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Mouth rinses Toothpastes Chewing Gum Lozenges

Dr. Anumala Department of Oral Health

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Bisguanide Quaternary Ammonium Compounds Phenolic Antiseptics Hexetidine Povidone Iodine Triclosan Delmopinol Salifluor Metal Ions Natural Products Oxygenating Agents

Kills a wide range of microorganisms by damaging cell wall Bisguanide antiseptics that possess anti-plaque activity are: Chlorhexidine Alexidine Octenidine

Digluconate of chlorhexidine is a synthetic broadspectrum antimicrobial agent Effective against gram +ve and ve bacteria including aerobes and anaerobes, yeasts and fungi Action: increases cellular membrane permeability followed by coagulation of the cytoplasmic macromolecules

Reduces bacterial adherence by binding to the bacterial outer membrane According to research 0.2% chx will prevent experimental gingivitis after withdrawal of oral hygiene However chx is more effective in preventing plaque accumulation on a clean tooth surface than in reducing preexisting plaque deposits

Chx is able to inhibit plaque formation in a clean mouth but will not significantly reduce plaque in an untreated mouth Therefore, it should not be given to patients before necessary periodontal treatment

Substantivity of Chx
Substantivity: ability of drugs to adsorb onto and bind to soft and hard tissues This ability of chx allows it to maintain effective concentrations for long periods of time and which makes it suitable for inhibition of plaque formation

Safety of Chx
Excreted through feces Poorly absorbed by GIT Low toxicity

Clinical Use
Formulations:
Mouth Rinses:
0.2% chlorhexidine 10mL per rinse (Corsodyl) 0.12% chlorhexidine 15mL per rinse (Peridex)

Can be combined with fluoride in rinses to provide anti-plaque and anti-cariogenic effect:
0.12% chlorhexidine with 100ppm fluoride 0.05% chlorhexidine with 0.05% sodium fluoride

It is difficult to incorporate chlorhexidine into toothpastes and gels because of the binding of chx to components in toothpaste Chx can also be incorporated into a sugar-free chewing gum
Contains 20mg of chx E.g. Fertin A/S, Vejle

Side Effects of Chx


Unpleasant taste Alters taste sensation Stains teeth (pts should avoid tea, coffee and red wine) Encourages supragingival calculus formation Stains restorations (margins and surfaces of composites and GIC) Rare Side Effects:
Mucosal erosion Parotid swelling

have moderate plaque inhibitory activity Greater oral retention and equivalent antibacterial activity to chx Less effective in inhibiting plaque and preventing gingivitis Reason: rapidly desorbs from oral mucosa

Example of QAC is cetylpyridinium chloride (CPC) Most effective in 0.1% formulations Available as CPC rinses and CPC lozenges (Cepacol) Causes staining

Used either alone or in combination in mouth rinses or lozenges Has moderate plaque inhibiting effects and some anti-inflammatory effects in reducing gingivitis E.g. is Listerine, which is an essential oil/phenolic mouthwash

Its lack of profound plaque inhibitory effect is because of poor oral retention Thus, Listerine has moderate effect on plaque re-growth and some anti-inflammatory effect which may reduce the severity of gingivitis

Has some plaque inhibitory activity Oral retention: 1 3 hours, which accounts for the low plaque inhibitory effects Concentrations >0.1% can cause oral ulceration Combining zinc with hexetidine improves its plaque inhibiting activity Product: Oraldene

No significant activity when used as 1% mouthwash Absorption of significant levels through oral mucosa makes it unsatisfactory for prolong use in oral cavity Can cause iodine sensitivity Either full strength or equal parts of povidone iodine and water is used for subgingival irrigation.

Non-ionic antiseptic Has moderate plaque inhibitory effects Usually used in combination with zinc to increase oral retention Extent of plaque inhibitory effects seems to be dependent upon presence of co-polymers to increase retention

Acts as an anti-inflammatory agent in mouth rinses and toothpastes Inhibits cyclo-oygenease and lipooxygenase thus reducing prostaglandins and leukotrienes Anti-inflammatory effect of depends on its ability to penetrate into gingival tissues and this is dependent upon the nature of solvent (s) in mouthwash formulation

Triclosan has also been added to a number of experimental and commercial toothpastes with and without zinc and these appear to produce moderate inhibition of plaque formation Brushing with a Triclosan toothpaste reduces gingival inflammation Effective formulations:
Triclosan/ Copolymer Triclosan/ Zinc Citrate

Has plaque inhibiting effects:


Interferes with plaque matrix formation and reduction of bacterial adherence

This causes plaque to be more loosely adherent to tooth making it easier to be removed by mechanical cleaning, therefore its suitable for a pre-brush rinse Formulations: 0.1% and 0.2%

Has plaque inhibiting effects:


Interferes with plaque matrix formation and reduction of bacterial adherence

Mediates its plaque inhibitory and antiinflammation effects without causing a major shift in bacterial populations apart from the reductions in dextran-producing streptococci Side effects:
Transient numbness of tongue Tooth and tongue staining Taste disturbances Mucosal soreness Erosion

This causes plaque to be more loosely adherent to tooth making it easier to be removed by mechanical cleaning, therefore its suitable for a pre-brush rinse Possesses anti-inflammatory effects

Is a salicylanide which has anti-bacterial and inflammatory properties Mechanism of action not fully understood Experimentally 0.12% is as effective as 0.12% chlorhexidine Clinically more studies needed before it can be released for clinical use

Zinc, copper, and tin possess plaque inhibitory effect Copper and tin: causes staining Fluoride compounds such as stannous fluoride and amine fluoride have plaque inhibitory effect due to stannous ion and the surface-active amine portions

Zinc is retained by dental plaque and inhibits its regrowth without disrupting oral ecology Zinc has additive or synergistic effect with hexetidine, Triclosan and sanguinarine

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Sanguinarine Propolis

Contains iminium ion which is responsible for its activity Is retained in plaque for several hours after use and is poorly absorbed by GIT Mode of action: inhibition of glycolysis with assistance from zinc

Is an effective plaque inhibitory agent but less effective than chlorhexidine Prevents development of gingivitis Mouthwash is more effective plaque inhibitory agent than toothpaste due to binding of other components in toothpaste to the chemically reactive site of the sanguinarine molecule

Has an antiseptic, anti-inflammatory, antimycotic and bacteriostatic effect Not effective as mouthwash Some benefits in toothpastes, effective against some periodontal pathogens

Examples:
Hydrogen peroxide Buffered sodium peroxyborate Peroxycarbonate

Inhibits anaerobic bacteria As obligate anaerobes are important in the development of gingivitis and periodontitis, these effects are useful

Many mouthwashes contain significant quantities of alcohol, which leads to a number of possible disadvantages:
If accidentally swallowed by young children it can cause alcohol toxicity Can increase the incidence of oral and pharyngeal cancer Increases alcohol content of exhaled breathe and thus could change the readings of the police breathe test Reduces hardness of composite and hybrid-resin restorations

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To replace mechanical toothbrushing when it is not possible in the following situations:


After oral or periodontal surgery and during healing period After intermaxillary fixation used to treat jaw fractures or following cosmetic surgery With acute oral mucosal or gingival infections when pain and soreness prevents mechanical oral hygiene

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For mentally or physically challenged pts who are unable to brush:


However, these pts may not be able to use a mouthwash so swabbing the gingival margins by a care giver may be the only option Long-term use of effective agents has the major disadvantage of causing tooth staining

As an adjunct to normal mechanical oral hygiene in situations where this may be compromised by discomfort or inadequacies: Following subgingival scaling and root planning when the gingivae maybe sore for a few days. Use of mouthwash is usually only necessary for about 3 days in this situation

Following scaling when there is cervical hypersensitivity due to exposed root surfaces. Its use needs to be combined with measures to treat the hypersensitivity since duration for use of mouthwash should not exceed 2 weeks to avoid staining. Amount of staining varies between patients

Following scaling in situations where the patients oral hygiene remains inadequate. The inadequacy needs to be remedied quickly since the duration of the mouthwash use should not exceed 2 weeks in order to avoid staining It would be better to have suitable antibacterial agent which does not cause significant staining in a toothpaste or pre-brush rinse