Anti-plaque agent

Dr.Foysal Sirazee
BDS(DU),MS(FINAL PART), BSMMU,DHAKA.

Dental plaque
Dental plaque can be defined as the soft deposits that form the biofilm adhering to the tooth surfaces or other hard surfaces in the oral cavity, including removable and fixed restoration. It also termed as biofilm.

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Biofilm community is initially formed through bacterial interaction with the tooth and then through physical and physiological interactions among different species within the microbial mass. Bacteria found in the plaquebiofilm mass are strongly influenced by external environmental factors that may be host mediated.

Types of dental plaque

DENTAL PLAQUE
SUPRAGINGIVAL PLAQUE SUBGINGIVAL PLAQUE

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#Supra-gingival plaque.. It is formed at or above the gingival margin, the supragingival plaque that is in direct contact with the gingival margin is referred as marginal plaque. It is mainly responsible for marginal gingivitis.

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#Sub-gingival plaque.. It is formed below the gingival margin, between the tooth and gingival sulcular tissue. Supra-gingival plaque and tooth associated sub-gingival plaque are critical in calculus formation and root caries, whereas tooth associated sub-gingival plaque is important in the soft tissue destruction that characterizes different forms of periodontitis.

The major differences between supra-gingival and sub-gingival plagues

SUPRAGINGIVAL PLAQUE. SUBGINGIVAL PLAQUE.

Contains 50% matrix It contains mostly gram+ve Has few motile bacterial Its aerobic unless its thick It metabolizes predominantly carbohydrates.

Has little or no matrix Mostly gram-ve Motile bacterial is common Highly anaerobic area is present Predominantly metabolizes protein.

MACROSCOPIC STRUCTURE OF DENTAL PLAQUE

Plaque may be differentiated from other deposits that may be found on the tooth surface such Materia alba and Calculus.

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Materia alba : It refers to soft accumulations of bacteria and tissue cells that lack the organized structure of dental plaque and are easily displaced with a water spray. Calculus : It is a hard deposit that forms by mineralization of dental plaque and is generally covered by a layer of unmineralized plaque.

COMPOSITION OF DENTAL PLAQUE

#Microorganisms (70%of plaque mass) .. Definition Primarily of microorganisms .In 1gm of plaque contains approximately 2x1011 bacteria. More than 500 distinct microbial species are found in dental plaque. Non-bacterial microorganism that are found in plaque include --Mycoplasma, yeast, protozoa and viruses. Few host cells such epithelial cells, macrophages and leukocytes are also found.

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#Intra-cellular matrix (20-30%0f plaque mass) . *OrganicPolysaccharide, Lipid, Protein, Glycoprotein. *InorganicCalcium, Phosphate, Trace amounts of other minerals such as Na ,K ,Fl. As the mineral content increases plaque mass become calcified to form calculus.

Formation of dental plaque

The process of plaque formation can be divided into 3 phases :
A. FORMATION OF PELLICLE COATING ON THE TOOTH SURFACE. B. INITIAL COLONIZATION BY BACTERIA C. SECONDARY COLONIZATION & PLAQUE MATURATION.

Formation of acquired pellicle

*Initial phase of plaque development. All the surfaces of the oral cavity, including all tissue surfaces as well as surfaces of teeth, fixed and removable restorations are coated with a glycoprotein pellicle.

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*Pellicle is derived from components of saliva, crevicular fluid as well as bacterial and host tissue cell products and debris.

*Pellicles function as a protective barrier, providing lubrication for the surfaces and preventing tissue desiccation. However, they also provide a substrate to which bacteria in the environment attach.

Initial colonization on the tooth surface

*It is a transient stage .With in a few hours initial bacteria are found on the tooth surfaces. *The initial bacteria colonizing the pellicle coated tooth surface are predominantly Gram +ve such as Actinomyces viscosus & Streptococcus sanguis.

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*These initial colonizers adhere to the pellicle through specific molecules, termed adhesions, on the bacterial surface that interact with receptors in the dental pellicle. *The plaque mass then matures through the growth of attached species ,as well as colonization and growth of additional species.

Secondary colonization & plaque maturation

*Secondary colonizers are the microorganisms that do not initially colonize clean tooth surfaces, including Prevotella intermedia, P. loescheii, Capnocytophaga sp., Fusobacterium nucleatum and Porphyromonas gingivalis. *These microorganisms adhere to cells of bacteria already in the plaque mass, this Co aggregation.

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*Well characterized interactions of
secondary colonizers with early colonizers include the co aggregation of F.nucleatum with S. sanguis, P.loescheii with A. viscosus. *In the later stages of plaque formation, co aggregation between different Gram ve species is likely to predominate.

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WHY IS PLAQUE FORMATION ON THE TOOTH SURFACE AND NOT ON OTHER ORAL SOFT TISSUES

The first stage in pellicle formation involves adsorption of salivary protein to apatite surface. This formation results from electrostatic ionic interaction between hydroxyapatite surface which has negatively charged phosphate group that interacts with opposite charged groups in the salivary macromolecules.

Mechanical plaque control

# Toothbrushes, # Inter-dental cleaning aids, # Inter-dental brushes. *Single tufted brush, *Dental floss, # Gum stimulators, # wooden tips, # Oral irrigation device, # Dentifrices.

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Anti-plaque agent
Anti-plaque agents are the drugs or agents, which are used to prevent or inhibit plaque formation on the surface of teeth of the oral cavity.

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Ideal properties of anti-plaque agents

#It should remove pathogenic bacteria only. # It should prevent development of resistance bacteria. # It should decrease plaque formation and gingivitis. # It should inhibit mineralization of plaque to calculus. # It should not harm the oral epithelium at recommended dose. # It should not stain the enamel surface of the teeth.

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#It should not have any adverse effect on the tooth surface. # It should be non toxic, non allergic and non irritating. # It should have pleasant taste, flavor and color. # It should be inexpensive, available and easy to use.

Classification of anti-plaque agents

#Cationic surfactant (+ve charged) * Bisbiguanids ---Chlorhexidine gluconate. ---Alexidine. *Quaternary ammonium compound ---Benzalkonium chloride. ---Cetylperidinium chloride. #Anionic surfactant (-ve charged) *Plax. *Na lauryl sulphate.

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#Enzymes *Mucinase. *Mutanase. *Dextrinase. *Lactoperoxidase. #Phenolic compound *Triclosan. *Listerine. #Herbal extracts *Sanguinarine. #Others *Povidone iodine.

Chlorhexidine
#It is a cationic surfactant. #It binds with teichoic acid in gram positive bacteria and lipopolysaccharide in gram negative bacteria. # Chlorhexidine causes precipitation of cellular protein. # Chlorhexidine is a chlorophenyl bisbiguanids that has been used as acetate and more commonly gluconate salts. #It has both disinfectant and antiseptic properties. #It has also bactericidal and bacteriostatic in nature.

Mechanism of action
# As a disinfectants
*Bactericidal action.. CHX binds with teichoic acid in gram positive bacteria and lipopolysaccharide in gram negative bacterial cell membrane. Enter inside the bacterial cell. Increase permeability of the cell. Out flux of cell organelles. Lysis of bacterial cell.

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*Intracellular coagulation of protein
High concentration of CHX cause intracellular coagulation of protein and pathogenic cell die.

#As an antiseptics
*Binds with phosphate and sulphate of salivary glycoprotein and prevents its absorption on the tooth surface. Thus slow down acquired pellicle formation. *Binds with bacterial surface and reduces adhesion of bacteria to the tooth surface. *Incase of dental plaque , it cause agglutination of plaque ,so it becomes less sticky for adhesion of bacteria to tooth surface .

Adverse effects of CHX

As a long time use of CHX causes the followings effects..
1.Change the taste sensation due to thickening or make a cover over the dorsal surface of tongue. 2.Block the opening of the parotid or stansons duct of parotid gland and causes swelling and severe pain of that gland. 3.May causes hypersensitivity reaction. 4.High concentration of CHX has an unpleasant bitter taste and causes irritation of oral mucosa.

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5.Local tissue damage occurs if used in open wound and abraded skin. 6.If CHX is ingested ,it may produce systemic toxicity like nausea, vomiting. 7.Staining of the tooth surface. * Millard reaction occurred due to condensation reaction between CHX and amino acid CHX + amino acid millanoid pigment. *Formation of metallic sulfate. *Ketone or aldehyde binds with CHX which precipitated on the tooth surface.

Toothbrushes
The first true bristled brush was invented in China in.. 1498 for the Emperor using animal hair (pigs) Nylon bristles were introduced around 1938

Requirements of a Satisfactory Toothbrush

1. Have good cleaning ability. 2.Cause minimal damage to soft and hard dental tissues. 3. Having a reasonable lifespan (good wear characteristics) 4. Non-toxic. 5. Handle size appropriate to the users age and dexterity. 6.Head size ---appropriate for the users mouth Adult 2.5 cm Child 1.5 cm

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7.Compact arrangement of soft, end rounded nylon filaments not larger than 0.009 inches in diameter 8.Hard brushes should never be recommended *Lacerate the gingiva , gingival recession and tooth abrasion. *Diameter is too large to enter the gingival crevice. 9.Bristle patterns that enhance plaque removal in a proximal spaces and along gum margin. Filaments arranged at different heights and angles significantly more effective at reducing plaque and gingivitis than flat trim brushes.

Brushing Techniques
1. Vertical 2. Horizontal 3. Roll Technique 4. Vibrating (Bass, Stillman, Charter) 5. Circular 6. Scrub #NOTE..Bass technique most recommended by dentists.#

# Aims to clean the gingival crevice. # Brush held at 45 to the axis of the teeth, so that the end pointing into the gingival crevice. # Research shows no particular method superior to any other. # Modify the patients method. # Emphasize need to repeat the procedure on all tooth surfaces.

Powered toothbrushes
# Oscillating, rotating or counter-rotational movements # Oscillating/rotating (Braun Oral B) more effective in removing plaque and reducing gingivitis than a manual toothbrush (2003)

Manual vs. Electric

Which toothbrush is better???????

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# Electric toothbrushes remove more plaque than manual toothbrushes # Electric toothbrush is recommended for individuals who are unable to maintain effective plaque control *Physical or learning disability *Fixed orthodontic appliances # A manual toothbrush is appropriate for most people

When we Replace Toothbrush

# Splaying of the toothbrush is the most obvious sign of toothbrush wear # Renewal is usually recommended after 3 months use

Inter-proximal Cleaners
1.Dental floss 2.Interdental brush 3.Wood points (toothpicks)

Dental Floss
1. Waxed. 2. Unwaxed. 3.Superfloss.

Toothpicks
# Effective only when sufficient inter-dental space is available. # Triangular toothpicks are superior to round or rectangular. # Incorrect use may cause gingival lesions.

Inter-dental Brush
# Superior to floss for cleaning open spaces. # May be used for cleaning around fixed orthodontic appliances.