –ve organisms, fungi, yeasts and
viruses. Exhibit antiplaque & antibacterial properties
• The compound is a strong base and dicationic at pH levels
above 3.5, with two positive charges on either side of a
hexamethylene bridge.
3 Forms : Digluconate ; Acetate ; Hydrochloride

33. PHARMACOKINETICS
Approximately 30% of chlorhexidine is retained in the oral cavity
following rinsing and is slowly released into the oral fluids.
It is poorly absorbed from the GI tract.
Detectable levels are not present in the plasma 12 hours after
administration.
Excretion occurs primarily through the feces (90%) and 1% is
excreted in the urine.

34. MECHANISM OFACTION
Antiplaque action of chlorhexidine
1. Prevents pellicle formation by blocking acidic
groups on salivary glycoproteins thereby reducing
glycoprotein adsorption on to the tooth surface
2. Prevents adsorption of bacterial cell wall on to the
tooth surface
3. Prevents binding of mature plaques

35. ANTI BACTERIAL ACTION
• LOW CONC. – Bacteriostatic
• HIGH CONC. – Bactericidal
• PIN CUSHION EFFECT – one charge end interact with
tooth and other remains available to initiate the
interaction with bacterial membrane as
microorganism approaches the tooth surface

36. Antibacterial action of chlorhexidine
It shows two actions
1. Bacteriostatic at low concentrations
Bacterial cell wall (-ve charge)
Reacts with +ve charged chlorhexidine molecule
Integrity of cell membrane altered
CHX binds to inner membrane phospholipids & increase
permeability
Vital elements leak out & this effect is reversible

37. 2. Bacteriocidal action
Increased concentration of chlorhexidine
Progressive greater damage to membrane
Larger molecular weight compounds lost
Coagulation and precipitation of cytoplasm
Free CHX molecule enter the cell & coagulates proteins
Vital cell activity ceases
cell death

38. SUBSTANTIVITY OF CHLORHEXIDINE
• The ability of the drug to absorb onto and bind
to hard and soft tissues is called substantivity.
• Chlorhexidine is gold stranded mouthwash
due to its substantivity of 12 hours, which is
maximum among all mouthwashes.
• Advocated twice daily.

39. TOXICOLOGY, SAFETY AND SIDE
EFFECTS
• In oral use as a mouthrinse, chlorhexidine has
been reported to have a number of local side
effects
These side effects are:
1. Brown discoloration of the teeth and some
restorative materials and the dorsum of the
tongue.

40. STAINING OF TEETH

41. STAINING OF TONGUE

42. 2.Taste perturbation where the salt taste appears to be
preferentially affected (Lang et al. 1988) to leave food and drinks
with a rather bland taste.
3. Oral mucosal erosion . This appears to be
an idiosyncratic reaction and concentration dependent.
Dilution of the 0.2% formulation to 0.1%,
but rinsing with the whole volume to maintain dose, usually
alleviates the problem.
Erosions are rarely seen with 0.12% rinse products used at 15 ml
Volume.

43. MUCOSAL EROSION

44. 4. Unilateral or bilateral parotid swelling .
This is an extremely rare occurrence and an explanation is not available.
5. Chlorhexidine also has a bitter taste, which is difficult to mask completely.
6. Increase calculus levels
• dead bacteria accumulates on the tooth surfaces, acting as sites for
calculus deposition
• Also dead bacteria release pyrophosphatase leading to decreased natural
pyrophosphate levels

45. CHLORHEXIDINE STAINING
• The mechanisms proposed for chlorhexidine
staining can be debated (Eriksen et al. 1985, Addy
& Moran1995, Watts & Addy 2001) but have been
proposed as:
1.Degradation of the chlorhexidine molecule to
release parachloraniline (Addy & Roberts 1981).
2.Catalysis of Maillard reactions (Nordbo 1979).
3.Protein denaturation with metal sulfide formation
(Ellingson et al 1982).
4.Precipitation of anionic dietary chromogens.
(Addy & Moran 1995).

46. SHORT -TERM APPLICATIONS
Healing phase in
periodontal therapy
Healing phase in oral
surgery : mandibular
fractures , third molar
extractions ,
immediate denture
Presurgical use to
reduce bacteremia
Therapy for apthous
ulceration
Therapy for denture
stomatitis
Therapy for acute
necrotizing ulcerative
gingivitis

47. INTERMITTENT SHORT TERM APPLICATION (3 TO 4
MONTHS CYCLE )
Repeated
denture
stomatitis
Adjunct
to
periodontal
maintenanc
e care
High caries
level
Dental
implant
s

48. LONG TERM APPLICATION
Medically compromised patients (Agranulocytosis,
leukemia, hemophilia, thrombocytopenia, kidney disease,
allergies, bone marrow transplant, AIDS).
Iatrogeniic risk patients (immunosuppressive agents,
radiation therapy
Physically handicapped patients ( Arthritis, scleroderma,
disturbed motor capacity or muscle function)
Mentally handicapped patients.

49. QUATERNARY
AMMONIUM
COMPOUNDS

50. QUATERNARY AMMONIUM
COMPOUNDS
• Cetylpyridinium chloride - 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
appears to be only 3-5 hours either due to
loss of activity once adsorbed or rapid
desorption…..Roberts & Addy 1981.

51. COMMERCIAL PRODUCTS
• cetylpyrinidium chloride (Cepacol .05%)
• cetylpyrinidium chloride with domiphen
bromide (Scope)
• benzethonium chloride (Colgate 100).

52. TRICLOSAN

53. PHENOLS AND ESSENTIAL OILS-
TRICLOSAN
• Phenol derivative
• Synthetic, non-ionic topical antimicrobial agent.
• Colorless, crystalline, readily soluble in some
organic solvents (Zinkernagel & Koenig 1967).
• Broad spectrum of action (Diamant 1976).
• Available as toothpaste and mouthrinses.
• In simple solutions, at relatively high
concentrations (0.2%) and dose (20 mg twice per
day), triclosan has moderate plaque inhibitory
action and antimicrobial substantivity of around 5
hours.

54. MECHANISM OF ACTION
• Acts on the microbial cytoplasmic membrane,
inducing leakage of cellular
constituents…..bacteriolysis (Regos & Hitz
1974).

55. Three strategies have been
developed to enhance the
clinical effectiveness of oral
triclosan products:

56. • combine it with zinc citrate to take
advantage of the potential anti-plaque
and anti-calculus properties of the
latter,
• incorporate triclosan in a copolymer of
methoxyethylene and maleic acid to
increase its retention time; and
• combine it with pyrophosphates to
enhance its calculus reducing
properties.

57. • Significant reduction in plaque, gingivitis, and
calculus have also been found with a dentifrice
containing 3% triclosan and 2% of the
copolymer of methoxyethylene and maleic
acid.
TRICLOSAN CONTAINING TOOTHPASTE
• Colgate total, Anchor, Sensodyne, Crest cavity
protection
TRICLOSAN CONTAINING MOUTHRINSE
• Plax

58. FLUORIDES

59. FLUORIDES
• The caries preventive benefits for a number of fluoride
salts are well established but the fluoride ion has no effect
against the development of plaque and gingivitis.
• Amine fluoride and stannous fluoride provide some
plaque inhibitory activity and antigingivitis action but not
comparable to CHX….Brecx et al 1990, 1992.
Interfere with enzyme activity & reduce acid
production…Marsh 1988, Hamilton 1990, Shani 2000.

60. • Side effect of fluoride rinse included slight
staining which can be easy to remove, as in the
case of stannous fluoride in Gel Kam (anti-
hypersensitivity agent).

61. HYDROGEN PEROXIDE

62. OXYGENATING AGENTS
• Oxygenating agents have been used as
disinfectants in various disciplines of dentistry,
including endodontics and periodontics.
• Hydrogen peroxide (Wade et al.1966).
• Peroxyborate may be used in the treatment of
acute ulcerative gingivitis.

63. MECHANISM OF ACTION
• The mechanism of action are the ability to
altered membrane permeability. Hydrogen
peroxide breaks down to form oxygen and
hydrogen.
• When applied to tissue, protective enzyme
such as peroxidase and catalase act on the
material, causing rapid decomposition with
resulting effervescence.

64. INDICATIONS
INDICATED IN ANAEROBIC INFECTIONS:
• Pericoronitis
• ANUG
• Staining of teeth

65. SIDE EFFECTS
• Branemark and Ekhol studied the effect of 3%
hydrogen peroxide , showed that increase
degree of the injury to damage tissue, thus
delayed wound healing.
• Hydrogen peroxide also may cause soft tissue
lesion in high dose in animal studies, hairy
tongue, and also overgrowth of opportunistic
microbial organism such as Candida Albicans.
• Emphysema due to bubble formation.

66. POVIDONE
IODINE

67. POVIDONE IODINE
HISTORY
• In 1811 Bernard Courtois, a chemist, discovered the
natural element iodine and in 1880, Devaine described its
bactericidal efficacy.
Spectrum and Mechanism of Microbial Destruction
• PVP-I is microbicidal for Gram-positive and negative
bacteria, fungi, mycobacteria, viruses, and protozoans.
• Its bacterial activity is due to oxidation of amino (NH−),
thiol (SH−), and phenolic hydroxy(OH−) groups in amino
acids and nucleotides.
• PVP-I also reacts strongly with double bonds of
unsaturated fatty acids in cell walls and organelle

68. Schreier et al. reported that electron
microscopic and biochemical assessments
supported the contention that PVP-I
interacted with cell walls, causing a transient
or permanent pore formation. This resulted
in loss of cytoplasmic material and
deactivation of enzymes due to direct contact
with iodine.

69. Use of PVP-1 for reduction of salivary
bacteria and prevention of transient
bacteremia. Provide better results than
chlorhexidine in-(INDICATIONS)
Preprocedural rinse
Subgingival irrigation
as, spectrum of antimicrobial activity is
broader for povidone iodine than
chlorhexidine.

70. PVP-I used as a preprocedural rinse, considered better
than chlorhexidine:
• The greatest decrease of streptococci was attained
when PVP-I was diluted 1/1, creating a 5%
concentration and applied for 30 seconds. (action is
better in diluted form)
• When PVP-I (5%) was compared to chlorhexidine
(0.2%), the PVP-I achieved a 2 to 3 log decrease of
streptococci, whereas the chlorhexidine achieved
only 1.5 log reduction.
• The data indicated that the amount of bacteria in
saliva can be reduced almost 33% by rinsing with
PVP-I (5%) for 30 seconds prior to dental procedures.

71. • Furthermore, the decrease found within 5
minutes did not rebound to baseline after 90
minutes.
• The author suggested, but did not verify, that
pre-rinsing with PVP-I would reduce the amount
of bacteria in aerosols generated after using an
ultrasonic scaler or high-speed handpiece.

72. SIDE EFFECTS
• Staining of teeth.
• Staining of the tongue
• PVP-I should not be used in individuals who
are allergic to iodine.
• Its use is contraindicated in pregnant women
and nursing mothers ,because it can induce
thyroid dysfunction due to excessive
incorporation of iodine.