Chronic treatment with hydrogen peroxide. Is it safe?

Hamster Cheek Pouch Bioassay of Dentifrices Containing Hydrogen Peroxide and Baking Soda

The objective of this study was to determine the effects of hydrogen peroxide alone and in combination with 7,12-dimethylbenza[a]anthracene (DMBA) in the oral cavity because H2o2, has been implicated as a complete carcinogen or cocarcinogen in two animal models. In the two independent studies, golden Syrian hamsters were used to evaluate the carcinogenic and cocarcinogenic potential of dentifrices containing H2o2 and NaHCO3. In the first study, the cocarcinogenic potential of a dentifrice containing 0.75% H2O2/ 5% baking soda was compared with that of a commercial dentifrice with similar ingredients except baking soda and H2O2. In the second study, the cocarcinogenic potential of a dentifrice formulated with 1.5% H, sb>2O2/7.5% baking soda was compared with a mixture of 3% H2O2/baking soda. All materials were applied to the right cheek pouches of experimental animals, and the left cheek pouches were untreated. In the first study. 0.5% DMBA was administered five times weekly for 20 weeks, and the dentifrices were applied immediately after the DMBA. Dentifrices or mineral oil alone were also applied five times weekly. In the second study. 0.5% DMBA or 0.25% DMBA were applied three times weekly for 16 weeks; dentifrices (or 3% H2O2/baking soda) were applied five times weekly for 16 weeks. The dual-phase dentifrice containing 0.75% H2O2/5% baking soda was not carcinogenic, and in combination with DMBA resulted in no observable acceleration of tumor onset, compared with DMBA alone. In fact, animals treated with 0.5% DMBA and the H2O2/baking soda dentifrice had a significantly delayed onset of tumor formation than did animals treated with DMBA alone. In the second bioassay, an increased latency period for tumor formation was observed with 0.5% DMBA and a dual-phase dentifrice containing 1.5% H2O2/7.5% baking soda, compared with 0.5% DMBA alone. With 0.25% DMBA, latency was not affected by addition of the dual-phase dentifrice. In contrast, animals receiving 0.25% DMBA and 3% H2O2/ NaHCO3 had a significantly lower rate of tumor formation and overall mass incidence. Croton oil also reduced the rate of tumor formation when applied with 0.25% DMBA. Histopathologic examination of cheek pouches revealed squamous cell carcinomas in the majority of DMBA-treated animals. Cheek pouches of DMBA-treated animals killed at interim times indicated a progression from keratotic changes and/or dyskeratosis at 6 weeks with the occurrence of carcinomas in approximately half the animals examined at 12 weeks. No significant histopathologic abnormalities were observed in animals not receiving DMB A other than slight keratosis in the oral mucosa of one or two animals per group. These results demonstrated that an oral product containing baking soda and hydrogen peroxide was not carcinogenic, and that baking soda and H2O2 did not enhance the tumorigenicity of DMB A. Furthermore, the tumor-igenic response of DMBA was reduced by coadministration of 3% H2O2 and sodium bicarbonate.

Non-surgical chemotherapeutic treatment strategies for the management of periodontal diseases

Periodontal diseases are initiated by subgingival periodontal pathogens in susceptible periodontal sites. The host immune response toward periodontal pathogens helps to sustain periodontal disease and eventual alveolar bone loss. Numerous adjunctive therapeutic strategies have evolved to manage periodontal diseases. Systemic and local antibiotics, antiseptics, and past and future host immune modulatory agents are reviewed and discussed to facilitate the dental practitioner's appreciation of this ever-growing field in clinical periodontics.

Effect of home bleaching and smoking on marginal gingival epithelium proliferation: a histologic study in women

BACKGROUND

Animal studies have suggested that home bleaching agents can cause morphological alterations and changes in the proliferative rate of oral epithelium.

METHODS

A bleaching agent containing 10% carbamide peroxide with carbopol was used in 11 women (five smokers and six non-smokers) during a 5-week period. Two biopsies were performed, one of them 15 days before the beginning of the home bleaching treatment and the other immediately after the 5-week bleaching treatment. Two analyses were performed in the histological sections obtained from the biopsies: epithelium morphometry and assessment of the epithelium's proliferative activity by proliferating cell nuclear antigen (PCNA) immunohistochemistry.

RESULTS

The home bleaching agent increases epithelium thickness and the PCNA index in both smoker and non-smoker patients.

CONCLUSION

Carbamide peroxide (10%) caused an augmentation in the proliferative activity within the basal and parabasal layers of the gingival epithelium, resulting in a change in this tissue's morphometry.

Safety issues relating to the use of hydrogen peroxide in dentistry

Hydrogen peroxide is used widely in professionally and self-administered products. Hydrogen peroxide is a highly reactive substance which can damage oral soft tissues and hard tissues when present in high concentrations and with exposures of prolonged duration. This report provides an overview of health issues relating to the use of hydrogen peroxide, with an emphasis on safety with prolonged exposure to low concentrations of peroxide products. There is good evidence for the safety of hydrogen peroxide when used at low concentrations on a daily basis over extended periods of time, in self-administered oral health care products such as dentifrices and mouthrinses. These low concentrations neither damage oral hard or soft tissues, nor do they pose a significant risk of adverse long-term effects. Caution should be exercised with the increasingly higher concentration peroxide products used for 'walking' or 'power' bleaching due to the possibility of chemical irritation of oral soft tissues with injudicious use. The volumes of material and application times should be controlled carefully. Thorough education of patients is particularly important with self-applied gels because of the lack of professional supervision with such products. Such education is part of the duty of care of the dentist who supplies bleaching gels for at-home use.

Role of saliva and salivary components as modulators of bleaching agent toxicity to human gingival fibroblasts in vitro

Mild oxygenating agents generating H2O2 are used for effective at-home tooth bleaching, but can cause gingival ulcers in some patients. There are concerns about the possible pathological effects of relatively long-term exposure of oral tissues to bleaching agents. Previous work in our laboratory showed that a bleaching agent, which generates approximately 3% H2O2 from carbamide peroxide, was toxic to human gingival fibroblasts in vitro, but that the toxicity was abolished by treatment with the H2O2-destroying enzyme catalase. The purpose of the present study was to determine if whole saliva, the salivary enzyme lactoperoxidase (LP) (which, like catalase, removes H2O2), or salivary mucin protected fibroblasts from bleaching agent toxicity. The cells were exposed to 0.05% agent with or without saliva, LP, mucin or catalase (as a positive control based on our previous study) and assessed for effect on viability/morphology (by microscopic observation), proliferation (by [3H]-thymidine incorporation), and the production of fibronectin (FN) and type I collagen (by ELISA). While the bleaching agent at 0.05% caused cell death, the cells appeared viable and morphologically normal when treated with the bleaching agent and LP (> or = 0.1 microM), saliva LP, and catalase from agent inhibition of proliferation (P < or = 0.04) and FN production (P < or = 0.01). Mucin had statistically insignificant or no protective effect as assessed by the above parameters. Treatment with saliva, LP, mucin, and catalase gave complete or partial protection from agent-inhibition of collagen production (P < or = 0.04).(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of a bleaching agent on human gingival fibroblasts

Mild oxygenating agents generating low concentrations of hydrogen peroxide (H2O2) are effective alternatives to heat-activated 30% H2O2 in bleaching discolored, vital teeth. There are concerns about possible pathological effects of long-term exposure to bleaching agents, and irritation and ulceration of the gingiva and other oral soft tissues can occur. The objective of this study was to determine the effect of one of these agents on gingival fibroblasts in vitro. Microscopic examination revealed that concentrations of 0.05% to 0.025% of the agent appeared to kill most of the cells. At concentrations of 0.025% to 0.017% some morphological changes were noted; the cells appeared normal at concentrations of < or = 0.0125%. The agent significantly (P < or = 0.002) decreased proliferation (measured by incorporation of [3H]-thymidine into cellular DNA) at concentrations as low as 0.006%. The agent also had a dose-dependent effect on fibronectin production, measured by ELISA, causing significant (P < or = 0.03) decreases at concentrations as low as 0.017%. The agent significantly decreased the production of types I (P < or = 0.01) and III (P < or = 0.04) collagens (measured by ELISA) at concentrations as low as 0.0125%. Type V collagen was not detected under any conditions. Catalase, which catalizes the breakdown of H2O2, abolished toxic effects of a 0.05% solution. The results show that in vitro, the agent is toxic to human gingival fibroblasts, inhibiting several cellular functions.(ABSTRACT TRUNCATED AT 250 WORDS)

The effects of bleaching application time on the dental pulp

This study evaluated and compared pulpal responses of teeth exposed to a 10 percent carbamide peroxide bleaching gel using short and extended application times. Of 28 subjects, four discontinued use because of thermal sensitivity. For the remaining participants, there was no difference between the pulpal readings recorded before the use of the gel or at any point during the study.

Agents for the management of plaque and gingivitis

Numerous chemical agents have been evaluated for the supplementation of patient-dependent mechanical plaque control and thus the reduction or prevention of oral diseases. Agents discussed in this paper are those most frequently evaluated in recent studies and include chlorhexidine, essential oils, triclosan, sanguinarine, fluorides, oxygenating agents, quaternary ammonium agents, prebrushing rinses, enzymes, and antibiotics. Of the agents discussed, the greatest effect on the reduction of plaque and gingivitis can be expected from chlorhexidine, essential oils, and triclosan-containing products. These chemical agents vary in dosage form and include mouthrinses, gels, and dentifrices. Some may also be of value as irrigants. Adverse effects vary according to the chemical agent and include poor taste, burning sensation of oral tissue, staining of teeth and soft tissues, excess supragingival calculus, oral lesions in young patients, and allergic reactions. When a product is selected for a patient, consideration should be given to necessity, efficacy, adverse effects, and cost-effectiveness.

Tooth bleaching: its effect on oral tissues

After investigating the literature, we suggest these guidelines for tooth bleaching: If bleaching solutions of high concentration are used, prevent accidental exposure of gingival tissues to the solutions by use of a rubber dam. If using lower concentrations of bleaching solutions, avoid long-term exposures to gingival tissues. To maintain pulp vitality, keep bleaching time and temperatures to a minimum. Check teeth for exposed dentin and enamel fractures. Advise patients that thermal sensitivity may occur after the bleaching procedure and may persist for several days. Prescribe premedication with an anti-inflammatory drug, when necessary. Avoid bleaching the cervical area of the tooth by covering the area with a base to avoid cervical resorption. Avoid dentin exposure by noting that abrasive bleaching techniques can remove significant amounts of enamel. Take special care when bleaching enamel--especially near the cervix of the tooth, where the enamel is thin.

Is home tooth bleaching gel cytotoxic?

Tooth whitening systems are widely used clinically and for home usage. The aim of this study was to determine the effects of two bleaching gels, each containing 10 percent and 15 percent carbamide peroxide, respectively, a 'bleaching gel' without carbamide peroxide, and carbamide peroxide alone on the viability of human endothelial cells in vitro in comparison with culture medium that acted as a negative control. The incubation period used was 30 minutes. A colorimetric viability assay (MTT assay) was employed. The results showed that the gel without carbamide peroxide is not cytotoxic compared to the negative control, while carbamide peroxide on its own and 10 percent and 15 percent carbamide peroxide bleaching gels were cytotoxic, but there were no significant differences (p greater than 0.05) among these latter three test groups. These data indicate that 10 percent and 15 percent carbamide peroxide bleaching gels are cytotoxic and that carbamide peroxide is the component responsible for this cytotoxic effect. This paper also discusses why this in vitro cytotoxic effect appears not to be significant in vivo.

Effects on gingivitis of daily rinsing with 1.5% H2O2

The purpose of this study was to compare 2 groups of adolescents undergoing orthodontic treatment with fixed appliances to determine whether once daily use of a mouthrinse containing 1.5% H2O2 along with toothbrushing would be better than toothbrushing alone in maintaining their periodontal health. The 2 groups of subjects were selected non-randomly but were matched for age and sex. The control group (N = 34) used toothbrushing and a mint-flavored 0.05% NaF mouthrinse once daily, while the treatment group (N = 25) used toothbrushing and a once daily rinse with a preparation containing 0.05% NaF and 1.5% H2O2 (Orthoflur). 2 calibrated clinical examiners made single-blind clinical assessments of the plaque index, gingival index, and bleeding tendency in 6 standard sites per subject. They also noted any generalized mucosal irritations or staining of the teeth or tongue. Assessments were made before appliances were placed (baseline) and 1, 3, 6, 9, 12 and 18 months after appliances were placed. Results indicated that although there were no significant differences at baseline, the Orthoflur group had significantly fewer study sites with gingival indes or bleeding tendency scores greater than 1 than the control group from the 1-month through the 18-month examinations (P less than 0.01), and significantly fewer sites with plaque index greater than 1 and bleeding tendency scores of 2 or more from the 3-month through the 18-month examinations (P less than 0.02 and 0.01, respectively). No generalized mucosal irritations or clinically significant staining of the tongue or teeth were noted in either group during the study.

Managing the side effects of chemotherapy

More chemotherapy is being administered today than ever before. Megadoses of these drugs are becoming commonplace. Better methods of drug delivery, patient monitoring, and sophisticated support services such as infectious disease specialists, transfusion therapy, intensive care facilities, oncology clinical nurse specialists, and others, enable the physician to treat the patient in a variety of settings, including ambulatory care centers and the home. Just as the nurse needs advanced skills and the knowledge to know the subtle differences between an expected side effect and a toxic reaction, the patient needs to learn preventive health care and which symptoms to report at a time when management strategies can be most effective. Research by Dodd indicates that patients who received information on side-effect management techniques performed more self-care behaviors, and many acted promptly before side effects became persistent or severe. In addition, Stromberg advocates teaching self care to encourage persons with cancer to increase their sense of self-control and lessen feelings of helplessness that often accompany cancer and its treatment. The nurse is further challenged to teach patients to actively participate in their care rather than remaining dependent on the health-care professional. Using skill as a patient educator, the nurse enlists the patient and family members in a partnership to promote self-care. This requires the nurse to use great creativity and flexibility to individualize the approach to patient management problems.

Effects of subgingival irrigation on A. actinomycetemcomitans

The effects of repeated subgingival irrigation on Actinobacillus actinomycetemcomitans was examined. 24 periodontal pockets harboring A. actinomycetemcomitans in 3 juvenile and 4 adult periodontitis patients were studied. The protocol included bi-weekly subgingival irrigation with hydrogen peroxide of the periodontal sites until the micro-organism was no longer detected by selective culture, or for 6 months. A. actinomycetemcomitans was gradually suppressed to below detection following the irrigation regime and could no longer be detected in 46% of the sites at completion of the irrigation protocol. The sites were microbiologically re-examined 5 months after cessation of the irrigation regime. A. actinomycetemcomitans re-occurred in only 2 of the sites from which it had originally been suppressed below detection. The results indicate: (1) that the irrigation regime tested has some potential to suppress A. actinomycetemcomitans in periodontal pockets; (2) that the effect of the irrigation protocol generally lasted for 5 months; (3) that the reduction rate of A. actinomycetemcomitans to below detectable levels seems related to the initial number of cultivable bacteria from the periodontal pocket.

Mouthrinses in "experimental gingivitis" studies

The experimental gingivitis study design is a frequently used clinical model for the evaluation of the effects of antimicrobial agents on developing plaque and gingivitis. In individuals who at the start of the experiment have clean teeth and healthy gingivae and who use a mouthrinse containing the test agent as the only tooth cleaning measure during a period of 14-21 days, the anti-plaque and anti-gingivitis potential of the agent can be properly evaluated. The present paper describes different designs of experimental gingivitis studies for the evaluation of chemotherapeutic agents used to control supragingival plaque formation. Findings reported in the literature with respect to the effects obtained by various antimicrobial compounds are also reported.

Microbiological and clinical effects of chlorhexidine digluconate and hydrogen peroxide mouthrinses on developing plaque and gingivitis

While the ability of chlorhexidine (CHX) to prevent plaque formation and inhibit the development of gingivitis has been well documented in the literature, the therapeutic value of hydrogen peroxide (H2O2) in preventing gingivitis is in dispute. The purpose of this study was to compare the clinical and microbiological effects of an established therapeutic agent, such as chlorhexidine with that of H2O2 in the experimental gingivitis model. Following a period of stringent oral hygiene, 32 subjects were allocated to 1 of 3 treatment groups which were balanced on the basis of their pre-experimental gingivitis scores. The subjects then refrained from any oral hygiene for 21 days. During this period, they rinsed twice a day with either a placebo, 0.12% CHX, or a 1% H2O2 mouthrinse. After 21 days, supragingival and marginal plaque was collected from each subject and assayed for total cultivable microbiota, total facultative anaerobes, facultative Streptococci, Actinomyces, Fusobacterium, Veillonella and Capnocytophaga. At the end of the experimental period, the group rinsing with 0.12% CHX showed 95% reduction in gingivitis incidence, 100% reduction in bleeding sites, and 80% reduction in plaque scores compared to the group rinsing with placebo. Conversely, the group using 1% H2O2 showed a marginal reduction in gingivitis incidence of 15% and a 28% reduction in bleeding sites compared to the placebo group, but no significant reduction in plaque scores. The microbiological results showed that 0.12% CHX was an excellent broad-spectrum antimicrobial agent which significantly reduced the number of both facultative and obligate anaerobes in plaque.(ABSTRACT TRUNCATED AT 250 WORDS)

Periodic subgingival antimicrobial irrigation of periodontal pockets (I). Clinical observations

The present investigation was undertaken to study the clinical effect of professionally performed periodic subgingival irrigation per se and as an adjunct to scaling and root planing. 10 patients suffering from moderate-severe periodontal disease participated in the study. Following an initial 3-month period of supervised supragingival plaque control, a total of 102 periodontal sites with probing pocket depth greater than or equal to 6 mm and "bleeding on probing" were selected and subjected to a Baseline examination comprising assessments of oral hygiene and gingival conditions, probing depths and probing attachment levels. The pockets in the various jaw quadrants were randomly assigned to one of the following treatment groups: (1) periodic subgingival irrigation with hydrogen peroxide, (2) periodic subgingival irrigation with chlorhexidine, (3) periodic subgingival irrigation with saline and (4) no subgingival treatment. During the first part of the study (baseline-32 weeks), no mechanical debridement of the subgingival area was performed. The irrigation treatment was carried out by the operator 3 times per week during weeks 1 + 2 and 5 + 6 of the trial. In the 2nd part of the trial (32-52 weeks), the sites were subjected to scaling and root planing combined with professional irrigation during weeks 32-38. The previously non-irrigated control sites were not subjected to adjunctive irrigation when mechanically debrided. During the entire study, the patients were recalled for professional tooth cleaning once every 4 weeks. Re-examinations were carried out at 4, 6, 32, 40 and 52 weeks. The results revealed that repeated professional irrigation of unscaled periodontal pockets with chlorhexidine or hydrogen peroxide resulted in a temporarily reduced frequency of bleeding sites, but not in any clinically significant changes in probing assessments. A similar improvement of bleeding scores was observed in the saline-irrigated control group. Scaling and root planing, in combination with an optimal supragingival plaque control, resulted in a marked resolution of the clinical symptoms of periodontal disease. Adjunctive irrigation with chlorhexidine or hydrogen peroxide did not improve the healing result above and beyond that obtained after mechanical debridement alone or in combination with saline irrigation. Hence, the study failed to demonstrate that professionally performed periodic subgingival irrigation with chlorhexidine or hydrogen peroxide, used alone or in combination with thorough mechanical debridement, has a significant therapeutic effect.

The use of sodium bicarbonate and hydrogen peroxide in periodontal therapy: a review

The comparative benefits from the use of sodium bicarbonate and hydrogen peroxide over the use of a commercial dentifrice in periodontal therapy is controversial. The consensus of the clinical research indicates that application by patients of sodium bicarbonate and hydrogen peroxide offers no advantage over the preestablished, properly performed home oral hygiene procedures. Any improvements in clinical and microbial parameters generally were attributed to scaling and root planing. The studies that have reported beneficial results with sodium bicarbonate and hydrogen peroxide have used additional antimicrobial agents, concomitant professional application of these substances, and scaling and root planing. In one of these reports, inorganic salts and chloramine-T were delivered subgingivally throughout root-planing procedures, in addition to home application of inorganic salts. Most of these patients also received at least one course of systemic tetracycline therapy. Because this study had no control group, it is impossible to determine whether this program is more effective than are other periodontal therapy programs. A more controlled clinical study involving professional application of sodium bicarbonate, sodium chloride, hydrogen peroxide, and povidone-iodine has shown greater gains in clinical attachment and bone mass than has brushing with toothpaste and water. Again, subgingival scaling and root planing were necessary to attain these results. Because multiple topical agents were applied in both of these reports and systemic antimicrobial agents were used by the Keyes group, it is impossible to determine which agent was responsible for the improvements. Further, professional application may be the crucial factor.(ABSTRACT TRUNCATED AT 250 WORDS)

Oral ulcerations with use of hydrogen peroxide

Hydrogen peroxide has been advocated for many years as an oral rinse useful in control of various oral conditions. Several authorities, however, have suggested that this material may be harmful to oral tissues, especially if the tissues have been previously injured. This article presents two case reports demonstrating harmful oral effects from hydrogen peroxide rinses. The findings suggest that oral hygiene techniques emphasizing the use of 3% hydrogen peroxide in periodontal therapy may require reevaluation.

Antimicrobial properties of hydrogen peroxide and sodium bicarbonate individually and in combination against selected oral, gram-negative, facultative bacteria

The topical application of hydrogen peroxide (H2O2) and sodium bicarbonate (NaHCO3), individually and in combination, has been used empirically in the treatment of periodontal diseases. In this study, we examined both minimum inhibitory concentrations (MIC) and minimum bactericidal concentrations (MBC) of these disinfectants individually and in combination against selected facultative, Gram-negative oral bacteria in a microtiter dilution assay. The bacteria studied included Actinobacillus actinomycetemcomitans, Haemophilus aphrophilus, Eikenella corrodens, and Capnocytophaga gingivalis. These bacteria exhibited MBC (one hr) values ranging from 75 mumol/L to greater than 10 mmol/L and MIC from less than 5 to 500 mumol/L for H2O2. The tested bacteria exhibited MIC values for NaHCO3 of from 23 to 182 mmol/L, and the MBC (one hr) exceeded 728 mmol/L for most of the strains examined. At sublethal (sub-MIC) concentrations, sodium bicarbonate antagonized the ability of H2O2 to inhibit bacterial growth in MIC assays, but sublethal concentrations of H2O2 had no effect on the MIC values of NaHCO3. Lethal concentrations of H2O2 and NaHCO3 exhibited synergistic antimicrobial activity in combination in one-hour bactericidal assays. Since the bactericidal properties of these antimicrobial agents are synergistic, we conclude that it may be rational to use them in combination to treat certain forms of periodontal disease. Also, lower and perhaps safer concentrations of H2O2 can be used in combination with NaHCO3 when oxidative antimicrobial chemotherapy is indicated.

The Keyes technique and self-inflicted injuries. Three case reports

Three cases of self-inflicted gingival injuries resulting from the improper use of the Keyes technique are presented. The profession must assume responsibility for studies to determine the safety of the methods of application of the hydrogen peroxide, salt and baking soda mixtures and disseminate this information for the public interest.