Antimicrobials Flashcards
Adverse effect:
Side effect:
harmful to patient
may be harmful, useful, or beneficial
Compliance:
patient’s ability, desire, and motivation to use a product
Substantivity:
ability of an agent to absorb to teeth and surfaces and be released at therapeutic levels
Cosmetic:
pleasant taste and sensation, decrease in microorganisms, halitosis control
Therapeutic:
reduction in plaque, gingivitis and/or dental caries
DELIVERY SYSTEMS
Local:
paste, gel,
liquid, fibers
DELIVERY SYSTEMS
Systemic:
antibiotics
REGULATION (PRESCRIPTION
AND OTC DRUGS):
Government level:
Food and Drug Administration (FDA)
(3)
Protects consumers from useless or harmful products
Therapeutic claims must be backed with proof
Evaluates Rx and OTC
REGULATION (PRESCRIPTION
AND OTC DRUGS):
Government level:
Federal Trade Commission (FTC)
(1)
Advertising OTC and Rx
REGULATION (PRESCRIPTION
AND OTC DRUGS):
Professional level:
Council on Scientific Affairs of the American Dental Association (ADA) (voluntary)
ADA SEAL OF ACCEPTANCE
(4)
Program is voluntary
Started in 1930 to “help consumers make wise choices”
Products submitted for seal must have independent, controlled studies to demonstrate effectiveness and safety
Seal is found on consumer products (professional product seal has been phased out)
ADA SEAL FOR ANTI-PLAQUE/ANTI-
GINGIVITIS AGENTS:
(4)
Product must be tested in randomized, parallel-group,
cross-over design and compared to a negative control
Must have minimum two 6-month studies, conducted
independently with indices recorded at baseline,
intermediate, and 6 months, and averaging 20% gingivitis
reduction
Statistically significant reduction of plaque and gingivitis
(compared to control)
Establish product safety (soft tissues, teeth, toxicology,
effects on oral flora)
New product submission: $
15,000
Annual maintenance fee (per product): $
4000
PLAQUE/GINGIVITIS REDUCING
MOUTHRINSES
(2)
Claim to reduce plaque is not enough. Product should be
therapeutic.
ADA Council on Scientific Affairs: must be therapeutic and
show long term safety to be approved
EVALUATING PRODUCT CLAIMS
(4)
Published vs non-published
Sponsor
Peer review
Length and duration
Important to recommend
— products
ADA approved
Only applies to
consumer/OTC products
ALCOHOL IN
MOUTHRINSES/MOUTHWASHES
(3)
Used as solvent for active ingredients
High content can cause hyper-keratotic lesions
Possible link to oral cancer? (inconclusive and still heavily debated)
http://ebd.ada.org/en/evidence/evidence-by-topic/6066/mouthwash-and-oral-
cancer-risk-quantitative-meta-analysis-of-epidemiologic-studies
Conclusions:
This quantitative analysis of
mouthwash use and oral malignancy revealed no
statistically significant associations between
mouthwash use and risk of oral cancer, nor any
significant trend in risk with increasing daily use; and
no association between use of mouthwash
containing alcohol and oral cancer risk.
CHLORHEXIDINE
(8)
0.12% CHX
Peridex, Perio-gard and others
Cytoplasmic poison; causes rupture of cell membrane allowing leakage
Binds to mucins, reducing pellicle formation and inhibiting colonization
Binds to bacteria, inhibiting their
adhesion onto teeth
Substantivity: 12-24 hours
12% alcohol
35-40% decrease in plaque and gingivitis
ALCOHOL-FREE CHLORHEXIDINE
(5)
0.12% CHX
Alcohol free (water-based)
Therapeutically equivalent (?)
Evidence suggests it is as effective as AOH-based
CHX
Consider as option for those pts who are intolerant
of AOH or who might have other risk factors
SIDE EFFECTS (CHX)
(4)
Staining
Altered taste
Supragingival calculus
mucositis
CHX
Dosage:
15ml, bid, 30 seconds
each
CHX
(3)
Most effective anti-plaque agent currently available
Available with prescription only
FDA approved (no longer carries the ADA seal of
approval due to a change in the program)
CHX on established biofilm will have only — effects.
superficial
CHX is more effective when plaque is removed prior to —.
rinsing
The biofilm will adapt and protect itself from the
effects of CHX.
CHX
Inactivated by
toothpaste—important to rinse well
with water prior to rinsing with CHX (or wait 30 min
before rinsing with CHX)
DO NOT rinse with water immediately after rinsing
with
CHX
CHX
Recommend for patients who
(2)
cannot or will not
maintain adequate plaque control
Post (periodontal) surgical cases
PHENOLIC COMPOUNDS (LISTERINE ANTISEPTIC AND ITS GENERIC EQUIVALENTS)
(7)
Active ingredients: Essential oils: thymol, eucalyptol, methyl salicylate, menthol
Original formula: 26.9% alcohol (Cool Mint: 21.6% alcohol)
Alters cell membrane, causing leakage and cell death
18-25% decrease in plaque and gingivitis
Low substantivity
Rinse with 20ml, bid, for 30
seconds
ADA approved (Antiseptic)
PHENOLIC COMPOUNDS (LISTERINE ANTISEPTIC AND ITS GENERIC EQUIVALENTS)
SIDE EFFECTS (3)
Bad taste
Burning
sensation
Tooth
staining (?)
Label prior to
ADA acceptance
LISTERINE ZERO
(6)
Introduced in 2010
“…powered by our 4 essential oils formula”
“…for patients who prefer an alcohol-free rinse”
This product is NOT Listerine Antiseptic without alcohol
COSMETIC
Contains essential oils for flavoring—they are NOT a therapeutic concentration
CETYLPYRIDINIUM CHLORIDE (CPC)
(.05% COSMETIC CONCENTRATION)
(4)
Ingredient in many OTC ‘cosmetic’ mouthwashes (.05%)
Quaternary ammonium compound
Marginally effective in reduction of plaque and gingivitis
Little to no substantivity
CETYLPYRIDINIUM CHLORIDE (CPC)(.07% THERAPEUTIC CONCENTRATION)
(4)
ie: Crest Pro-Health Rinse Multi-Protection Rinse* // Crest Gum Care //Colgate Advanced Pro-Shield
no alcohol
Studies indicate plaque and gingivitis reduction comparable to Listerine Antiseptic.
Mechanism of action: ruptures cell wall; also may alter bacterial
Both products contain
.07% CPC
CPC VS CHX
(2)
CPC binds to tooth structure and plaque, but not as strongly as
CHX binds to them
CPC is rapidly released from binding sites so it is not as
efficacious as CHX
HYDROGEN-PEROXIDE-BASED
(4)
1.5% hydrogen peroxide
Alcohol free
Cleanses oral wounds, irritations
Preliminary information reported
H2O2 to be effective against
COVID
*More investigation: Data
does not currently support
VIADENT
FORMER active
ingredient:
sanguinarine
(blood root plant)
VIADENT
(5)
In the mid to late 90’s, higher than normal incidence of leukoplakia was seen.
Sanguinarine determined to be cause.
Pts were 8-11 times more likely to develop leukoplakia
Lesions seen in former users-5 yrsafter use
Risk was highest in patients who used both mouthrinse and toothpaste
PRE-BRUSHING RINSES
PLAX (and others)
“…Plaque Loosening Rinse”
(5)
Marketed as pre-brushing rinse
Ingredients: surfactants (detergents), sodium bicarbonate, glycerin, alcohol (7.5%)
Non-toxic, non-irritating, no enamel damage
Claims are
unsubstantiated with
sound research
“The data provided do
not support the use of
PLAX dental rinse as part
of an oral hygiene
program.”*
SMART MOUTH
(4)
Claim: “Eliminate & Prevent Sulfur
Gas, Never have bad breath again”
Active ingredient: zinc
What does the evidence say?
Evidence is unclear. Potential
efficacy is weak.
Should be marketed as an ‘oral
deodorant’
skipped
WHEN DO YOU RECOMMEND A
MOUTHRINSE?
(7)
Determine need (caries and/or periodontal)
Caries risk (OTC fluoride, Rx fluoride)
Patients who are unable to adequately
remove plaque
Patients who, despite their best attempts,
need adjunctive measures
Patients with ANUG (Acute Necrotizing
Ulcerative Gingivitis)
Pre/post periodontal surgery
Patients undergoing disease control therapy
ADA HAS ALWAYS STRESSED THE IMPORTANCE
OF GOOD ORAL HYGIENE BY ADVISING
CONSUMERS TO:
(5)
Brush your teeth twice a day with an ADA Accepted fluoride toothpaste.
Clean between teeth daily with an ADA Accepted floss or an ADA-accepted inter-dental cleaner
Eat a balanced diet and limit between meal snacks.
Visit your dentist regularly for professional cleanings and oral exams.
In addition to these basic oral hygiene recommendations, consumers should be aware of the oral health benefits of other ADA Accepted products, such certain kinds of mouthrinses and toothpastes.
THERAPEUTIC
(5)
Peridex (CHX)
Listerine Antiseptic (and
generic equivalents)
(Essential oils)
Crest Pro-Health Multi-
Protection Rinse (.07% CPC)
Crest Gum Care (.07% CPC
Colgate Total Advanced
Pro-Shield (0.07% CPC)
COSMETIC
(4)
Scope, Cepecol, Lavoris,
etc. (.05% CPC)
Whitening rinses
Plax and other pre-brushing
rinses
Listerine Zero
Oil Pulling
(2)
Practice of holding a
tablespoon of edible oil
(coconut, sunflower,
sesame, olive) inside the
mouth and ‘pulling’ the oil
through the teeth, anywhere
from 1-5 minutes, up to 20
minutes or longer
Ancient, traditional folk
remedy, practices in India
and Southern Asia.
Benefits?
Proponents claim it
improves oral health
and…
What does the Evidence Say?
Jauhari, D, et al: Comparative evaluation of the effects of fluoride mouthrinse,
herbal mouthrinse and oil pulling on the caries activity and streptococcus
mutans count using Oratest and Dentocult SM Strip Mutans Kit. Int J Clin
Pediatr Dent, 2015
52 healthy children, ages 6-12, divided into four groups
Fluoride (200ppm NaF)
Herbal (Salvadora Persica)
Oil pulling
Control
Estimation of caries activity and S. mutans done prior to and following respective rinsing for 2 wks
Conclusions:
(2)
Fluoride and herbal rinses were comparable. Both equally effective in reducing caries activity and S mutans
Oil pulling did not provide any additional benefit as an effective antimicrobial agent in reducing bacterial
colonization
