Strategies and agents in supragingival chemical plaque control

Evaluating the effects of chlorhexidine and vitamin c mouthwash on oral health in non-surgical periodontal therapy: a randomized controlled clinical trial

Chlorhexidine (CHX) is the most commonly used mouthwash with proven antiplaque and antibacterial activity. The aim is to evaluate the effect of vitamin C (VitC) in CHX mouthwash on plaque accumulation and gingivitis, and to compare it with CHX alone mouthwash and antiseptic phenol-containing mouthwashes. This study conducted as a multicenter, randomized, controlled, double-blind, parallel design clinical study. Sixty patients were included, randomly divided into three groups. 1. Antiseptic phenol agent (P, Phenol), 2. Antiseptic bisbiguanide agent CHX-only (CHX) and 3. Antiseptic bisbiguanide agent CHX + VitC mouthwash (CHX + VitC). The study assessed oral hygiene and periodontal health status, followed by scaling and root planning (SRP) and subsequent polishing. After using the mouthwash for 60 s twice daily along 14 days, patients recalled for evaluation of plaque index (PI), gingival index (GI), bleeding on probing (BOP) and staining. One-way analysis of variance (ANOVA) was used to compare the differences formed between groups and Tukey multiple comparison analysis was used to determine groups that showed the differences. Statistical significance was determined using a p-value threshold of 0.05. There were no significant differences between the groups regarding baseline PI, GI and BOP (p > 0.05). Changes at 14th day in PI, GI and BOP in all groups were similar and no significant differences were observed (p > 0.05). Regarding 'all surfaces', staining density of two mouthwashes containing CHX was significantly higher than that of P mouthwash. CHX, CHX + VitC, and P mouthwashes appeared to exhibit comparable effects as oral hygiene adjuncts to periodontal mechanical treatment, with the exception of staining, which was more noticeable in the CHX groups compared to the P group. Adding vitamin C did not enhance the effects of CHx alone.

Is plaque regrowth inhibited by dentifrice?: A systematic review and meta-analysis with trial sequential analysis

Objectives

The aim of this systematic review was to establish in studies with human participants the effect of a regular fluoride dentifrice compared to water or saline on dental plaque inhibition.

Methods

MEDLINE‐PubMed, Cochrane‐CENTRAL, EMBASE and other electronic databases were searched, up to April 2018. The inclusion criteria were controlled clinical trials among participants aged ≥18 years with good general health. Papers that evaluated the effect of dentifrice slurry compared with water or saline on plaque regrowth during a 4‐day nonbrushing period were included. Data were extracted from the eligible studies, the risk of bias was assessed, and a meta‐analysis was performed where feasible.

Result

The search retrieved eight eligible publications including 25 comparisons. The estimated potential risk of bias was low for all studies. Based on three different indices, overall plaque regrowth was significantly (P < 0.01) inhibited for 0.25 or more by the use of a dentifrice slurry as compared to water. All subanalysis on specific dentifrice ingredients and the overall descriptive analysis supported these findings.

Conclusion

The results of this review demonstrate moderate‐quality evidence for a weak inhibitory effect on plaque regrowth in favour of the use of a dentifrice intended for daily use.

Efficacy of a Rinse Containing Sea Salt and Lysozyme on Biofilm and Gingival Health in a Group of Young Adults: A Pilot Study

Objectives

To evaluate new mouth rinse containing sea salt, xylitol, and lysozyme on biofilm formation and gingival health in a group of young adults.

Methods

The subjects were divided into two groups of 15 subjects each: control (A) and experimental group (B). The Turesky modification of Quigley-Hein plaque index was used to evaluate plaque scores while the presence or absence of gingival bleeding was used to determine gingival health. Measurements were done at baseline and at the end of the one-month trial period by one blinded examiner on six representative teeth. Group (A) maintained standardized oral health practices for the duration of the experiment. In addition, group (B) rinsed with a tablespoon of the provided sea salt mouth rinse for 30 seconds once in the morning and at night. After the 30-day trial period, subjects in both groups were reassessed as per baseline. Results. There were no statistically significant differences in the overall reduction from baseline in the mean plaque and gingivitis scores on all surfaces or on individual surfaces.

Conclusion

Within the limitations of the study, rinsing with sea salt for thirty days did not affect the gingival and plaque scores in a group of young adults.

Comparison of Dill Seed Oil Mouth Rinse and Chlorhexidine Mouth Rinse on Plaque Levels and Gingivitis - A Double Blind Randomized Clinical Trial

INTRODUCTION

Mouthrinses have been in use for centuries as breath fresheners, medicaments, and antiseptics. Dill is said to be a good source of calcium, manganese and iron. It contains flavonoids known for their antioxidant, anti-inflammatory, and antiviral properties. Dill can help with microbial infections in the mouth; and its anti-oxidants minimize damage caused by free radicals to the gums and teeth. Being a good source of calcium, dill also helps with bone and dental health.

AIMS AND OBJECTIVES

To compare the effectiveness of commercially available 0.2% chlorhexidine gluconate mouthrinse and dill seed oil mouthrinse on plaque levels and gingivitis.

MATERIAL AND METHODS

A randomized controlled, double blind parallel arm study was conducted over 90 days on 90 subjects. The subjects were randomly divided into 2 groups and baseline data was collected using Loe and Silness gingival index and Quigley Hein plaque index and oral prophylaxis was performed on all the subjects. The mouthrinses included in the present study were dill seed oil and Hexodent (0.2% chlorhexidine gluconate). Intervention regarding the mouthrinsing was given to the subjects and were followed up for 45 days and 90 days, after this post intervention changes were assessed using the respective indices.

RESULTS

It was observed that there is no significant difference in gingival & plaque scores among two mouthrinses from baseline to 45 days and 90 days. It was observed that there is statistical difference in gingival and plaque scores when compared with baseline to 45 days (p<0.001), baseline to 90 days (p<0.001) and 45 days to 90 days (p<0.001) when intergroup comparisons were done.

CONCLUSION

It was concluded that dill seed oil and Hexodent (0.2% chlorhexidine gluconate) mouthrinse have similar antiplaque and antigingival effectiveness.

Genotoxic assessment of chlorhexidine mouthwash on exfoliated buccal epithelial cells in chronic gingivitis patients

Background:

Chlorhexidine (CHX) is the gold standard of all chemical plaque control agents and the most commonly prescribed mouthwash. However, several studies have shown cytotoxic and genotoxic effects of CHX on various eukaryotic cells. In this study, we have used micronuclei as a biomarker of DNA damage in buccal epithelial cells of chronic gingivitis patients who were given adjunct 0.2% CHX for plaque control.

Materials and Methods:

Chronic gingivitis patients who were exclusively on mechanical plaque control methods were taken as control (Group A) (n = 101), and chronic gingivitis patients who along with mechanical plaque control measures were taking 0.2% chlorhexidine mouthwash as adjunct were taken as cases (Group B) (n = 255). The Group B was further divided into 5 subgroups (B1, B2, B3, B4, B5) (n = 51) on increasing duration of usage of CHX from ≤1 week to 24 weeks. Buccal epithelial cells were gently scrapped from the buccal mucosa using soft toothbrush. The epithelial cells were collected in buffer solution and centrifuged at 8000 rpm for 5 min. The buccal epithelial cells were air dried, fixed, and stained with 5% Giemsa stain on preheated glass microscopic slides and observed under microscope to screen 2000 nucleated cells per individual for number of micronucleated cells and micronuclei as genotoxic measure.

Results:

The mean number of micronucleated cells was found to be 0.41 ± 0.71 for Group A as compared values ranging from 1.65 ± 2.09 (Group B1) to 11.7 ± 1.87 (Group B5) in different subgroups of Group B, and similarly, the mean number of micronuclei was found to be 0.48 ± 0.80 for Group A as compared to values ranging from 2.57 ± 1.64 (Group B1) to 14.5 ± 2.49 (Group B5) in different subgroups of Group B using analysis of variance (P < 0.001).

Conclusion:

We conclude that CHX mouthwash is genotoxic to buccal epithelial cells and there is incremental trend in genotoxicity as the duration of usage is increased.

A double-blind randomized placebo-controlled study on the clinical and microbial effects of an essential oil mouth rinse used by patients in supportive periodontal care

AIM

This 3-month double-blind randomized placebo-controlled study evaluated the clinical and microbial effects of an essential oil mouth rinse used as an adjunct to mechanical plaque control by patients in supportive periodontal care.

MATERIAL AND METHODS

Fifty patients were randomly allocated to an essential oil group (Listerine(®) Coolmint; Johnson & Johnson, New Brunswick, NJ, USA) or placebo group to rinse twice per day as an adjunct to mechanical plaque control. At baseline and after 3 months, plaque index (PI), gingivitis index (GI), probing pocket depth, bleeding on probing (BoP) and clinical attachment level were registered. Subgingival plaque samples were collected for the detection and quantification of Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Tannerella forsythia, Treponema denticola, Micromonas micros, Prevotella intermedia, Fusobacterium genus and Streptococcus mutans by means of real-time PCR (qPCR). Patient's compliance, satisfaction and side effects were registered.

RESULTS

Twenty-three patients in the essential oil group (mean age: 57) and 21 in the placebo group (mean age: 55) with acceptable oral hygiene at intake (mean PI <1.5 on a scale of 5) adhered to the study protocol. Gingivitis index, PI and BoP significantly reduced over time (P ≤ 0.029); however, between group analyses revealed no significant differences. There was no significant change over time neither in detection frequency nor load for any of the microbiota. Daily rinsing with an essential oil rinse was found safe and perceived beneficial by the patients.

CONCLUSION

Patients in supportive periodontal care who are fairly compliant with oral hygiene may not benefit from additional mouth rinsing using an essential oil solution.

Natural products in caries research: current (limited) knowledge, challenges and future perspective

Dental caries is the most prevalent and costly oral infectious disease worldwide. Virulent biofilms firmly attached to tooth surfaces are prime biological factors associated with this disease. The formation of an exopolysaccharide-rich biofilm matrix, acidification of the milieu and persistent low pH at the tooth-biofilm interface are major controlling virulence factors that modulate dental caries pathogenesis. Each one offers a selective therapeutic target for prevention. Although fluoride, delivered in various modalities, remains the mainstay for the prevention of caries, additional approaches are required to enhance its effectiveness. Available antiplaque approaches are based on the use of broad-spectrum microbicidal agents, e.g. chlorhexidine. Natural products offer a rich source of structurally diverse substances with a wide range of biological activities, which could be useful for the development of alternative or adjunctive anticaries therapies. However, it is a challenging approach owing to complex chemistry and isolation procedures to derive active compounds from natural products. Furthermore, most of the studies have been focused on the general inhibitory effects on glucan synthesis as well as on bacterial metabolism and growth, often employing methods that do not address the pathophysiological aspects of the disease (e.g. bacteria in biofilms) and the length of exposure/retention in the mouth. Thus, the true value of natural products in caries prevention and/or their exact mechanisms of action remain largely unknown. Nevertheless, natural substances potentially active against virulent properties of cariogenic organisms have been identified. This review focuses on gaps in the current knowledge and presents a model for investigating the use of natural products in anticaries chemotherapy.

Effects of orally administered lactoferrin and lactoperoxidase-containing tablets on clinical and bacteriological profiles in chronic periodontitis patients

This study was undertaken to evaluate the effect of oral administration of lactoferrin (LF) and lactoperoxidase-(LPO-)containing tablet on periodontal condition. Seventy-two individuals with chronic periodontitis were randomly assigned to take either bovine LF and LPO-containing tablets (test group, n = 37) or control tablets (control group, n = 35) every day for 12 weeks. Periodontal parameters and levels of subgingival plaque bacteria, human and bovine LF, and endotoxin in gingival crevicular fluid (GCF) were evaluated at baseline, 1 week, 4 weeks, and 12 weeks. Significant differences were observed in GCF levels of bovine LF between the test and control groups throughout the study (P < .05). However, clinical and bacteriological parameter values proved comparable between the two groups at 1 week to 12 weeks. Therefore, the effect of oral administration of LF and LPO-containing tablets might be weak on periodontal and bacteriological profile in this study.

Antibacterial effect of taurolidine (2%) on established dental plaque biofilm

Preliminary data have suggested that taurolidine may bear promising disinfectant properties for the therapy of bacterial infections. However, at present, the potential antibacterial effect of taurolidine on the supragingival plaque biofilm is unknown. To evaluate the antibacterial effect of taurolidine on the supragingival plaque biofilm using the vital fluorescence technique and to compare it with the effect of NaCl and chlorhexidine (CHX), 18 subjects had to refrain from all mechanical and chemical hygiene measures for 24 h. A voluminous supragingival plaque sample was taken from the buccal surfaces of the lower molars and wiped on an objective slide. The sample was then divided into three equal parts and mounted with one of the three test or control preparations (a) NaCl, (b) taurolidine 2% and (c) CHX 0.2%. After a reaction time of 2 min, the test solutions were sucked of. Subsequently, the plaque biofilm was stained with fluorescence dye and vitality of the plaque flora was evaluated under the fluorescence microscope (VF%). Plaque samples treated with NaCl showed a mean VF of 82.42 ± 6.04%. Taurolidine affected mean VF with 47.57 ± 16.60% significantly (p < 0.001, paired t test). The positive control CHX showed the lowest mean VF values (34.41 ± 14.79%; p < 0.001 compared to NaCl, p = 0.017 compared to taurolidine). Taurolidine possesses a significant antibacterial effect on the supragingival plaque biofilm which was, however, not as pronounced as that of CHX.

An 8-week, randomized, controlled, clinical study of the use of a 0.1% chlorhexidine mouthwash by chronic periodontitis patients

AIM

  To evaluate the efficacy of a 2-week administration of a 0.1% chlorhexidine mouthwash in the short-term treatment of chronic periodontitis patients and the impact of this product when administered twice by pocket irrigation.

METHODS

  Sixty patients were enrolled in a single-centre, placebo-controlled, randomized study with the blind allocation of product to two parallel groups. Clinical assessments were performed, and samples from six selected subgingival sites were collected for microbial analysis by culture at baseline, D15 and D56. Three of the six sites were randomly selected and were treated by subgingival irrigation with the same 0.1% chlorhexidine product at D0 and D7. A subsequent statistical analysis was performed using the paired Student's t-test and Wilcoxon rank sum test for within-group analyses; analysis of variance and the Kruskall-Wallis test were used for between-group analyses.

RESULTS

  Two-week treatment with a 0.1% chlorhexidine mouthwash slightly reduced the gingival inflammation associated with periodontitis. We observed a significant decrease in Gram-negative, facultative anaerobes and micro-aerophiles, and a significant increase in Gram-positive cocci. No increase in the treatment effect was demonstrated by irrigation of the periodontal pockets.

CONCLUSION

  The 0.1% chlorhexidine mouthwash showed limited beneficial effects in the treatment of periodontitis patients.

Essential oils compared to chlorhexidine with respect to plaque and parameters of gingival inflammation: a systematic review

BACKGROUND

The purpose of this review is to systematically evaluate the effects of an essential-oil mouthwash (EOMW) compared to a chlorhexidine mouthwash with respect to plaque and parameters of gingival inflammation.

METHODS

PubMed/MEDLINE and Cochrane CENTRAL databases were searched for studies up to and including September 2010 to identify appropriate articles. A comprehensive search was designed, and the articles were independently screened for eligibility by two reviewers. Articles that evaluated the effects of the EOMW compared to chlorhexidine mouthwash were included. Where appropriate, a meta-analysis was performed, and weighted mean differences (WMDs) were calculated.

RESULTS

A total of 390 unique articles were found, of which 19 articles met the eligibility criteria. A meta-analysis of long-term studies (duration ≥ 4 weeks) showed that the chlorhexidine mouthwash provided significantly better effects regarding plaque control than EOMW (WMD: 0.19; P = 0.0009). No significant difference with respect to reduction of gingival inflammation was found between EOMW and chlorhexidine mouthwash (WMD: 0.03; P = 0.58).

CONCLUSION

In long-term use, the standardized formulation of EOMW appeared to be a reliable alternative to chlorhexidine mouthwash with respect to parameters of gingival inflammation.

Inhibition of Streptococcus mutans biofilm accumulation and development of dental caries in vivo by 7-epiclusianone and fluoride

7-Epiclusianone (7-epi), a novel naturally occurring compound isolated from Rheedia brasiliensis, effectively inhibits the synthesis of exopolymers and biofilm formation by Streptococcus mutans. In the present study, the ability of 7-epi, alone or in combination with fluoride (F), to disrupt biofilm development and pathogenicity of S. mutans in vivo was examined using a rodent model of dental caries. Treatment (twice-daily, 60s exposure) with 7-epi, alone or in combination with 125 ppm F, resulted in biofilms with less biomass and fewer insoluble glucans than did those treated with vehicle-control, and they also displayed significant cariostatic effects in vivo (p < 0.05). The combination 7-epi + 125 ppm F was as effective as 250 ppm F (positive-control) in reducing the development of both smooth- and sulcal-caries. No histopathological alterations were observed in the animals after the experimental period. The data show that 7-epiclusianone is a novel and effective antibiofilm/anticaries agent, which may enhance the cariostatic properties of fluoride.

Influence of cranberry proanthocyanidins on formation of biofilms by Streptococcus mutans on saliva-coated apatitic surface and on dental caries development in vivo

Cranberry crude extracts, in various vehicles, have shown inhibitory effects on the formation of oral biofilms in vitro. The presence of proanthocyanidins (PAC) in cranberry extracts has been linked to biological activities against specific virulence attributes of Streptococcus mutans, e.g. the inhibition of glucosyltransferase (Gtf) activity. The aim of the present study was to determine the influence of a highly purified and chemically defined cranberry PAC fraction on S. mutans biofilm formation on saliva-coated hydroxyapatite surface, and on dental caries development in Sprague-Dawley rats. In addition, we examined the ability of specific PAC (ranging from low-molecular-weight monomers and dimers to high-molecular-weight oligomers/polymers) to inhibit GtfB activity and glycolytic pH drop by S. mutans cells, in an attempt to identify specific bioactive compounds. Topical applications (60-second exposure, twice daily) with PAC (1.5 mg/ml) during biofilm formation resulted in less biomass and fewer insoluble polysaccharides than the biofilms treated with vehicle control had (10% ethanol, v/v; p < 0.05). The incidence of smooth-surface caries in rats was significantly reduced by PAC treatment (twice daily), and resulted in less severe carious lesions compared to the vehicle control group (p < 0.05); the animals treated with PAC also showed significantly less caries severity on sulcal surfaces (p < 0.05). Furthermore, specific A-type PAC oligomers (dimers to dodecamers; 0.1 mg/ml) effectively diminished the synthesis of insoluble glucans by GtfB adsorbed on a saliva-coated hydroxyapatite surface, and also affected bacterial glycolysis. Our data show that cranberry PAC reduced the formation of biofilms by S. mutans in vitro and dental caries development in vivo, which may be attributed to the presence of specific bioactive A-type dimers and oligomers.

Antibacterial activity and anti-biofilm effect of chitosan against strains of Streptococcus mutans isolated in dental plaque

Streptococcus mutans is the major cause of dental plaque and is often associated with biofilm formation. The aim of this study is to evaluate the activity of a hydrosoluble derivative of chitosan against S. mutans biofilms in vitro and in vivo. Strains of S. mutans were isolated from the dental plaque of 84 patients enrolled in the study. The antibacterial activity of chitosan was determined by broth microdilutions. The effect of chitosan at different concentrations and exposure times on S. mutans biofilms at different phases of development was assessed by a clinical study using the classical "4-day plaque regrowth" experiment in adult volunteers. The MIC values of chitosan were between 0.5 and 2 g/L. Compared to distilled water, the chitosan solution significantly decreased the vitality of plaque microflora (p<or=0.05). Chlorhexidine, used as a positive control, reduced vitality even further. The results showed that S. mutans in the adhesion phase (4 h) was completely inhibited by chitosan at any concentration (0.1, 0.2, 0.5XMIC) or exposure time investigated (1, 15, 30, 60 min), while S. mutans at successive stages of accumulation (12-24 h) was inhibited only by higher concentrations and longer exposure times. These data confirm the effective action of chitosan against S. mutans biofilms.

A systematic review of the effects of full-mouth debridement with and without antiseptics in patients with chronic periodontitis

OBJECTIVES

To assess the clinical and microbiological effects of full-mouth debridement with (FMD) and without the use of antiseptics [full-mouth scaling and root planing (FMSRP)] in comparison with conventional staged debridement (CSD) in patients with chronic periodontitis after at least 6 months.

MATERIAL AND METHODS

The search in MEDLINE (PubMed), covering a period of 1975 to October 2007, and hand searching yielded 207 titles. Forty-two abstracts and 17 full-text articles were screened for inclusion.

RESULTS

Twelve articles allowed a direct comparison of FMD with CSD, FMSRP with CSD and FMD with FMSRP. Probing pocket depth reductions were significantly greater (0.2 mm) with FMD and FMSRP compared with CSD. Moreover, a modest reduction in BOP (9%) favoured FMD. Likewise, clinical attachment levels were improved by 0.2-0.4 mm in favour of FMD and FMSRP, respectively. In all comparisons, single-rooted teeth and deep pockets benefitted slightly from FMD and FMSRP. Limited differences in the changes of the subgingival microbiota were noted between the treatment modalities.

CONCLUSIONS

Despite the significant differences of modest magnitude, FMD or FMSRP do not provide clinically relevant advantages over CSD. Hence, all three treatment modalities may be recommended for debridement in the initial treatment of patients with chronic periodontitis.

Inhibitory effect of methyl gallate and gallic acid on oral bacteria

This study examined the ability of methyl gallate (MG) and gallic acid (GA), the main compounds of gallo-tannins in Galla Rhois, to inhibit the proliferation of oral bacterial and the in vitro formation of Streptococcus mutans biofilms. The antimicrobial activities of these compounds were evaluated in vitro using the broth microdilution method and a beaker-wire test. Both MG and GA had inhibitory effects on the growth of cariogenic (MIC<8 mg/ml) and periodontopathic bacteria (MIC=1 mg/ml). Moreover, these compounds significantly inhibited the in vitro formation of S. mutans biofilms (MG, 1 mg/ml; GA, 4 mg/ml; P<0.05). MG was more effective in inhibiting bacterial growth and the formation of S. mutans biofilm than GA. In conclusion, MG and GA can inhibit the growth of oral pathogens and S. mutans biofilm formation, and may be used to prevent the formation of oral biofilms.

The effects of an essential oil and an amine fluoride/stannous fluoride mouthrinse on supragingival plaque regrowth

BACKGROUND

The side effects of chlorhexidine (CHX) have stimulated the search for alternative antiplaque agents such as amine fluoride/stannous fluoride (ASF) and essential oils (EO). The aim of the study was to investigate the plaque-inhibiting effects of two commercially available mouthrinses containing ASF and EO, respectively.

METHODS

The study was an observer-masked, randomized, 5 x 5 Latin square cross-over design, balanced for carryover effects, involving 15 volunteers in a 4-day plaque regrowth model. A 0.12% CHX rinse and a saline solution served as positive and negative controls, respectively. On day 1, subjects received professional prophylaxis, suspended oral hygiene measures, and commenced rinsing with their allocated rinses. On day 5, subjects were scored for disclosed plaque. The ASF rinse was tested at two dosages: 10 and 20 ml (ASF-10 and ASF-20, respectively).

RESULTS

The ASF and EO rinses showed a significant inhibition of plaque regrowth compared to saline (P <0.0001), but the lowest plaque indices were obtained with the CHX product (P <0.01). There were no significant differences among products containing ASF-10, ASF-20, and EO (P >0.05). There was no correlation between the occurrence of side effects and the use of a particular rinse product (P >0.2).

CONCLUSIONS

ASF and EO mouthrinses exerted effective and similar plaque inhibition. The two dosages tested for ASF did not differ in plaque reduction. These findings, together with those from long-term trials, suggest that ASF and EO rinses may represent effective alternatives to CHX rinse as adjuncts to oral hygiene.

Substantivity of amine fluoride/stannous fluoride following different modes of application: a randomized, investigator-blind, placebo-controlled trial

OBJECTIVE

Amine fluoride/stannous fluoride (ASF) is proven to be effective against plaque and gingivitis. The purpose of this clinical controlled study was to investigate the influence of different application modes on the substantivity of this formulation.

MATERIAL AND METHODS

Seventeen healthy volunteers received a professional dental prophylaxis. Undisturbed plaque growth was permitted for the next 48 h. In a crossover design, participants received ASF as a single mouthrinse, toothpaste, slurries with high (HA) or low (LA) air content, or a placebo. Vitality of plaque bacteria was investigated before and at 1, 2, 3, 4, 6, and 8h after application of ASF. ANOVA was applied on a 0.05 significance level.

RESULTS

Highest reduction of plaque vitality resulted after toothpaste application, followed by mouthrinse, LA, and HA slurry. No changes occurred in the placebo group. Compared to baseline and placebo, statistically significant changes were detected up to 4h in all ASF groups. Toothpaste exerted antibacterial efficacy up to 8h. Vitality reduction was higher in the LA group than in the HA group.

CONCLUSIONS

The concentration of ASF in formulations influences the time course of the antibacterial effect. Contact of ASF formulations with air might reduce their efficacy.

How to select the right mouthrinses in periodontal prevention and therapy. Part II. Clinical use and recommendations

Based on scientific proof, only few mouthrinse solutions can be recommended. However, it is impossible to construct an extended table that would provide precise recommendations or advices for mouthrinse utilisation related to any possible discomfort or diseases. Only reliable information on the drugs available against periodontal disease can be offered to the therapist. By evaluation of her or his individual experiences, she or he has to judge all the armamentarium she or he possesses to react in the best possible way in each specific situation.

Effect of water-soluble reduced chitosan on Streptococcus mutans, plaque regrowth and biofilm vitality

The purpose of the present study was to examine the effects of a newly developed water-soluble reduced chitosan on Streptococcus mutans, plaque regrowth, and biofilm vitality. A 1.0%, water-soluble reduced chitosan, with pH ranging from 6.0 to 6.5, molecular weights between 3,000 and 5,000 Da, and 70% degree of deacetylation, was used. To determine antibacterial and antiplaque potency of chitosan, minimal inhibitory concentrations (MICs) for S. mutans and S. sanguinis (formerly S. sanguis), short-term exposure to S. mutans, and clinical trial of plaque regrowth and biofilm vitality were conducted. Twelve dental students volunteered to participate in the 6-week, double blind, randomized clinical trial using the classical 4-day plaque regrowth design. The MIC of water-soluble reduced chitosan for S. mutans was 1.25 g/l. While the cells exposed to distilled water (DW) grew rapidly, with a maximum turbidity reached by 16 h postinoculation, S. mutans exposed to chitosan (5.0 g/l) exhibited a substantial delay in growth and reached a maximum turbidity by 32 h postinoculation. The chitosan solution reduced the plaque index and the vitality of the plaque flora significantly when compared to DW, but this was less than the reductions found with the positive control of 0.1% chlorhexidine solution. The water-soluble reduced chitosan exhibited potent antibacterial effect on S. mutans, and displayed a significant antibacterial and plaque-reducing action during the 4-day plaque regrowth.

The Effects of Antimicrobial Sprays and Mouthrinses on Supragingival Plaque Regrowth: A Comparative Study

BACKGROUND

Due to the side effects of chlorhexidine digluconate (CHX) mouthrinsing, a spray has been proposed as an alternative method of CHX delivery to the oral cavity. The aim of this study was to investigate the plaque inhibitory effects of CHX, cetylpyridinium chloride (CPC), and triclosan (TRN) delivered by sprays and mouthrinses.

METHODS

The study was an observer-masked, randomized cross-over design balanced for carryover effects, involving 15 healthy volunteers in a 4-day plaque regrowth model. Products being tested (0.2% CHX, 0.12% CHX, 0.05% CPC, and 0.03% TRN) were used both as sprays and mouthrinses. A saline solution served as a negative control. On day 1, subjects received professional prophylaxis, suspended oral hygiene measures, and commenced using their allocated products. On day 5, subjects were scored for disclosed plaque.

RESULTS

CHX sprays (P<0.01) were the most effective sprays in preventing plaque regrowth, without significant differences between the two concentrations tested (P>0.05). TRN spray showed a significant inhibition of plaque regrowth in comparison to the negative control (P<0.05). CPC spray did not differ from saline spray (P>0.05). A similar trend of efficacy was detected for rinses. Although the effect on plaque regrowth observed with CHX rinses was superior to that of CHX sprays (P<0.0003), the latter did not cause side effects (P>0.2).

CONCLUSIONS

These findings, together with those from clinical trials, suggest that the CHX-containing sprays may represent an effective alternative to CHX rinses when mechanical oral hygiene has to be avoided in restricted areas. On the contrary, the TRN and CPC sprays showed little or no plaque inhibitory effects.

How to select the right mouthrinses in periodontal prevention and therapy. Part I. Test systems and clinical investigations

The use of mouthrinses is increasing, especially as adjuncts to the daily mechanical oral hygiene. Different test systems may and can be used to test their antibacterial and clinical effects: bacteriology in vitro, substantivity in vivo, 4-day plaque re-growth, experimental gingivitis and long-term use. The plaque re-growth investigations of a few days are not only of limited use but may also be dangerous because often too extensive conclusions have been drawn from their design. The 'gold standard' test is the experimental gingivitis model to reveal the antiplaque as well as the antigingivitis effects of any mouthrinse preparation during 3 weeks. The last kind of investigations are of several months' duration, where the substances are used as supplements to mechanical oral hygiene measures.

Effect of gingival and dental plaque antiseptic decontamination on nosocomial infections acquired in the intensive care unit: a double-blind placebo-controlled multicenter study

OBJECTIVE

To document the effect of gingival and dental plaque antiseptic decontamination on the rate of nosocomial bacteremias and respiratory infections acquired in the intensive care unit (ICU).

DESIGN

Prospective, multicenter, double-blind, placebo-controlled efficacy study.

SETTING

Six ICUs: three in university hospitals and three in general hospitals.

PATIENTS

A total of 228 nonedentulous patients requiring endotracheal intubation and mechanical ventilation, with an anticipated length of stay > or =5 days.

INTERVENTIONS

Antiseptic decontamination of gingival and dental plaque with a 0.2% chlorhexidine gel or a placebo gel, three times a day, during the entire ICU stay.

MEASUREMENTS AND MAIN RESULTS

Demographic and clinical characteristics, organ function data (Logistic Organ Dysfunction score), severity of condition (Simplified Acute Physiologic Score), and dental plaque status were assessed at baseline and until 28 days. Bacteriologic sampling of dental plaque and saliva was done every 5 days, and blood, tracheal aspirate, and bronchoalveolar lavage cultures were performed when appropriate. The primary efficacy end point was the incidence of bacteremia, bronchitis, and ventilator-associated pneumonia, expressed as a percentage and per 1000 ICU days. All baseline characteristics were similar between the treated and the placebo groups. The incidence of nosocomial infections was 17.5% (13.2 per 1000 ICU days) in the placebo group and 18.4% (13.3 per 1000 ICU days) in the plaque antiseptic decontamination group (not significant). No difference was observed in the incidence of ventilator-associated pneumonia per ventilator or intubation days, mortality, length of stay, and care loads (secondary end points). On day 10, the number of positive dental plaque cultures was significantly lower in the treated group (29% vs. 66%; p < .05). Highly resistant Pseudomonas, Acinetobacter, and Enterobacter species identified in late-onset ventilator-associated pneumonia and previously cultured from dental plaque were not eradicated by the antiseptic decontamination. No side effect was reported.

CONCLUSIONS

Gingival and dental plaque antiseptic decontamination significantly decreased the oropharyngeal colonization by aerobic pathogens in ventilated patients. However, its efficacy was insufficient to reduce the incidence of respiratory infections due to multiresistant bacteria.

Improving oral health care for the frail elderly: a review of widespread problems and best practices

Oral health is an important component of overall health, well-being, and quality of life for institutionalized elders. Despite reports by nurses of the importance of oral hygiene, empirical evidence shows that daily oral care interventions have not been effective in safeguarding the oral and general health of this vulnerable population. Effective practice must involve not only recognizing its importance but also ensuring that daily oral hygiene receives the same priority as other care practices.

Substantivity of toothpaste slurries and their effect on reestablishment of the dental biofilm

OBJECTIVES

Toothpastes are good vehicles for antibacterial substances to exert a prolonged effect. This effect depends on the substantivity and ability to interfere with plaque metabolism and/or vitality. It was the purpose of this clinical, randomized 2 x 4 cell crossover study to evaluate and to compare the antibacterial effects of two toothpastes (Colgate Total(R), COL and Parodontax(R), PAR) applied as slurries on established plaque over 24 h (Part I) and their effect on 4-day plaque regrowth (Part II). Chlorhexamed(R) (0.1%; CHX) and water served as positive and negative controls.

MATERIAL AND METHODS

After professional toothcleaning eight students were asked to refrain from all mechanical hygiene measures for the next 72 h. After 48 h plaque was sampled and vitality of the plaque flora examined (baseline, VF0%). The subjects then rinsed for 1 min with 15 mL of one of the test or control solutions. Every second hour up to 14 h and 24 h after rinsing, plaque sampling and staining was performed to assess plaque vitality (VF2-24, Part I). In Part II, the classical 4-day plaque regrowth design was used with two rinses (1 min) a day as the only oral hygiene measure. Vitality values were assessed on day 1 and day 4 (VF1, VF2). At day 4, teeth were stained to assess the whole mouth plaque index (PlI) and to evaluate the percentage of plaque area (PA) of the anterior teeth.

RESULTS

Compared to placebo, all active rinses reduced plaque vitality significantly over a period of 24 h (Part I). PAR, COL and CHX revealed reductions of 18-31%, 28-50% and 19-50%, respectively. In Part II, similar reductions of all parameters were found for all active rinses (PAR 12-30%, COL 34-51%, CHX 40-64%).

CONCLUSIONS

Colgate Total has shown a significant action on plaque regrowth and a high substantivity during 24 h, while Parodontax revealed a more moderate but still significant effect.

Effect of an amine-fluoride-triclosan mouthrinse on plaque regrowth and biofilm vitality

BACKGROUND

The purpose of this double-blind, prospective, latin-square crossover randomised study was to examine the efficacy of a mouthrinse solution containing a combination of triclosan, amine fluoride and sodium fluoride on supragingival plaque regrowth compared to a placebo and a chlorhexidine solution.

METHODS

12 volunteers refrained after professional oral prophylaxis from all mechanical hygiene measures for the following 96 h and rinsed instead cross-over in a randomised order with either chlorhexidine digluconate (0.2%, positive control), a verum solution (0.5% amine fluoride, 0.028% sodium fluoride, 0.03% triclosan) or a placebo solution. The plaque index was assessed after 24 and 96 h (PI 1, PI 2) and the plaque area (PA) photographed and calculated after 96 h of undisturbed plaque regrowth. Moreover plaque samples were taken after 24 and 96 h and examined with the vital fluorescence technique to assess the vitality of the biofilm microbiota (VF 1, VF 2).

RESULTS

The amine-fluoride-triclosan solution reduced the clinical parameters (PI and PA) as well as the vitality of the plaque flora (VF) significantly when compared to the placebo solution. The verum reached a 36.5% (p<0.05) and a 39.8% reduction (p<0.0001) in PI 1 and PI 2, respectively, concomittant with a reduction of 23.8% and 32.2% (p<0.001) in VF 1 and VF 2 and of 46.9% (p<0.0001) in PA at day 4. This was less than the reductions found with the positive control, i.e., the 0.2% chlorhexidine solution (54.2% and 71.1% reduction in PI 1 and PI 2, 40.0% and 53.4% in VF 1 and VF 2 and 71.5% in PA). However, significant differences between both active solutions were only established for PI 2 and PA.

CONCLUSION

During 4-day plaque regrowth the amine-fluoride-triclosan product displayed a significant antibacterial and plaque-reducing action in comparison to the control.

Amine and tin fluoride inhibition of Streptococcus sanguis adhesion under continuous flow

This study evaluated the ability of topically applied amine fluoride (AmF) and AmF-tin fluoride to inhibit the adhesion of Streptococcus sanguis within a parallel plate flow cell system. One of three AmF compounds and two tin fluoride preparations significantly reduced the net bacterial adhesion to conditioned glass over a 1-h period. Tin(IV) fluoride inhibited S. sanguis adhesion to the greatest extent, and this was shown to be dependent on the formation of the conditioning film prior to agent application.

Alcohol-free mouthrinse solutions to reduce supragingival plaque regrowth and vitality. A controlled clinical study

BACKGROUND

The aim of this study was to evaluate the clinical and antibacterial properties of alcohol-free mouthrinses, an amine fluoride/stannous fluoride mouthrinse (ASF) and two triclosan solutions in comparison with a chlorhexidine and a placebo rinse.

MATERIAL AND METHODS

In a double-blind, randomised 5-cell cross-over 4-day plaque regrowth study, 19 volunteers rinsed 2 x a day with 15 ml of each of the distributed solutions. Each test cycle was followed by a 10 days wash-out period. On day 0 of each test week, volunteers received a dental prophylaxis. Thereafter they refrained from all mechanical oral hygiene procedures for the next four days. Plaque regrowth was assessed daily by the plaque index and on day 4 by calculating the plaque area with a computer program after disclosure and photography of the front teeth. The vitality of the plaque was examined on days 1 to 4 by the vital fluorescence technique.

RESULTS

19 participants completed the study. Compared to the placebo the ASF solution showed 15.7% (p>0.5), 30.6% (p<0.001), 40.5% (p<0.001) and 44.7% (p<0.001) reductions on the consecutive days 14 in plaque index and a reduction of 61.9% in plaque area. The decrease of vitality of supragingival plaque was highly significant compared to placebo on every test day ranging between 30.9% and 36.6%. A reduction in plaque index from 19.4% (p<0.01) on day 2, 34.9% (p<0.001) on day 3 and 40.4% (p<0.001) on day 4 concommitant with a reduction in plaque area of 48.9% (p<0.001) was noted for alcohol-free chlorhexidine. Concerning the vitality chlorhexidine reduced the percentage of vital bacteria significantly on every day (16.0% to 24.9%). The reductions in mean plaque index for the 0.15% triclosan solution during the test period were 6.3%, 22.4%, 24.6% and 36% and in plaque area 41.8%. Vitality was significantly reduced at every day compared to placebo. Plaque Index reduction with the 0.02% triclosan increased from 15.3% (day 2) to 31.0% (day 4) and a reduction of 23.6% was seen in plaque area. A significant effect concerning the vitality of the plaque was only found at the first and the last day of the test cycle.

CONCLUSION

Alcohol-free mouthrinse solutions were shown to be effective in reducing both plaque accumulation and plaque biofilm vitality compared to a placebo solution.

The influence of a 0.2% chlorhexidine mouthrinse on plaque regrowth in orthodontic patients. A randomized prospective study. Part II: Bacteriological parameters

In a prospective plaque regrowth study focusing on oral hygiene during fixed appliance therapy 12 adolescent patients (mean age 14.1 +/- 1.5 years) were evaluated twice over 2-day test periods. In the randomized, double-blind study the influences of a 0.2% chlorhexidine mouthrinse (Corsodyl, CHX) and a commercially available dentifrice supplementing fluoride (Odol-med-3) were compared intra- and interindividually in a crossover design with regard to the bacteriological parameters. The bacteriological parameters of vital fluorescence, bacteriological counts (BC), colony forming units (CFU), plating efficiency (PE) and mutans streptococci (MS) were related to the clinically assessed indices of plaque and gingivitis. All parameters analyzed demonstrated significant differences between the control and the test (chlorhexidine) group. Where-as the values of BC, CFU, and PE progressively increased in the control group from T0 to T2, these parameters distinctly decreased in the chlorhexidine group. All values of vital flora (VF) scored around 75% in the control group compared to values of 30% in the test group. BC, CFU und PE correlated significantly. The score of mutans streptococci persisted or increased in the controls whereas mutans streptococci approached 0 in the chlorhexidine group. Until the 5th day of washout a clear-cut carry over of the chlorhexidine rinse on mutans streptococci as well as on the gingival index was evident. Since dead microorganisms remain on the tooth surface and in order to maintain oral health, chlorhexidine application might advisedly be supplemented by mechanical plaque control.

Chlorhexidine-induced changes to human gingival fibroblast collagen and non-collagen protein production

BACKGROUND

Chlorhexidine (CHX) has been used extensively as an adjunctive therapy in the treatment of periodontal disease. It is well known that chlorhexidine is toxic to bacteria, but recent evidence has suggested that chlorhexidine may also have deleterious effects on gingival fibroblast proliferation as well as collagen and non-collagen protein production in cell culture. The purpose of this study was to examine the effects of chlorhexidine on gingival fibroblast proliferation as well as collagen and non-collagen protein production in cell culture.

METHODS

Human gingival fibroblasts were incubated in MEM containing chlorhexidine concentrations ranging from 1 microM to 1300 microM at 37 degrees C for 1, 5, or 15 minutes. Control cells received an equal volume of MEM without chlorhexidine for similar times at 37 degrees C. Following incubation, the media were removed, cells washed twice with MEM supplemented with 10% FBS, and fibroblasts in treatment and control groups were allowed to recover in the same media for 24 hours.

RESULTS

In all strains, cellular proliferation was dependent on the concentration of solubilized chlorhexidine in cell culture but independent of the duration of chlorhexidine exposure. The average inhibitory concentration necessary to reduce cellular proliferation by 50% (ID50) was 222.1 microM. In regard to collagen and non-collagen protein production, fibroblasts exposed to chlorhexidine concentrations (1 microM) well below the ID50 had a 65% reduction in collagen production and a 57% reduction in noncollagen protein production.

CONCLUSIONS

These results suggest that chlorhexidine will induce a dose dependent reduction in cellular proliferation and that concentrations of chlorhexidine that have little effect on cellular proliferation can significantly reduce both collagen and noncollagen protein production of human gingival fibroblasts in vitro. Hence, the introduction of commercially available concentrations (0.12%) or diluted commercial concentrations (as low as 0.00009%) of chlorhexidine to surgical sites for short periods of time prior to wound closure can conceivably have serious toxic effects on gingival fibroblasts and may negatively affect wound healing.

An approach to differentiate between antibacterial and antiadhesive effects of mouthrinses in vivo

An experimental set-up allowing differentiation in vivo between antibacterial and antiadhesive properties of mouthrinses is described. The percentage of vital bacteria (= microbial vitality) and the bacterial counts were microscopically evaluated in saliva and in supragingival dental plaque both collected simultaneously at various times during de novo plaque formation. In a cross-over design, 12 healthy participants refrained from all oral hygiene for four separate periods of 2 x 4 h and 2 x 72 h after having rinsed with either an amine fluoride/stannous fluoride solution (Meridol) or 0.9% NaCl (placebo). Stimulated whole saliva was collected before and after the rinse. Together with whole-saliva samples, representative 4, 24 and 72-h-old plaque samples were separately taken from defined vestibular tooth surfaces that had been either exposed to the mouthrinse (unprotected sites) or temporarily covered with inert plastic films (protected sites) during rinsing. The pooled plaque and saliva were stained with fluorescent dyes to differentiate vital from dead micro-organisms which permitted the estimation of the percentages of vital bacteria. The total bacterial counts were quantified under the darkfield microscope. The Wilcoxon test was used for selected pairwise comparisons (alpha = 0.05). The percentage of vital bacteria in saliva fell significantly from 80-95% to about 50-60% as a result of the antibacterial activity of the test solution. These baseline values and those found in the presence of 4 and 24-h-old plaque were frequently lower than those recorded after the placebo rinse. In comparison to the placebo, microbial vitality was significantly reduced in early supragingival plaque formed on unprotected sites after applying the test solution. The similar total bacterial counts in 4-h-old plaque recorded after the use of the test solution on the unprotected and the protected areas did not point to an antiadhesive effect of the agent. It is concluded that this new experimental set-up allows decoding of the mode of action of a mouthrinse.