chlorhexidine and other mouthwashes
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RESOURCE FACULTY:DR. SHIVALAL SHARMADR. KHUSHBOO GOELDR. SAJEEB SHRESTHA
KASHMIRA POKHREL-483
CHLORHEXIDINE AND OTHER
MOUTHWASHES
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HISTORYChlorhexidine
Introduction Structure Ingredients MOA Properties Uses Toxicity Side effects Contraindications
Other mouth washes
CONTENTS
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HISTORY…..
The Egyptians used many products to freshen their breath. They chewed sodium carbonate or rinsed their mouth with honey and water to which goose fat, frankincense, cumin, and ocher had been added.
A.D. 1: The Romans used to buy bottled Portuguese urine to purge bacteria from the mouth.
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A.D. 23:people used to swish tortoise blood around in their mouth at least three times a year to prevent toothaches
A.D. 40 – 90: Greek surgeon and physician, Pedanius Dioscorides, suggested the mixture of the juice and leaves of olives, milk, gum myrrh, pomegranate, vinegar and wine could help fight bad breath
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12th Century: German philosopher and mystic, Saint Hildegard von Bingen, suggests that swishing pure, cold water around in the mouth can help remove tarter and plaque
16th Century: Medieval oral hygiene practices centered around a mint and vinegar rinsing solution was believed to rid the mouth of bad breath and germs.
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19th Century: Mouthwashes as we know them today, developed in the late 1800s. Instead of rinses containing urine, alcohol was added to help fight germs and bacteria while stabilizing the formula. One of the most popular mouthwashes on the market today for its germ-killing qualities
Today: Sodium hexametephosphate and hydrogen peroxide are found in more abundant quantities in mouthwashes to help lift and prevent future stains on the surfaces of teeth and more companies are coming out with solutions that won’t irate sensitive mouths.
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CHLORHEXIDINE
It was developed in 1940s by Imperial Chemical Industries, England & marketed in1954 as an antiseptic for skin wounds.
Chlorhexidine (CHX) is mainly available in three forms: Digluconate, Acetate & Hydrochloride salts.
Use in Dentistry was initially for presurgical disinfection of mouth & in endodontics.
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Plaque inhibition by CHX was first investigated in 1969 by Schroeder but the definitive study was performed by Loe & Schiott in 1970.
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CHLORHEXIDINE is a GOLD STANDARD IN CHEMICAL PLAQUE CONTROL with bacteriostatic and bactericidal properties.
Broad spectrum anti-microbial drug
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Structure of chlorhexidine..
Chlorhexidine is a symmetrical molecule consisting four chlorophenyl rings and two bisguanide groups connected by a central hexamethlene ring
The compound is strongly base & dicationic at ph levels above 3.5 with positive charges on either side of hexamethylene bridge.
It is the “dicationic nature” of chlorhexidine
making it extremely intractive with anions
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Ingredients
Chlorhexidine Alcohol Glycerine Sodium saccharin PEG-40 sorbitan diisostearate Flavoring agent Purified water
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cationic CHX molecule+ negatively charged bacterial cell wall
Instant adsorption of CHX to Phosphate containing compounds
CHX binds with the phospholipids in the inner cell membrane causing cell wall integrity
Leakage of the lesser molecular weight components viz. potassium ions(bacteriostatic)
Mechanism of actionBacteriostatic and bactericidal
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Intracellular coagulation
Slows down leakage of intracellular components
Cytoplasmic coagulation
Irreversible cell damage [bactericidal]
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MOA
CHX mainly inhibits plaque by 3 mechanism:
1) It prevents pellicle formation by blocking the acidic groups on the salivary glycoproteins ,hence reducing the glycoprotein adsorption on the tooth surface.
2) Prevents the adsorption of bacterial cell wall onto the tooth surface by binding to the bacteria.
3) Prevents binding of the mature plaque by precipitating the agglutination factors in the saliva and displacing the calcium from the plaque matrix.
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Properties
It is effective against an array of microorganisms, including gram positive & gram negative organisms, fungi, yeast & viruses.
Chlorhexidine exhibits both antiplaque and anti bacterial properties.
Chlorhexidine shows different concentration effects at different concentration
- Bacteriostatic at low concentration- Bactericidal at high concentration
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Substantivity - the prolonged adherence of the antiseptic to the oral surfaces(mucosa & teeth) & it’s slow release at effective doses that guarantees the persistence of its microbial activity.
Approximately 30% i.e. 5.5-6.9 mg from a 10 ml solution of 0.2% CHX will be bound to the oral surface.
The CHX molecules bound to the salivary proteins will be released in excess of 12 hrs in active form.
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How to use?
Dose: 10ml of 0.2% CHX in 1:1 dilution Frequency:- Twice daily oral rinsing for 30 second in
the morning and evening after 30 minutes of tooth brushing.
Instructions Do not rinse with water or other
mouthwashes, brush teeth or eat immediately after using CHX mouthwash.
Avoid intake of tea,coffee and alcohol during use.
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Uses
1. As an adjunct to oral hygiene and professional prophylaxis
- Improved plaque control- Improved gingival health
2. Post oral surgery including periodontal surgery or root planing
- Reduces bacterial loading oral cavity- Improves healing and discomfort is reduced
3. For patients with jaw fixation- Reduce markedly bacterial load which tends to
increase during jaw immobilization- Improve plaque control
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4. For oral hygiene and gingival health benefits in the mentally and physically handicapped
- Improve oral hygiene & gingival health of mentally & physically handicapped
- Spray delivery of 0.2%
5. Medically compromised individuals predisposed to oral infections
- Mainly candidiasis, used in combination with anticandidal agents
- Improves oral and systemic infections- Those with blood dyscrasias, under chemotherapy
radiotherapy.
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6. High-risk caries patients- CHX considerably reduces streptococcus mutans counts- Synergistic with sodium fluoride
7. Recurrent oral infections- Reduces incidence, duration and severity of recurrent
apthous ulcer by reduction in contamination of ulcer by oral bacteria
8. Removal & fixed orthodontic appliance wearers- Plaque control in early stages of therapy for the first 4-8
weeks- Also reduce the number & severity of traumatic ulcers
during first 4 week of fixed therapy.
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9. In denture stomatitis- Candidal associated infection
10. Immediate preoperative chlorhexidine rinsing and irrigation
- Used immediately prior operative t/t when ultrasonic or high speed instruments are used
- Reduces bacterial load and contamination of operative area and operator and staff as well
- Reduces incidence of bacteremia
11. Subgingival irrigation
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Toxicity and safety
Minimum absorption through skin & mucosa, including GI tract.
Systemic toxicity from topical application or ingestion is not reported.
No evidence of teratogenicity in animal model.
Hypersensitivity reaction including anaphylaxis have been reported.
Neurosensory deafness can occur if CHX is introduced in middle ear.
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Side effects
Brown discoloration of the teeth and some restorative materials and the dorsum of the tongue (staining): Mechanism:
1. Degradation of chlorhexidine molecules to release parachloraniline.
2. Catalysis of Maillard reactions.3. Protein denaturation with metal
sulfide formation.4. Precipitation of anionic dietary
chromogens
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An alteration of taste perception. Oral mucosal erosion which appears to
be idiosyncratic reaction and conc dependent.
Unilateral or bilateral parotid swelling. Enhanced supragingival calculus
formation which maybe due to the precipitation of salivary proteins on to the surface, thereby increasing pellicle thickness &/or precipitation of inorganic salts on pellicle layer.
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Contraindications
It is contraindicated in patients who are known to be hypersensitive to CHX gluconate or other formula ingredients
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Other mouthwashes
Triclosan Delmopinol Listerine Povidone iodine Metallic ions Quaternary ammonium compounds Sanguinarine
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Triclosan Phenol derivative It is synthetic, non-ionic, and is used as
topical antimicrobial agent. Broad spectrum of activity against both
gram positive & negative bacteria. Also includes mycobacterium spores, and candida species.
MOA: - Acts on the microbial cytoplasmic
membrane, including leakage of cellular constituents & thereby causing bacteriolysis.
- Can delay plaque maturation & also inhibit formation of prostaglandins &leukotrienes which are key mediators of inflammation via inhibition of both cyclo-oxygenase & lipo-oxygenase pathways.
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Delmopinol
Morpholinoethanol derivative Inhibits plaque growth and reduces gingivitis. Low substantivity. Indicated as pre brushing mouth rinse. MOA: It interferes with plaque formation & reduces
bacterial adhesion easy removal of plaque by mechanical procedure.
Adverse effects:- Transient numbness of tongue & tongue
staining.- Taste disturbance- Mucosal soreness & erosion
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Listerine
Listerine was created by Dr. Joseph Lawrence and Jordan Lambert and named in honour of Dr. Joseph Lister, the pioneer of antiseptic surgery.
Consists of essential oils, salicylate.
It is used for reducing supragingival plaque & gingivitis and halitosis.
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Povidone Iodine
No significant plaque inhibitory activity when used as a 1 %. Mouthwash.
Unsatisfactory in long term use because significant amount of this compound is absorbed by the oral cavity.
Certain studies shows it can reduce inflammation and progression of periodontal disease.
Low substantivity.
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Metallic ions
Some metal ions have a plaque inhibitory capacity.
Salts of zinc & copper are most commonly used
MOA:- Acts by reducing the glycolytic
activity in microorganisms and delays bacterial growth.
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QUATERNARY AMMONIUM COMPOUNDS
They are cationic antiseptic & surface active agents.
Are more active against gram +ve than –ve organisms.
MOA: The positively charged molecule reacts with the negatively charged cell membrane phosphates disrupts the cell wall structure of the microorganism
E.g. Benzylconium chloride, cetylpyridinium chloride etc.
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SANGUINARINE
It is a benzophenanthridine alkaloid, which is derived from the plant Sanguinaria Canadensis.
They are effective against a wide variety of gram negative organisms.
It exhibits good retentive properties with dental plaque when used as a mouth rinse.
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Substantivity highest in:A.ChlorhexidineB.Triclosan C.SanguinarineD.Delmopinol
mcq
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Chlorhexidine staining is due to:1.Degradation of chlorhexidine molecules to release parachloraniline.2.Catalysis of Maillard reactions.3.Protein denaturation with metal sulfide formation.4. all of the above
mcq
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Which of the following is phenol derivative? 1. Chlorhexidine2. triclosan 3. Povidone-iodine4. listerine
mcq
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Refrences
Clinical Periodontology & Implant Dentistry – Jan Lindhe
Essentials of Preventive and Community Dentistry – Soben Peter
Internet sources
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THANK - YOU