The rationale for chemical adjuncts in plaque control

Inhibition of Tongue Coat and Dental Plaque Formation by Stabilized Chlorine Dioxide Vs Chlorhexidine Mouthrinse: A Randomized, Triple Blinded Study

BACKGROUND

Chlorine dioxide (ClO2) is an oxidizing agent with known bactericidal, viricidal and fungicidal properties. Its efficacy in reducing the halitosis has been established by previous literature. However, data evaluating its antiplaque property is scarce. Chlorhexidine (CHX) is considered as the gold standard and an effective adjunctive to mechanical plaque removal. However, it is associated with few reversible side effects. Therefore a study was conducted to assess the antiplaque property of ClO2 containing mouthrinse against CHX mouthrinse.

AIMS AND OBJECTIVES

To evaluate the efficacy of stabilized chlorine dioxide containing mouthrinse and CHX containing mouthrinse in inhibition of tongue coat accumulation and dental plaque formation using a four day plaque regrowth model clinically and microbiologically in a healthy dental cohort.

MATERIALS AND METHODS

A Single Center, Randomized, Triple blinded, Microbiological clinical trial was conducted involving 25 healthy dental students volunteers (11 males, 14 females). Two commercially available mouthrinse: Mouthrinse A - Aqueous based ClO2 mouthrinse Freshchlor(®) and Mouthrinse B - Aqueous based 0.2% CHX mouthrinse Hexidine(®) were selected as the test products. Subjects were asked to rinse and gargle for 1 minute with the allocated mouthrinse under supervision after supragingival scaling, polishing and tongue coat removal. After four hours, smears were taken from the buccal mucosa and tooth surface. On the fifth day from baseline of four day non brushing plaque regrowth model the samples were again taken from buccal mucosa and tooth surface followed by recording of plaque scores by Rastogi Modification of Navy Plaque index, extent of tongue coat by Winkel's tongue coating index and measuring tongue coat wet weight in grams. The samples collected were subjected to microbial analysis and the results were expressed as colony forming units (CFUs) per sample.

STATISTICAL ANALYSIS

The Data was analysed using SPSS 16.00 and presented using descriptive statistics. Independent t-test was used for the comparison between mouthrinse A groups & mouthrinse B group.

RESULTS

The plaque scores and Winkels tongue coat scores, wet tongue coat weight recorded on the fifth day after the use of the two mouthrinse didn't show a statistically significant difference. The CFU per sample from tooth and mucosa after four hours revealed low bacteria count with respect to mouthrinse B however the CFU obtained on the fifth day did not show a statistically significant difference between the two mouthrinse.

CONCLUSION

The clinical antiplaque efficacy of CHX and ClO2 mouthwash is comparable and so is the efficacy in reducing the oral bacterial load.

The development and validation of a new technology, based upon 1.5% arginine, an insoluble calcium compound and fluoride, for everyday use in the prevention and treatment of dental caries

OBJECTIVE

This paper briefly discusses caries prevalence, the multi-factorial nature of caries etiology, caries risk and the role and efficacy of fluoride. The paper also highlights research on bacterial metabolism which provided understanding of the mouth's natural defenses against caries and the basis for the development of a new technology for the everyday prevention and treatment of caries. Finally, evidence that the technology complements and enhances the anti-caries efficacy of fluoride toothpaste is summarized.

CONCLUSIONS

Global data show that dental caries is a prevalent disease, despite the successful introduction of fluoride. Caries experience depends on the balance between consumption of sugars and oral hygiene and the use of fluoride. Three scientific concepts are fundamental to new measures to detect, treat and monitor caries: (1) dental caries is a dynamic process, (2) dental caries is a continuum of stages from reversible, pre-clinical to irreversible, clinically detectable lesions, and (3) the caries process is a balance of pathological and protective factors that can be modulated to manage caries. Fluoride functions as a protective factor by arresting and reversing the caries process, but fluoride does not prevent pathological factors that initiate the process. A novel technology, based upon arginine and an insoluble calcium compound, has been identified which targets dental plaque to prevent initiation of the caries process by reducing pathological factors. As the mechanisms of action of arginine and fluoride are highly complementary, a new dentifrice, which combines arginine with fluoride, has been developed and clinically proven to provide superior caries prevention.

Desarrollo y validación de una nueva tecnología, basada en arginina al 1.5%, un compuesto de calcio insoluble y fluoruro, para el uso diario en la prevención y tratamiento de la caries dental

OBJETIVO

este artículo discute brevemente la prevalencia de caries, la naturaleza multifactorial de su etiología, el riesgo de caries y el papel y eficacia del fluoruro. Resalta también la investigación sobre el metabolismo bacteriano, que ha aportado conocimientos sobre la defensa natural oral contra la caries y la base para el desarrollo de una nueva tecnología para la prevención diaria y el tratamiento de la caries. Por último, se resume la evidencia que respalda que la tecnología complementa y mejora la eficacia anti-caries de la crema dental con fluoruro.

CONCLUSIONES

los datos globales muestran que a pesar de la exitosa introducción del fluoruro, la caries dental es una enfermedad prevalente. La experiencia de caries depende del balance entre el consumo de azúcares, la higiene oral y el uso del fluoruro. Hay tres conceptos científicos que son fundamentales en las nuevas mediciones para detectar, tratar y monitorear la caries: (1) la caries dental es un proceso dinámico, (2) la caries dental es un proceso continuo de etapas que van desde reversible (pre-clínica) hasta irreversible (lesiones clínicamente detectables), y (3) el proceso de la caries es un balance de factores patológicos y protectores que pueden modularse para el manejo de la caries. El fluoruro funciona como factor protector al detener y revertir el proceso de la caries, pero el fluoruro no previene los factores patológicos que inician el proceso. Se ha identificado una tecnología novedosa, basada en arginina y un compuesto insoluble de calcio, que está dirigida a la placa dental para prevenir la iniciación del proceso de caries al reducir los factores patológicos. Como los mecanismos de acción de la arginina y el fluoruro son altamente complementarios, se ha desarrollado un nuevo dentífrico que combina la arginina y el fluoruro, y se ha probado clínicamente que brinda una prevención superior contra la caries.

Chlorhexidine, toothbrushing, and preventing ventilator-associated pneumonia in critically ill adults

BACKGROUND

Ventilator-associated pneumonia is associated with increased morbidity and mortality.

OBJECTIVE

To examine the effects of mechanical (toothbrushing), pharmacological (topical oral chlorhexidine), and combination (toothbrushing plus chlorhexidine) oral care on the development of ventilator-associated pneumonia in critically ill patients receiving mechanical ventilation.

METHODS

Critically ill adults in 3 intensive care units were enrolled within 24 hours of intubation in a randomized controlled clinical trial with a 2 x 2 factorial design. Patients with a clinical diagnosis of pneumonia at the time of intubation and edentulous patients were excluded. Patients (n = 547) were randomly assigned to 1 of 4 treatments: 0.12% solution chlorhexidine oral swab twice daily, toothbrushing thrice daily, both toothbrushing and chlorhexidine, or control (usual care). Ventilator-associated pneumonia was determined by using the Clinical Pulmonary Infection Score (CPIS).

RESULTS

The 4 groups did not differ significantly in clinical characteristics. At day 3 analysis, 249 patients remained in the study. Among patients without pneumonia at baseline, pneumonia developed in 24% (CPIS >or=6) by day 3 in those treated with chlorhexidine. When data on all patients were analyzed together, mixed models analysis indicated no effect of either chlorhexidine (P = .29) or toothbrushing (P = .95). However, chlorhexidine significantly reduced the incidence of pneumonia on day 3 (CPIS >or=6) among patients who had CPIS <6 at baseline (P = .006). Toothbrushing had no effect on CPIS and did not enhance the effect of chlorhexidine.

CONCLUSIONS

Chlorhexidine, but not toothbrushing, reduced early ventilator-associated pneumonia in patients without pneumonia at baseline.

Duration of action of a single, early oral application of chlorhexidine on oral microbial flora in mechanically ventilated patients: a pilot study

OBJECTIVE

The purpose of this study was to describe the effect of an early post-intubation oral application of chlorhexidine gluconate on oral microbial flora and ventilator-associated pneumonia.

METHODS

Thirty-four intubated patients were randomly assigned to chlorhexidine gluconate by spray or swab or to control group. Oral cultures were done at study admission, 12, 24, 48, and 72 hours, whereas the Clinical Pulmonary Infection Score (CPIS) was documented at study admission, 48, and 72 hours.

RESULTS

Reductions in oral culture scores (less growth) were only found in the treatment groups (swab and spray); no reduction was found in the control group. There was a trend for fewer positive cultures in the combined treatment groups. The mean CPIS for the control group increased to a level indicating pneumonia (4.7 to 6.6), whereas the CPIS for the treatment group increased only slightly (5.17 to 5.57).

CONCLUSIONS

Trends in the data suggest that use of chlorhexidine gluconate in the early post-intubation period may mitigate or delay the development of ventilator-associated pneumonia.

Oral Health and Care in the Intensive Care Unit: State of the Science

Oral health is influenced by oral microbial flora, which are concentrated in dental plaque. Dental plaque provides a microhabitat for organisms and an opportunity for adherence of the organisms to either the tooth surface or other microorganisms. In critically ill patients, potential pathogens can be cultured from the oral cavity. These microorganisms in the mouth can translocate and colonize the lung, resulting in ventilator-associated pneumonia. The importance of oral care in the intensive care unit has been noted in the literature, but little research is available on mechanical or pharmacological approaches to reducing oral microbial flora via oral care in critically ill adults. Most research in oral care has been directed toward patients’ comfort; the microbiological and physiological effects of tooth brushing in the intensive care unit have not been reported. Although 2 studies indicated reductions in rates of ventilator-associated pneumonia in cardiac surgery patients who received chlorhexidine before intubation and postoperatively, the effects of chlorhexidine in reducing ventilator-associated pneumonia in other populations of critically ill patients or its effect when treatment with the agent initiated after intubation have not been reported. In addition, no evaluation of the effectiveness of pharmacological and mechanical interventions relative to each other or in combination has been published. Additional studies are needed to develop and test best practices for oral care in critically ill patients.

Locally delivered antimicrobials for the treatment of chronic periodontitis

The basic treatment of chronic periodontitis is a mechanical debridement of periodontal pockets by scaling and root planing (S/RP) in combination with efficient plaque control. Locally delivered antiseptics (LDA) have been proposed to practitioners and, while subgingival irrigation of antiseptics is still used in clinical practice, the introduction in our therapy of a slow release and sub-gingival delivery of tetracycline has changed the rationale from a mechanical treatment towards a combined therapy for full mouth/sites disinfection. Various antibiotics, antiseptics and resorbable carriers are now proposed with similar targets to arrest disease progression. In chronic periodontitis, LDA cannot be used routinely in combination with S/RP, because of the limited clinical benefit, even if an increased percentage of deep sites may show an improvement. Prospective multicenter studies considering risk factors for disease progression have to be designed to identify patients who may benefit the most from LDA. For non-responding sites or recurrent pockets, the controversies are limited, because a combined S/RP and LDA may avoid the need for surgery. However, the patient cost/benefit ratio needs to be estimated as well as adverse effects in particular antibiotics.

Opportunities and obstacles in veterinary dental drug delivery

Dentistry is a relatively new field in veterinary medicine, despite the fact that dental disease is common in dogs and cats. Obstacles to the development of dental treatments in animals include the diversity of the dentition among the species, the difficulty in administration of oral treatments, the different presentations of oral disease, and the cost of regulatory approval for each species. Mechanical removal of plaque and calculus has been the mainstay of periodontal disease treatment in animals and humans. New adjunctive therapies, as well as new applications for older drugs, are being introduced for periodontal therapy.