Comprehensive Overview of Chemical Plaque Control in Periodontology

CHEMICAL PLAQUE CONTROL
Presented by: Dr. Janardhana Amaranath BJ
Department of Periodontology
Rama Dental College Hospital and Research Centre

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CONTENTS
 INTRODUCTION
 HISTORY
 OBJECTIVES
 MECHANISM OF ACTION
 CLASSIFICATION OF CHEMICAL PLAQUE CONTROL
 EVALUATION OF ACTIVITY OF AGENTS FOR CHEMICAL BIOFILM CONTROL
 ACTIVE AGENTS
 NATURAL PRODUCTS
 DELIVERY FORMATES
 CLINICAL INDICATIONS FOR CHEMICAL PLAQUE CONTROL:SELECTION OF AGENTS
 CONCLUSION
 REFERENCES

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 Plaque control is defined as the removal of microbial plaque and food debris from the oral cavity..
 Plaque management consists of the use of mechanical procedures and chemical agents that retard the formation
of plaque.
 Mechanical methods of plaque prevention include (toothbrushing, flossing, interdental aids) to reduce
microbial plaque accumulation and prevent periodontal diseases. Chemical plaque agents including
mouthrinses, dentifrices(Toothpastes & toothpowder), gels, Sprays, oral irrigants, Chewing gums & varnices
other local delivery systems.
 The most effective method of plaque control at present appears to be mechanical plaque control.
 Chemical plaque regulation was used only as an extension and not as a replacement to the mechanical means.
 Further improve the performance of plaque management programs using anti-plaque agents as an adjuvant to
mechanical plaque control.
INTRODUCTION

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 Chemical plaque control may be necessary in those subjects who are unable to properly control
supragingival biofilm with mechanical devices.
 Use of chemical products reduce the amount of biofilm and disrupt its structure, allowing for a more
effective action of the chemical formulations .
 Adjunctive use may be more relevant than sole use, since most chemical agents are only able to act against
the most external parts of the biofilm.
 Some agents have demonstrated some capacity for penetration, such as chlorhexidine (CHX) (Netuschil et
al. 1995) and essential oils (Pan et al. 1999, 2000; Fine et al. 2001).
 The use of chemical formulations (especially antiseptics) to control plaque and gingivitis.

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HISTORY OF CHEMICAL PLAQUE CONTROL
 First chemical used for plaque removal were dentifrices which have been used in conjunction with chemical
aids for centuries.
 Hippocrates (460-377) was the first who recommend the use of dentrifices.
 Egyptian used tooth powders or pastes to clean their teeth.
 12th
century, Saint Hildegard Von Bingen, a German Philospher advised mouth rinses with pure cold water to
prevent plaque and tartar formation.
 Chemical plaque control agents which are popularly known today as Mouthwashes began in late 1800s.
 First toothpaste was made by Dr. Washington Sheffield in 1892.
 Chlorhexidine was discovered in the1950s by the imperial Chemical Industries, Ltd (Manchester, UK) it was
introduced as disinfectant and topical antiseptic in 1954.
 Loe and Schiott (1970) were first to demonstrate the antiplaque property of CHX.

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OBJECTIVES
 Prevention and treatment of gingivitis.
 Prevention of Periodontal disease progression
 Reduction of microbial plaque accumulation
 Assistance in maintaining oral hygiene when mechanical methods are inadequate

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Chemical plaque control can be classified according to their effects
(Lang & Newman 1997):
 Antimicrobial agents: bacteriostatic or bactericidal effects in vitro
 Plaque reducing/inhibitory agents
‐ : quantitative or qualitative effect on the plaque that may or may not be
enough to affect gingivitis and/or caries
 Antiplaque agents: affect the plaque sufficiently to show a benefit in terms of gingivitis and/or caries
control
 Antigingivitis agents: reduce gingival inflammation without necessarily affecting dental plaque, include
anti inflammatory drugs.
‐

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Ideal Features
Chemical agent for plaque control have been proposed by different authors
(Loesche 1976; van der Ouderaa 1991; Baker 1993; Fischmann 1994)
Specificity: Agents and formulations for chemical plaque control should demonstrate a wide spectrum of action,
including against bacteria, viruses, and yeasts.
Efficacy:Antimicrobial capacity must be demonstrated against microorganisms implicated in gingivitis and
periodontitis, in both in vitro and in vivo studies. Although bactericidal effects may be only achieved at high dosages,
antimicrobial effects should also be present at lower dosages (FDI Commission 2002.)
Substantivity Substantivity has been defined as the duration of the antimicrobial action in vivo (FDI Commission
2002) and as a measurement of the contact time between the agent and the substrate in a defined medium. According
to their substantivity, agents have been divided into three distinct generations (Kornman 1986)

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First generation agents
‐ Antibacterial agents show effective in vitro but limited substantivity in vivo
with limited time of action they are capable of reducing plaque scores show 20-50% examples Antibiotics and
antimicrobial agent (penicillin,vancomycin,kanamycin,ninddamycin,spiromycin) phenols and essential
oils(thymol,Eucalyptol,Triclosan) metal salts (Tin ,Zinc, Copper, Stannous fluoride) Natural products
(sanguinarine, propolis) quaternary ammonium compounds (Cetylpyridinium, chloride, Benzalconium chloride)
oxygenating agents Hydrogen peroxide, sodium peroxyborate, sodium peroxycarbonate) Enzyme (protease,
Lipase,Nuclease, Dextranase ,Mutanase ) Surfactants /Detergents (sodium lauryl sulphate).
Based on antimicrobial activity & Substantivity (Kornman 1986)

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Second generation agents
‐ antibacterial agent with high substantivity and effective in vivo.
They are 70-90% more effectively retained by oral tissue than first generation. Example Bisbiguanides
(chlorhexidine, Alexedine, Octenidine)
Third generation agents
‐ – block microbial colonization relatively new preparation which
inhibit plaque growth and gingivitis by interfering with plaque matrix formation and also reducing bacterial
adhesion and adherence,E.g. Amine alcohols (octapinol Delmopinol)

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MECHANISM OF ACTION OF CHEMICAL PLAQUE CONTROL IN GENERAL
Chemical plaque control may be achieved by different
mechanisms of action with a quantitative (reduction
of the number of microorganisms
(b) Bactericidal or bacteriostatic effect, avoiding
bacterial proliferation and co aggregation: interference
‐
with bacterial division (damaged bacterial cells depicted
in red) leads to interference with biofilm formation. In
addition, biofilm maturation is also prevented as co‐
aggregation of new species (red arrows) is impeded, due
to the non favorable
‐ environmental conditions.
Mechanisms of effect of antiplaque agents on
bacterial biofilms (in green). (a) Prevention of
bacterial adhesion to tooth surfaces: the active agent
forms a pellicle (blue film) over the tooth surface,
interfering with bacterial adhesion (red arrows), thus
avoiding bacterial colonization.

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(c) Biofilm disruption from tooth surfaces:
“chemical brushing”. The agent induces
detachment and/or biofilm elimination from
the tooth surface by breaking the chemical
links between the surface and the biofilms,
and by disrupting the biofilm structure (red
arrows).
(d) Alteration of biofilm pathogenicity or enhancement of
host immune systems by different mechanisms: enhanced
host defense systems provide more effective biofilm
control by the host (short red arrows); or presence of
defined bacterial species that may influence biofilm
development and maturation, by means of the release of
different products, such as bacteriocins, or by competition
for nutrients (long red arrow).

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EVALUATION OF ACTIVITY OF AGENTS FOR
CHEMICAL BIOFILM CONTROL
Assess the plaque inhibitory and antiplaque activity of chemical compounds, consecutive phases of evaluation have
been proposed, with the last being randomized clinical trials of home use with at least 6 months’ duration (Addy &
Moran 1997).
In vitro studies
Evaluate the antimicrobial activity of a product by measuring the minimum inhibitory concentration (MIC) and
minimum bactericidal concentration (MBC) against different bacterial species.
In vivo studies
studies assess the retention of an agent in the mouth after a single use by measuring the agent level in saliva or in
dental plaque. These studies do not provide information on the activity of the product (Rolla et al. 1971; Bonesvoll
et al. 1974a, Gjermo et al. 1974, 1975; Bonesvoll 1978).

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ACTIVE AGENTS
Antibiotics
Penicillin, tetracyclines, metronidazole, vancomycin, kanamycin, and spiramycin.
Enzymes
Disrupt the biofilm Dextranase, mutanase, proteases, and lipases.
Enhance the host defenses
Glucose oxidase and amyl glucosidase.
Amine alcohols
Detergents
Oxygenating agents

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Metal salts
Zinc salts
Zinc lactate, zinc citrate, zinc sulphate, and zinc chloride
Stannous fluoride
Stannous fluoride with amine fluoride
Other fluorides
Sodium fluoride and sodium Mon fluorophosphate
Natural products
Sanguinarine extract and other herbal ingredients (camomile, echinacea, sage, myrrh, rhatany, peppermint
oil). Essential oils Mouth rinse with eucalyptol (0.092 %), menthol (0.042 %), methyl salicylate (0.060 %),
thymol (0.064 %), and alcohol (26.9 % in the original formulation)

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Bisbiguanides
CHX digluconate, alexidine dihydrochloride, and octenidine dihydrochloride
Chlorhexidine
CHX is the most widely evaluated and the most efficacious agent against oral biofilms. Its activity was first
investigated > 50 years ago (Schroeder 1969).
Characteristics. CHX is active against Gram positive and Gram negative bacteria, yeast, and viruses, including
‐ ‐
human immunodeficiency virus (HIV) and hepatitis B virus (Wade & Addy 1989).

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Mechanism of action of CHX
1.CHX, which is a bi-cationic positively charged molecule,
attaches to the negatively charged sulfates and phosphate ions
on the bacterial cell wall.
↓
2.CHX gets adsorbed on the bacterial cell wall.
↓
3.CHX alters the integrity of the bacterial cell membrane.
With increased concentration of CHX, there is progressive
damage to the cell membrane.
↓
4.CHX binds to the phospholipids in the inner membrane
and there is leakage of low molecular weight compounds, such
as potassium ions.
↓
5.There is coagulation and precipitation of cytoplasmic
components by formation of phosphate complexes, which
include adenosine triphosphate (ATP) and nucleic acids.
↓
Bacterial Cell Death

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 Mouth washes
 Tooth pastes
 Gels
 Sprays
 Irrigation
Chlorhexidine can be delivered in the form of

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 Most commonly used formulation of CHX .
 Most commercially available formulation use of chlorhexidine
digluconate for a mouth wash.
 The two 10 ml daily rinses guarantee full plaque inhibition with a
maximum of 0.12% or 0.2 % (chlorhexidine solution).
 short-term application of chlorhexidine digluconate in a
concentration of 0.12 % or 0.2 % chlorhexidine solution may be
recommended routinely after periodontal surgery.
Mouthwashes

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 The attempt to incorporate
chlorhexidine in to tooth paste was only
partially successful.
 Toothpaste formulated and tested for
antiplaque and anti-gingivitis .
 CHX containg toothpaste is Cariax R
which has 0.12% CHX.
Tooth pastes

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Gels
 CHX preparation in gel form are effective formulation for plaque control Specially in handicapped
individuals.
 These can be delivered with the help of a toothbrush or tray.
 Gel are available 0.1%, 0.12%, 0.2%, 0.5%, and 1%, to be used with toothbrushing or applied in trays.
 2 % gel formulation of CHX effective root canal lubricant.
 Reduction in the levels of plaque and inflammation has been reported with gel application in a dental
tray other purposes, such as the prevention of alveolitis after tooth extraction

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 The plaque inhibitory potentials are also at risk if chlorhexidine
rinses are decreased amount of stain.
 This was particularly observed when lower levels were used in
interproximal areas.
 The reduced clinical impact will counteract the increase in the
dose, making an irrigator an ideal tool for antimicrobial agents.
 The use of 400 ml of chlorhexidine 0.02% once daily in oral
irrigator has been shown in recent stores to result in full plaque
inhibition.
 for partial plaque reduction in concentration of as low as 0.006%
will still gave some plaque inhibition.
Irrigators

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Chewing gums
 Chewing gums containing therapeutic agents such as
fluorides, xylitol, metal salts, enzymes and CHX diacetate
commercially available by various companies.
 Indicate in patient with xerostomia and malodor.
 Chewing gum to minimize plaque formation.
 Patient to advised to chew 4-6 pieces of chewing gum
daily for approximately 20 minutes.
 One chewing gum contains 5mg of CHX so 20-30 mg of
CHX delivered in a day.
 Contraindication in hypersensitivity patients

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Sprays
 0.12 % and 0.2 % Sprays are available commercially.
 Very useful physically and mentally handicapped patients.
 Twice daily sprays of non-aerosol CHX deliver approximately 1.4 to 2 ml of CHX
which is one-seventh of the optimal mouthrinse dose of 0.2 % .
 Effect on plaque and gingival bleeding.
 The advantage of aerosols is that the agent can be applied exactly where it is needed.
However, the dosage is not predictable.
 Their use on all dental surfaces is associated with a reduction in plaque level similar to
that obtained with mouth rinsing, but the adverse effects are also the same (Francis et
al. 1987b; Kalaga et al. 1989a)

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Limitations of CHX long term use (Schiøtt
‐ et al.1970, 1976).
 Increase in calculus formation (Yates et al. 1993)
 Staining of teeth, mucosa, tongue dorsum, or restorations and on artificial teeth
(Fløtra et al. 1971).
Tooth staining after chlorhexidine use (a) Lingual aspect (b) buccal aspect

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 Hypersensitivity reaction (Beaudouin et al. 2004)
 Neurosensory deafness if the product is placed in the middle ear (Aursnes 1982)
 Taste alterations (Marinone & Savoldi 2000; Breslin & Tharp 2001)
 Uni or bi lateral parotid swelling (Fløtra
‐ ‐ et al. 1971; van der Weijden et al.2010)
 Mucosal erosion (Almqvist & Luthman 1988)
 Healing process alterations.

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Deliver agents for chemical plaque control:
 Rinses
 Gels
 Dentifrices
 Chewing gums
 Aerosols
 Varnishes
 Sustained release devices
‐
 Lozenges
 Irrigators
Delivery forms

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Mouth rinses
Mouth rinses are formulated with different ingredients
 Colourings.
 Flavourings
 preservatives (sodium benzoate)
 Stabilizers
 active agents

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Dentifrices
 Term dentifrices is derived from the lattin word dens(tooth) and
frices (to rub).
 A simple, contempory definition of a dentifrices is a mixture
used on tooth in conjunction with a toothbrush.
 Dentifrices is the integral part of daily oral health maintenance.
They not only help in cleaning and polishing the teeth, but also
fresh felling that comes with the use of a dentifrices.
 Available in paste, power, gel or liquid from.
 Dentifrices French word for toothpaste.

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Dentifrices
Ingredients in a dentifrice formulation are:
• Abrasives dental plaque and stain removal.(Paraskevas et al. 2006). The most common abrasives are calcium
carbonate, alumina, dicalcium phosphate, and silica.
• Detergents The most widely used is SLS, which provides some antimicrobial action (Jenkins et al. 1991),
although no evidence is available to support its effectiveness in plaque removal.
• Thickeners These include silica and gums, and they influence the viscosity of the toothpaste.
• Sweeteners such as sodium saccharin.
• Humectants These prevent the toothpaste from drying up; glycerine and sorbitol are the most commonly
used.
• Flavorings such as mint and strawberry.
• Colouring agents titanium oxide and chlorophyll
• Active agents including fluorides, triclosan, CHX (with some difficulties in the formulation, due to its
interference with anionic detergents and with flavorings), CPC, and other active agents (anticalculus agents,
whitening products, desensitizing agents)

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 CHX have been formulated as lozenges.
 Reductions in plaque and gingivitis levels have
also been reported for CHX lozenges.
 Mean plaque score was reduced by 62.8% (from
2.38 to 0.89; P <0.0001), after 1 week of usage
(Kaufman et al. 1989).
Lozenges

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 Varnishes are the effective way of professionally
delivering therapeutic agent.
 Commercially available CHX varnishes are
EC40,Chlorzoin and Cervitec
 CHX varnishes used in the prevention of root
caries and topical fluoride application in
permanent teeth of teenagers
 Application of subgingival CHX varnish in
conjuction with root planning has been shown to
reduce pocket dept at initially deep sites
Varnishes

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CHX is also formulated in sustained release devices designed with a therapeutic
‐
purpose:
 Chips
 Gels
 Xanthan gels
Sustained release devices
‐

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Different clinical situations, depending on the duration of product usage and the main objective of the intervention,
are considered:
 Single use.
 Short term use (either with a preventive or a therapeutic aim).
‐
 Long-term use (either with a preventive or a therapeutic aim).
Single use
 To decrease of the bacterial load.
 To decrease the risk of bacteremia.
 To decrease the risk of infection of the surgical area.
Clinical indications for chemical plaque control:
Selection of agents

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After scaling and root planning or periodontal surgery
Prevention of postsurgical infection
Short term use for the prevention
‐ of dental biofilm formation

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Patients with intermaxillary fixations
After bone fractures or after orthognathic or cosmetic maxillary surgeries when no mechanical hygiene is
possible, CHX mouth rinses have been shown to be useful in biofilm formation prevention (Nash & Addy 1979).
Patients with mucosal or gingival acute infections
In these patients, pain precludes mechanical hygiene and CHX mouth rinses may be useful in biofilm formation
prevention (Eley1999).

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Other clinical situations may require the short term use of antiseptic products with a therapeutic aim
‐
 Necrotizing gingivitis therapy.
 Candidiasis therapy.
 Peri implant mucositis therapy.
‐
 Peri implantitis therapy.
‐
 Periodontitis therapy.
Short term use for therapy
‐

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Patients carrying fixed or removable orthodontic appliances
Disabled patients
In physically or mentally disabled patients, the use of CHX improves plaque and gingival health (Storhaug
1977). In these patients, a spray (0.2% CHX) is the preferred vehicle (Francis et al. 1987a, b; Kalaga et al.
1989b; Clavero et al. 2003).
Patients with gingival overgrowth or enlargement
In these patients, mechanical control is difficult and a CHX mouth rinse may be helpful (O’Neil &
Figures 1982; Saravia et al. 1990; Francetti et al. 1991
Periodontitis patients
Patients with dental implants
General population: The main aim in the general population is to maintain periodontal health with the
presence of a biofilm in equilibrium with the host response.
Long term use for the prevention
‐ of dental biofilm formation

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Predisposed patients, with high risk of suffering oral infections
In patients with blood dyscrasia or who are immunosuppressed, the use of CHX mouth rinses may help to
prevent oral or systemic complications.
Oral mucositis prevention (associated with radiation or chemotherapy in head and neck cancer patients)
CHX rinses have been proposed as part of the treatment to prevent or treat oral mucositis. CHX mouth rinses for
the prevention of oral mucositis.
Long term use for the prevention
‐ of other oral conditions

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Caries prevention
CHX use has been shown to reduce counts of S. mutans in at risk patients (Ullsfoss
‐ et al. 1994; Quirynen et al. 2005).
Candidiasis prevention
CHX has been evaluated with regards to candidiasis prevention in patients with systemic diseases
and in patients with dental prosthesis (Ferretti et al. 1987, 1988; Toth et al. 1990; Barasch et al. 2004; Elad et.al. 2006 )
Prevention of recurrent aphthous ulcers
CHX use may reduce the incidence, duration, and severity of ulcers, including in patients with fixed
orthodontic appliances (Shaw et al. 1984). Triclosan formulations may also decrease the incidence of Oralet.al. 2006 )

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 Oral malodor indication for the use of mouth rinses.
 Chemical plaque control agents such as CHX, essential oils, triclosan etc reduce the volatile
sulfur-producing bacteria in oral cavity thus reducing oral malodor.
 Agent must be differentiated from mouth fresheners which do not kill the microorganism causing
malodor.
Halitosis therapy

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 chemical plaque control agents act as useful adjuvants for achieving the desired results.
 Antimicrobial and antiplaque agents in dentifrices and oral rinses act in several ways to reduce or
remove dental biofilms and inhibit bacterial growth..
Conclusion

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 Serrano Herrera D. Chemical oral and dental biofilm control:Clinical Periodontology and Implant Dentistry, Sixth
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 Perry D.A,Plaque control for the periodontal patient: Carranza’s Clinical periodontology, Tenth Edition, Elsevier
private limited.(2006)728-748.
 Nitin Saroch, Chemical plaqe control, Periobasics: A textbook of Periodontics and Implantology, Second Edition,
Sushrut Publications Pvt. Ltd. (2021) 647-666.
 Vyas T, Bhatt G, Gaur A, Sharma C, Sharma A, Nagi R. Chemical plaque control - A brief review. J Family Med
PrimCare 2021;10:1562-8.
 Jafer M, Patil S, Hosmani J, Bhandi SH, Chalisserry EP, Anil S. Chemical Plaque Control Strategies in the
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 Newman H N. The rationale for chemical adjuncts in plaque I control. International Dental Journal (1998) Vol.
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References

Comprehensive Overview of Chemical Plaque Control in Periodontology