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Periodontology
Definition
An antiseptic is a substance which
inhibits the growth and development of
microorganisms. It:
Is a chemical antimicrobial agent
Destroys microorganisms & inhibits
their reproduction or metabolism.
Functions
For practical purposes, antiseptics are
considered as topical agents:
1. For application to skin, mucous
membranes, and inanimate objects.
2. In periodontology, applied topically or
subgingivally to mucous membranes,
wounds, or intact dermal surfaces
Antibiotics
Chemical substances that:
kill and stop the growth of bacteria.
act by interfering with the cell wall &
protein synthesis and nucleic acid
metabolism.
are broadly classified as bacteriostatic,
Classifications
Bis-biguanides
Quaternary Ammonium Compound
Phenolics
Iodophores
Amine-Alcohols
Oxygenating Agents
Natural Products
Pyrimidines
Bis-biguanides
Bis-biguanides
Structure of Chlorhexidine
Anti-plaque Activities
Commercially Available
Examples
Mouth Rinses
Aqueous alcohol solutions of 0.12% and 0.2% chlorhexidine
rinses.
Also available are alcohol-free chlorhexidine rinses.
Corsodyl
Savacol
Gels
1% Chlorhexidine gel product is available.
Tablets
Lozenges with 2mg chlorhexidine gluconate for
disinfecting the oral cavity . Usually prepared as sugar
free , making it suitable for diabetics
Varnishes
Available varnishes cannot maintain a significant
suppression of Strep. Mutans for 6 months. ( repeated
application needed)
Clorzoin, EC40 and Cervitec
Biodegradable Chip
Slow release chip for controlled delivery of
chlorhexidine directly to the periodontal pocket. Chip
biodegrades and releases chlorhexidine within the
pocket over 7-109 days, used as an adjunct to scaling
and root planning.
Quaternary Ammonium
Compounds
Structure
Formulations
Formulations contd
Mouthrinses combining Cetylipyridium
chloride with Chlorhexidine (CHX 0.05%
+ CPC 0.05% + Zinc lactate 0.14% or
Chlorhexidine 0.12% + CPC 0.05% nonalcoholic formulation) are available and
compare well with established
Chlorhexidine products.
Both significantly reducing plaque and
gingivitis as well as monitoring halitosis
with a decreased number of side effects.
Commercially Available
Examples
Formulations contd
Phenols
Phenolics
Structure
Mechanism of Action
Formulations
1.
2.
3.
Tricolosan in dentrifices
Since it does not bind well to oral sites due to its
lack of strong positive charge, formulations have
been developed to enhance its ability to bind to
plaque and teeth. These include:
Combinations with Zinc Citrate to take advantage of
potential anti-plaque and anti-calculus properties.
Incorporation of triclosan in a copolymer of
methoxytheylene and maleic acid to increase its
retention time
Combinations with pyrophosphates to enhance its
calculus reducing properties
Commercially Available
Examples
Formulations
Triclosan in mouthwashes
Reduction in plaque and gingivitis
ranges from 24-36% and from 23-46%
respectively.
Iodophores
Idophour (active)
pyrolidone
N-vinyl
Mechanism of Action
Iodophores
Amine-Alcohols
Structure of AmineAlcohols
Oxygenating Agents
Oxygenating Agents
Natural Products
Sanguainarine:
Structure
Natural Products
Detergents
Detergents contd
Bisbiguanide Antiseptics
They kill a wide range of microbes by damaging the cell wall.
Chlorhexidine
Quaternary Ammonium
Compounds
Cetylpyridinium Chloride (CPC)
Phenolic Antiseptics
PyrimidineHextidine
IodophoresPovidone-Iodine
Triclosan
Oxybenzone
Amine AlcoholDelmopinol
Salifluor
Oxygenating Agents
SUBGINGIVAL PLAQUE
CONTROL
Chlorhexidine
Applications of Antiseptics
in Periodontology
Chlorohexedine
Essentials Oils
Iodophores
Bis-Biguanides
TOOTH, TONGUE & DENTURE
STAINING <10%
Possible causes:
1.
Degradation of the CHX molecule
to release parachloroaniline
2.
Catalysis to Maillard reactions
3.
Protein denaturation with metal
sulfide formation
4.
Precipitation of anionic dietary
chromogens
5.
Exacerbated by smoking, heavy
plaque and calculus
By-products bind to the surfaces of
tooth, denture & tongue and cause
brown pigmentation.
MINIMIZATION OF EFFECTS
1.
2.
Limiting the intake of foods and beverages (tea, red wine & coffee)
during treatment with CHX especially if its just the CHX formulation
present in agent.
3.
4.
5.
6.
7.
8.
9.
1.
2.
3.
4.
HYPOGEUSIA <10%
Reduced ability to taste
Concerns only salt and bitter,
not sweet and sour.
Thought to involve blockage of
taste receptors for affected taste
modalities.
Will last for days after
interruption of mouthrinses.
1.
2.
3.
4.
5.
MINIMIZATION OF
EFFECTS
Usually diminishes with
continued use.
Chlorhexidine concentration
in mouthwashes till 0.12%
and mucosa exposure not
exceeding 60" twice a day,
seem the best procedure to
protect tastes in clinical
practice.
Used after meals for better
food appreciation.
Addition of flavour agents.
Do not rinse with water
after use to avoid washing
away of flavour masking
agents.
IRRITATION OF MUCOSAL
MEMBRANES (<1%)
1. This includes burning, epithelial
desquamation, erythema and
peeling.
2. Rare
MINIMIZATION OF EFFECTS
1.Burning will ease after continued
use.
2.Dilution of the mouthwash using
5ml water with 10ml mouthwash,
freshly mixed, will often allow
continued use of the mouthwash.
3.Discontinue use if ulceration and
peeling present.
.
TOOTHACHE
Peridex has caused mild to
moderate toothache, which often
resolved spontaneously and
required no further treatment.
1.
2.
3.
4.
HYPERSENSITIVITY REACTIONS
Includes allergic reactions or
anaphylaxis.
Persons may experience urticaria,
dyspnea, and anaphylacticshock.
Very RARE.
Usually due to accidental ingestion of
the chlorhexidine formulation.
1.
2.
3.
4.
MINIMIZATION OF
EFFECTS
Discontinue use.
Seek medical attention
immediately.
Do not give to teens or
children.
3-5mls of 1:1000 epinephrine
given to avoid death from AS.
MINIMIZATION OF
EFFECTS
1. Discontinue use.
2. Spontaneous resolution has
occurred on discontinuing
treatment.
ENHANCED SUPRAGINGIVAL
.
CALCULUS FORMATION
(Varied)
1.
1. Thought to be due to precipitation
of salivary proteins onto tooth
surface, thereby increasing pellicle
thickness &/or inorganic salts
precipitation on pellicle layer.
.
MINIMIZATION OF
EFFECTS
Studies indicate need for
biofilm disruption prior to
the start of CHX
mouthrinses in order to
reduce side effects. Is
currently debatable.
QUATERNARY AMMONIUM
COMPOUNDS
1.
2.
3.
TOOTH STAINING
All CPC formulations produced tooth
staining and this was worst with the
CPC lozenges.
Agents are categorized as cationic,
which favors their attraction to tooth
surfaces and bacterial plaque.
Clearance of the Cetylpyridinium
chloride is rapid from oral cavity.
Appears to last only 3-5 hours due to
either loss of activity once adsorbed
or rapid desorption. Thus CPC
frequency of use must be doubled to
4 times daily to ensure adequate
efficacy. However this results in an
increase in tooth staining.
Side effects can also include oral
ulceration and a mild burning
sensation of the tongue. Quaternary
ammonium compounds may also
have a lingering bitter taste.
1.
2.
3.
4.
5.
6.
MINIMIZATION OF EFFECTS
Use of mouthrinses with
combination formulations of
CHX (0.05, 0.12%) and CPC
(0.05%) have shown reduced
staining and other side effects.
Brushing
of
teeth
with
conventional toothpaste just
before use of CPC mouth
rinse.
Clean denture with denture
cleanser before use of CPC.
Removal of stains by scaling
and in this regard ultrasonic
scaling is the most effective
method.
Other side effects are mild
and transitory.
Flavouring agents added to
mask bitterness.
MINIMIZATION OF
EFFECTS
1. Side effects are of Listerine
are transient and usually
disappear quickly after use.
2. Ensure proper removal of
triclosan containing
dentrifices from skin
surfaces that may be
exposed to sun.
3. Discontinue use.
Iodophores
MINIMIZATION OF
EFFECTS
1. Povidone-iodine should not
be used in patients with
thyroid dysfunction;
pregnant woman, infants, or
in routine patient self-care
as it may lead to iodine
induced hypothyroidism.
Pyrimidines: Hexetidine
Side effects are usually mild. Very MINIMIZATION OF
rare hypersensitive rxns; very rare, 1. EFFECTS
Discontinue use if any of
transient changes in taste; erosive
these side effects occur.
effects on enamel; staining of tooth
& composite restorations; erythema,
slight epithelial desquamation and
burning.
Concentrations greater than 0.1%
will cause oral ulceration.
Amine Alcohols
MINIMIZATION OF
EFFECTS
1. Discontinue use.
2. Side effects lessen with
continued use.
Salifluor
Mechanism behind antimicrobial
effects are not yet properly
understood and as such further
studies should be carried on
salifluor to determine possible side
effects.
Natural
Sanguinarine:
No effects
Products
known.
Chlorine Compounds
1.
2.
MINIMIZATION OF EFFECTS
Patients are also advised to rinse
orally with 0.2% sodium
hypochlorite for 30 seconds, 2 or
3 times per week. This is
equivalent to 8 mL (2 reduced
teaspoonfuls) of 6% household
bleach in 250 mL (a full glass) of
water.
If irritation occurs, reduce the
concentration or discontinue use.
Oxygenating Agents
Chronic use of hydrogen peroxide causes serious side effects such as
carcinogenesis, tissue damage, hyperkeratosis, oral ulceration and
hyperplasia.
To minimize effects use for short periods or discontinue use.
References