ROLE OF FLUORIDE & CHLORHEXIDINE IN THE PREVENTION OF DENTAL CARIES

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& CHLORHEXIDINE IN THE ROLE OF FLUORIDE PREVENTION OF DENTAL CARIES

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CARIES PREVENTION FLUORIDE C O N T E N T S Introduction Historical evolution as caries preventive agent Mechanism of action Modes of administration Systemic Topical Professionally applied Self applied Fluoride vehicles Clinical applications Advances in fluoride applications

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CARIES PREVENTION INTRODUCTION F L U O R I D E Essential agent in preventive dentistry ‘Flour’ – To Flow The most electronegative element – never exists in free state ; exists as fluoride compound Federal Register of United states Food and Drug Administration - 1973 1 F Rao A. Fluorides. Principles and Practice of pedodontics . New Delhi: Jaypee Medical publishers;2006 p. 204 – 18.

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CARIES PREVENTION INTRODUCTION F L U O R I D E Distribution of fluoride PLASMA SOFT TISSUE HARD TISSUE – Bone, Teeth Deposition in teeth Sucessive stages during life of tooth Initial deposition while organic & mineral phases laid down Next deposition – from tissue fluids during preeruptive maturation Finally – acquired topically – posteruptive maturation & aging period AMOUNT OF FLUORIDE IN TOOTH OUTER ENAMEL- 2200 – 3200 PPM DENTIN- 200-300PPM CEMENTUM- 4500 PPM PULP- 100-650PPM 2 Rao A. Fluorides. Principles and Practice of pedodontics . New Delhi: Jaypee Medical publishers;2006 p. 204 – 18 . Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358.

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CARIES PREVENTION HISTORY F L U O R I D E 1901 Fredrick Mc Kay – permanent stain on teeth of patients – COLORADO BROWN STAIN Mc Kay & Black – examined 6873 individuals – unkonwn causitive factor of mottled enamel possibly in domestic water during tooth calcification Spectrographic analysis – identification of fluoride in the drinking water -Churchill hv , Smith MC, Velu H 1916 1931 3 Rao A. Fluorides. Principles and Practice of pedodontics . New Delhi: Jaypee Medical publishers;2006 p. 204 – 18.

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CARIES PREVENTION HISTORY F L U O R I D E 1935 Dean gave mottling index- 1ppm no stain, 2.5-3ppm dull chalky appearance, 4ppm discrete pitting 1941 “ 21 city” Study by Dean et al – to define water fluoride levels which represented compromise between low caries & acceptable level of fluorosis – 0.7-1mg Worlds first artificial fluoridation started – Grand rapids, USA Fluoridation endorsed by WHO 1945 1969 4 Rao A. Fluorides. Principles and Practice of pedodontics . New Delhi: Jaypee Medical publishers;2006 p. 204 – 18.

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CARIES PREVENTION MECHANISM OF ACTION F L U O R I D E HYDROXYAPATITE CRYSTALS BACTERIA ENAMEL SURFACE ALTERATION OF TOOTH MORPHOLOGY Decreasing solubility Improoving crystallinity Remineralisation Inhibition of enzymes Supressing cariogenic bacteria Desorbing protein/bacteria Lowering free surface energy Rounded cusps, shallow fissures 5 Rao A. Fluorides. Principles and Practice of pedodontics . New Delhi: Jaypee Medical publishers;2006 p. 204 – 18.

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CARIES PREVENTION MECHANISM OF ACTION F L U O R I D E EFFECT ON HYDROXYAPATITE CRYSTALS – DECREASING SOLUBILITY VOID THEORY – Voids normally present in any crystal which decrease stability & increase chemical reactivity IN HA CRYSTAL Fluoride fills up spaces Formation of additional & stronger hydrogen bonds CRYSTAL More stable Lower solubility Greater resistence to dissolution in acids 6 Rao A. Fluorides. Principles and Practice of pedodontics . New Delhi: Jaypee Medical publishers;2006 p. 204 – 18.

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CARIES PREVENTION MECHANISM OF ACTION F L U O R I D E EFFECT ON HYDROXYAPATITE CRYSTALS – DECREASING SOLUBILITY 7 APATITE CRYSTAL WITHOUT F INCOORPORATION APATITE CRYSTAL WITH F INCOORPORATION INCREASE IN SIZE OF APATITE CRYSTAL LARGER CRYSTALS – LESS SURFACE AREA DISSOLVES MORE SLOWLY Murray JJ, Rugg-gunn AJ, Jenkins GN. Anticaries mechanisms of fluoride. Fluorides in caries prevention. 3rd Ed. Butterworth- Heinemann 1991.p

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CARIES PREVENTION MECHANISM OF ACTION F L U O R I D E EFFECT ON HYDROXYAPATITE- IMPROVING CRYSTALLINITY OF HA Fluorides Increase crystal size Produce less strain in crystal lattice Causes crystals to change from carbonated apatite & HA to FA & FHAP 8 Rao A. Fluorides. Principles and Practice of pedodontics . New Delhi: Jaypee Medical publishers;2006 p. 204 – 18.

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CARIES PREVENTION MECHANISM OF ACTION F L U O R I D E EFFECT ON HYDROXYAPATITE- REMINERALIZATION -Apatite like crystals ENAMEL MINERALS MINERALS OF SALIVA Continuously in exchange & in state of equilibrium METABOLISM OF FERMENTABLE CARBOHYDRATE PH DROPS Equilibrium disturbed Dissolution of enamel minerals In the presence of fluoride process is reversed - REMINERALIZATION 9 Rao A. Fluorides. Principles and Practice of pedodontics . New Delhi: Jaypee Medical publishers;2006 p. 204 – 18.

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CARIES PREVENTION MECHANISM OF ACTION F L U O R I D E EFFECT ON BACTERIA - SUPRESSING FLORA ENZYME INHIBITION- ENOLASE – transport of glucose involving PEP phosphotransferase system 10 Bacterial phosphatases – degradation of sugar phosphates Cation transport [ potassium] Rao A. Fluorides. Principles and Practice of pedodontics . New Delhi: Jaypee Medical publishers;2006 p. 204 – 18. Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358.

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CARIES PREVENTION MECHANISM OF ACTION F L U O R I D E EFFECT ON BACTERIA- BACTERIAL ENZYME INHIBITION ENOLASE- metalloenzyme requires Mg ++ for activity Fluoride due to its increased reactivity forms complexes with divalent cations inhibiting the metalloenzyme Mg++ INACTIVEENOLASE ACTIVE E NOLASE Mg++ F INACTIVEENOLASE 11 Rao A. Fluorides. Principles and Practice of pedodontics . New Delhi: Jaypee Medical publishers;2006 p. 204 – 18.

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CARIES PREVENTION MECHANISM OF ACTION F L U O R I D E EFFECT ON ENAMEL SURFACE- DESORPTION OF PROTEINS & BACTERIA HA CRYSTALS – AMPHOTERIC With both positive & negetive receptor site HA Ca ++ PO4-- ACIDIC PROTEIN GRP Acidic protein grp binds at Ca site Fluoride inhibits binding of acidic protein to hydroxyapatite F F ACIDIC PROTEIN GRP 12 Rao A. Fluorides. Principles and Practice of pedodontics . New Delhi: Jaypee Medical publishers;2006 p. 204 – 18.

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CARIES PREVENTION MECHANISM OF ACTION F L U O R I D E EFFECT ON ENAMEL SURFACE- LOWERING THE FREE SURFACE ENERGY Prevents the accumulation of plaque ALTERATION OF TOOTH MORPHOLOGY dentition in fluoridated communities show tendency towards rounded cusps, shallow fissures, wider tooth & improved alignment 13 Rao A. Fluorides. Principles and Practice of pedodontics . New Delhi: Jaypee Medical publishers;2006 p. 204 – 18.

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CARIES PREVENTION MODES OF ADMINISTRATION F L U O R I D E 14 SYSTEMIC WATER FLUORIDATION Community School DIETARY SUPPLEMENTS Fluoride drops Fluoride tablets Fluoride rinse supplements TOPICAL PROFESSIONAL Topical solutions Gels Varnish Foam Prophylactic pastes SELF APPLIED Fluoride rinse Fluoride gels Fluoride dentifrice Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358 .

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CARIES PREVENTION MODES OF ADMINISTRATION F L U O R I D E SYSTEMIC TOPICAL POST-ERUPTIVE INCORPORATION FLUORIDE INCORPORATION IN ENAMEL PRE-ERUPTIVE INCORPORATION POST-ERUPTIVE INCORPORATION 15 Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358.

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CARIES PREVENTION MODES OF ADMINISTRATION F L U O R I D E 16 METHOD AVERAGE % REDUCTION OF CARIES SELF APPLIED TOPICAL FLUORIDE COMMUNITY WATER FLUORIDATION SCHOOL WATER FLUORIDATION DIETARY FLUORIDE SUPPLIMNTN PROFESSIONALLY APPLIED TOPICAL FLUORIDE 50-65% 40% 50-65 % 30-40% 20-50% Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358.

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MODES OF ADMINISTRATION WATER FLUORIDATION F L U O R I D E Controlled adjustment of the concentration of fluoride in a community water supply so as to achieve maximum caries reduction & a clinically insignificant level of fluorosis STUDIES 1945- grand rapids/Muskegon 1945- Newburg/Kingston 1946- Evanston/Oak park RESULTS Caries reduction in primary teeth was 40-50%, permanent 50-60% Fluoride benefit is not uniform & varies depending on tooth surfaces Buccal & lingual- 85% P roximal- 75% Pit & fissures- 35% 17 Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358.

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MODES OF ADMINISTRATION WATER FLUORIDATION F L U O R I D E Optimum concentration of fluoride in drinking water is used to produce maximum anticaries benefit & minimum toxicity GALGAN & VERMILLION FORMULA Amt of fluoride = 0.34/E E = -0.038 + 0.0062 ˣ Temperature Recommended 0.7 – 1.2 SCHOOL WATER FLUORIDATION Level of fluoride is 4.5 times that of optimum level 18 Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358.

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MODES OF ADMINISTRATION SALT FLUORIDATION F L U O R I D E 1955 By Wesp , Switzerland 20-25 % reduction in caries with 90mg F/Kg To obtain same amount of benefit as water fluoridation amt in salt increased to 300mg F/Kg 19 Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358.

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MODES OF ADMINISTRATION MILK FLUORIDATION F L U O R I D E 1956 By Zeigler 36 % reduction in caries with 2.5mg NaF 20 Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358.

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MODES OF ADMINISTRATION TOPICAL FLUORIDE F L U O R I D E Professionally applied topical fluorides: Introduced by Bibby in 1942 Involve the use of high fluoride concentration products ranging from 5000-19,000ppm equivalent to 5-19 mgF /ml 22 Self applied products: Include fluoride dentifrices, mouth rinses & gels Are low fluoride concentration products ranging from 200-1000ppm or 0.2-1 mgF /ml Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358.

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MODES OF ADMINISTRATION TOPICAL FLUORIDE F L U O R I D E PROFESSIONALLY APPLIED Lead fluoride Potassium fluoride Ammonium fluoride Zirconium fluoride Titanium tetra fluoride Potassium fluorostannate Sodium fluorostannate 21 Neutral sodium fluoride Acidulated phosphate fluoride Stannous fluoride Amine fluoride Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358.

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MODES OF ADMINISTRATION TOPICAL FLUORIDE F L U O R I D E PROFESSIONALLY APPLIED INDICATIONS Past caries experience & incidence Number of initial smooth surface lesions Dietary factors Microbiological factors Salivary & tooth factors Age Oral hygiene & attitude 23 Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358.

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MODES OF ADMINISTRATION TOPICAL FLUORIDE F L U O R I D E PROFESSIONALLY APPLIED FLUORIDES 24 F- DEPTH RELATED TO CONCENTRATION TREATMENT TIME Ph TYPE OF FLUORIDE AGENT TEMPERATURE Tandon S. Preventive control to caries approach: Fluorides. Textbook of Pedodontics . 2nd Ed. New Delhi;Paras Medical Publisher; 2008.p 258-65 .

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PROFESSIONALLY APPLIED FLUORIDE VEHICLES F L U O R I D E 25 AQUEOUS SOLUTIONS GEL FOAM VARNISH Easily prepared No need for continuous wetting 2/4 quadrants simultaneously Hazards of accidental ingestion Much lighter- require small amt Surfactant-lowers surface tension- better INTRPROXIMAL penetration Increased time of contact PAINT ON TECHNIQUE TRAY TECHNIQUE Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358.

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TOPICAL FLUORIDE SODIUM FLUORIDE F L U O R I D E 26 M inimum of four applications with a 2% (9200 ppm) sodium fluoride solution gives a caries reduction of 30 % METHOD OF PREPARATION: It is prepared by dissolving 20 gms of NaF powder in 1L of distilled water in a plastic bottle Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358 .

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TOPICAL FLUORIDE SODIUM FLUORIDE F L U O R I D E 27 KNUTSONS TECHNIQUE Teeth cleaned with pumice slurry isolated with cotton rolls, dried with compressed air cotton-tipped applicators used to paint 2 % NaF -all tooth surfaces are visibly wet solution allowed to dry for 3-4 min Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358 .

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TOPICAL FLUORIDE SODIUM FLUORIDE F L U O R I D E 28 KNUTSONS TECHNIQUE P rocedure repeated for each of the isolated segments until all the teeth are treated 2nd, 3rd and 4th fluoride application- scheduled at intervals of approximately one week The four-visit procedure recommended for ages 3, 7, 11 and 13 years- coinciding with the eruption of different groups of primary and permanent teeth Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358.

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TOPICAL FLUORIDE STANNOUS FLUORIDE F L U O R I D E 29 A pplications of 8% (19500ppm) stannous fluoride solution gives a caries reduction of 30 % METHOD OF PREPARATION : Solutions of stannous fluoride-not stable due to the formation of tin hydroxide. F resh solution of stannous fluoride be prepared for each patient To prepare 8% stannous fluoride solution , 0.8 grams of stannous fluoride is dissolved in 10 ml of distilled water in a plastic container Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358.

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TOPICAL FLUORIDE STANNOUS FLUORIDE F L U O R I D E 30 MUHLER’S TECHNIQUE Each tooth surface cleaned with pumice for 5 to 10 seconds Stannous fluoride applied solution is kept for 4 minutes D ental floss passed between interproximal areas Repeat applications-every 6 months/more frequently if patient susceptible to caries Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358.

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TOPICAL FLUORIDE ACIDULATED PHOSPHATE FLUORIDE F L U O R I D E 3 1 Applications of 1.23% (12300 ppm)solution gives a caries reduction of 28% METHOD OF PREPARATION : aqueous solution prepared by dissolving 20 gm of NaF in 1L of 0.1 M phosphoric acid and to this is added 50% hydrofluoric acid to adjust the pH at 3.0 and fluoride ion concentration at 1.23 % Brudevold’s solution For APF gel, a gelling agent methylcellulose/ hydroxyethyl cellulose added to solution Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358.

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TOPICAL FLUORIDE ACIDULATED PHOSPHATE FLUORIDE F L U O R I D E 32 TECHNIQUE Oral prophylaxis is done Teeth to be treated isolated and thoroughly dried with air Application of (gels) using trays that fit upper & lower arches Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358.

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TOPICAL FLUORIDE ACIDULATED PHOSPHATE FLUORIDE F L U O R I D E 33 TECHNIQUE Saliva ejector is used to evacuate the stimulated saliva and excess fluoride Patient is instructed to not eat , drink or rinse his mouth for atleast 30 minutes M inimum amt of fluoride gel for complete coverage of the tooth surfaces to be dispensed Repeat applications-every 6 months/more frequently if patient susceptible to caries Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358.

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TOPICAL FLUORIDES FLUORIDE VARNISH F L U O R I D E 34 DURAPHAT : viscous yellow material, containing 22,600 ppm fluoride as sodium fluoride in a neutral colophonium base FLUORPROTECTOR:clear polyurethane based product containing 7000 ppm fluoride from difluorosilane Increase time of contact between enamel & topical fluoride- deposition of fluorapatite & fluorhydroxyapatite CAREX: Containing 1800ppm fluoride as sodium fluoride Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358.

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TOPICAL FLUORIDES FLUORIDE VARNISH F L U O R I D E 35 Following oral prophylaxis, teeth dried Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358. Application done with single tufted brush Patient asked to keep mouth open for 4 mins Patient asked not to rinse/drink – I hr

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MODES OF ADMINISTRATION TOPICAL FLUORIDE F L U O R I D E CLINICAL APPLICATIONS 36 Pumicing /professional prophylaxis removes fluoride rich layer of enamel Prophylactic pastes containing fluoride to be avoided prior to acid etching procedures Topical fluorides – not used in open cavities –DECREASED P h & FLUORIDE BOMBS Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358. Osmunson B. Editorial Water fluoridation intervention: dentistry's crown jewel or dark hour ? Fluoride 2007;40(4):214-221. Important to apply topical fluorides after procedures such as interproximal stripping FLUORIDE BOMB

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TOPICAL FLUORIDES SELF APPLIED F L U O R I D E 37 Dentifrices Mouth rinses Gels Frequent source of fluoride in low concentration Dentifrice Recommendations Below 4yrs - N ot recommended 4-6yrs - Once daily with fluoridated & twice with non fluoridated 6- 12 yrs - Twice with fluoridated & once with non fluoridated Above 12 yrs - Thrice with fluoridated dentifrice Mouthrinse - NaF , APF, SnF2 – reduced caries by 20 – 50% Non prescribed mouth rinse 0.05%NaF (225ppm) Once a day Prescribed mouth rinses 0.2%NaF (900ppm) Once a week Swished – 1 min Tandon S. Preventive control to caries approach: Fluorides. Textbook of Pedodontics . 2nd Ed. New Delhi;Paras Medical Publisher; 2008.p 258-65.

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CARIES PREVENTION RECOMMENDATIONS-OPTIMALLY FLUORIDATED COMMUNITY C A R I E S R I S K 38 0-3 YRS Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358 . 3-17 YRS 17 YRS & ABOVE FLUORIDATED WATER FLUORIDATED WATER FLUORIDATED WATER FLUORIDE DENTIFRICE FLUORIDE DENTIFRICE PROFESSIONAL TOPICAL PROFESSIONAL TOPICAL FLUORIDE ORAL RINSE SUPPLEMENTS FLUORIDE ORAL RINSES LOW HIGH FLUORIDE DENTIFRICE

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CARIES PREVENTION RECOMMENDATIONS- SUB OPTIMALLY FLUORIDATED COMMUNITY C A R I E S R I S K 39 0-3 YRS Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358 . 3-17 YRS 17 YRS & ABOVE FLUORIDE DENTIFRICE FLUORIDE DENTIFRICE PROFESSIONAL TOPICAL PROFESSIONAL TOPICAL FLUORIDE ORAL RINSE SUPPLEMENTS FLUORIDE ORAL RINSES LOW HIGH FLUORIDE DENTIFRICE DIETARY SUPPLEMENTS DIETARY SUPPLEMENTS

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FLUORIDES ADVANCED APPLICATIONS F L U O R I D E 40 Fluoride chewing gum Fluoride containing dental floss Fluoride impregnated prophylaxis paste & cup Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358. Iontophoresis Dental cements Pit & fissure sealants Fluoride containing amalgams Fluoride containing alginates

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CARIES PREVENTION CHLORHEXIDINE C O N T E N T S Introduction Historical evolution as caries preventive agent Mechanism of action Antimicrobial activity Antiplaque activity Modes of administration Advances in chlorhexidine applications Fluoride chlorhexidine combination preparations FluOride Vs Chlorhexidine

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CARIES PREVENTION INTRODUCTION C H L O R H E X I D I N E 41 Chlorhexidine a gold standard in chemical plaque control outstanding bacteriostatic and bactericidal properties Effective on both gram positive and gram negative bacteria Peter S. Plaque control. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house; 2007 p 432-51 .

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CARIES PREVENTION INTRODUCTION C H L O R H E X I D I N E 4 2 CHEMICAL STRUCTURE S ymmetrical molecule consisting of 2 chlorophenyl rings and 2 bisguanide groups connected by a central hexamethylene bridge strongly basic & dicationic at ph levels above 3.5 with positive charges on either side of hexamethylene bridge the Dicationic nature of chlorhexidine makes it extremely interactive with anions, which is relevant to its efficacy Peter S. Plaque control. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house; 2007 p 432-51 .

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CARIES PREVENTION HISTORY C H L O R H E X I D I N E 4 3 First report of Antiplaque activity – Schroeder 1962 1970, Loe & Schiott – use of 0.2% Chlorhexidine gluconate twice daily as mouthrinse Total inhibition of plaque formation Peter S. Plaque control. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house; 2007 p 432-51 . 1947 - study to synthesize new antimalarial agents led to the development of the polybiguanides

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CARIES PREVENTION MECHANISM OF ACTION C H L O R H E X I D I N E 4 4 ANTIMICROBIAL ACTIVITY Bacteriostatic at low conc ; bactericidal at high conc Wide spectrum – gram positive and gram negative bacteria, yeasts, dermatophytes & lipophilic yeasts "membrane-active agents" , acts on the cell membrane to increase its permeability and facilitate the release of intracytoplasmic material Peter S. Plaque control. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house; 2007 p 432-51 .

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CARIES PREVENTION MECHANISM OF ACTION C H L O R H E X I D I N E 4 5 ANTIMICROBIAL ACTIVITY - vely charged PO4 grps on microbial cell wall CHLORHEXIDINE Leakage of vital cell elements Cell lysis /coagulation Peter S. Plaque control. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house; 2007 p 432-51 .

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CARIES PREVENTION MECHANISM OF ACTION C H L O R H E X I D I N E 46 Long lasting bacteriostatic action, also termed as ‘ substantivity ’ Its action lasts for about 12 hours in the oral cavity after a single rinse Not to be used before/ immediately after using toothpaste – interaction with anionic surfactants The D icationic CHX molecule, attaches to the pellicle by one cation , to the bacteria attempting to colonize the tooth surface with the other. This is called the ‘Pin-Cushion Effect’ Peter S. Plaque control. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house; 2007 p 432-51 .

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CARIES PREVENTION MECHANISM OF ACTION C H L O R H E X I D I N E 4 7 ANTIMICROBIAL ACTIVITY + CHX + PIN CUSHION EFFECT Peter S. Plaque control. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house; 2007 p 432-51 .

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CARIES PREVENTION MECHANISM OF ACTION C H L O R H E X I D I N E 48 ANTIPLAQUE ACTIVITY Blocking of the acidic group of salivary glycoproteins reduce their adsorption to hydroxyapatite and formation of acquired pellicle The ability of bacteria to bind to tooth surface reduced by adsorption of CHX to the extracellular polysaccharides of their capsule Peter S. Plaque control. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house; 2007 p 432-51.

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MODES OF ADMINISTRATION PRODUCTS C H L O R H E X I D I N E 49 Mouth rinse- aqueous/ alcohol solutions of 0.2 % [ Peridex , Periogard , Periosol ] Advanced applications Sprays [ Hibispray } Varnishes Chewing gums Subgingival plaque control [ Periochip ] Gels Tooth pastes Peter S. Plaque control. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house; 2007 p 432-51.

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MODES OF ADMINISTRATION DOSAGE & INSTRUCTIONS C H L O R H E X I D I N E 50 USUAL DOSAGE - 15ml (1 tablespoon) of undiluted chlorhexidine oral rinse Recommended use - twice daily oral rinsing for 30 seconds after tooth brushing Patient should be instructed not to rinse with water or brush teeth or eat immediately after CHX oral rinse ADVERSE EFFECTS Discolouration of teeth , the tongue, restorations, and dentures Mucosal soreness & desquamation, Bitter taste Temporary taste disturbances calculus formation Acute parotitis Potential allergic reaction Peter S. Plaque control. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house; 2007 p 432-51.

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FLUORIDES CHLORHEXIDINE F / C H X 51 FLUORIDE – Prevent dental caries Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358 . Rao A. Fluorides. Principles and Practice of pedodontics . New Delhi: Jaypee Medical publishers;2006 p. 204 – 18 . Autio -Gold J. The role of chlorhexidine in caries prevention. Operative Dentistry 2008;33(6):710–6. CHLORHEXIDINE – Powerful inhibitor of ginigivitis & plaque formation COMPATIBILITY “SUGGESTIVE BUT INCOMPLETE”

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52 FLUORIDE CHLORHEXIDINE LOCATION OF ACTION ANTI MICROBIAL SPECTRUM EVIDENCE BASED EFFICACY AVAILABILITY & DEGRADATION PATIENT COMPLIANCE TOXICITY USAGE RECOMMENDATIONS BACTERIAL RESISTANCE COST EFFECTIVENESS MECHANISM OF ACTION

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53 FLUORIDE CHLORHEXIDINE MECHANISM OF ACTION INHIBIT DEMINERALIZATION PROMOTE REMINERALIZATION SUPRESSION OF S. MUTANS PREVENTION OF FORMATION OF BACTERIAL BIOFILM Peter S. Plaque control. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house; 2007 p 432-51.

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54 FLUORIDE CHLORHEXIDINE LOCATION OF ACTION SUPERFICIAL NOT INCORPORATED IN TOOTH INTERNAL INCORPORATED IN TOOTH Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358.

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55 FLUORIDE CHLORHEXIDINE ANTIMICROBIAL SPECTRUM NARROW ENZYME INHIBITION BROAD SPECTRUM CELL LEAKAGE & COAGULATION BACTERIOSTATIC BACTERICIDAL Peter S. Plaque control. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house; 2007 p 432-51.

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5 6 FLUORIDE CHLORHEXIDINE USAGE RECOMMENDATIONS LONG TERM USE LOCAL APPLICATION> SYSTEMIC APPLICATION INTERMITTENT SHORT TERM USE Peter S. Plaque control. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house; 2007 p 432-51.

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57 FLUORIDE CHLORHEXIDINE BACTERIAL RESISTANCE MICOORGANISMS DEVELOP RESISTANCE (REVERSIBLE) RESISTANCE IN MICROORGANIMS NOT DOCUMENTED Santos A. Evidence-based control of plaque and gingivitis. Journal of Clinical Periodontology 2003;30 Suppl 5:13–6. Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358.

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58 FLUORIDE CHLORHEXIDINE TOXICITY FLUOROSIS ACUTE/CHRONIC TOXICITY EXCRETED ALMOST 100%

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46 FLUORIDE CHLORHEXIDINE CONCENTRATION 1PPM 1000 PPM 1000 PPM 22,000 PPM 0.03% -0.2% 0.12% 40% Peter S. Plaque control. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house; 2007 p 432-51.

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59 FLUORIDE CHLORHEXIDINE AVAILABILITY & DEGRADATION SALIVARY RESERVOIR SMALL SIZE OF MOLECULE INORGANIC MOLECULE – NOT DEGRADED SUBSTANSIVITY LARGE SIZE OF MOLECULE ORGANIC MOLECULE - DEGRADES Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358. Peter S. Plaque control. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house; 2007 p 432-51.

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60 FLUORIDE CHLORHEXIDINE EFFECTIVE DELIVARY METHOD ALL TOPICAL – SIMILAR CARIES PREVENTION VARNISH GELS MOUTHWASH Emilson CG. Potential efficacy of chlorhexidine against mutans streptococci and human dental caries. Journal of Dental Research 1994;73(3):682–91 . Marinho VC, Higgins JP, Logan S, Sheiham A. Topical fluoride (toothpastes, mouthrinses , gels or varnishes) for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2003, Issue 4.

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61 FLUORIDE CHLORHEXIDINE PATIENT COMPLIANCE MYRIAD INNOVATIVE DELIVARY SYSTEMS NEW DELIVERY SYSTEMS NOT POPULARLY MARKETED Autio -Gold J. The role of chlorhexidine in caries prevention. Operative Dentistry 2008;33(6):710–6 .

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62 FLUORIDE CHLORHEXIDINE COST EFFECTIVENESS WATER FLUORIDATION DENTIFRICE MOUTH RINSE – NOT ECONOMICAL Autio -Gold J. The role of chlorhexidine in caries prevention. Operative Dentistry 2008;33(6):710–6 .

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63 FLUORIDE CHLORHEXIDINE EVIDENCE BASED EFFICACY EVIDENCE- “SUGGESTIVE BUT INCOMPLETE.” ESTABLISHED EVIDENCE BASED METHOD Santos A. Evidence-based control of plaque and gingivitis. Journal of Clinical Periodontology 2003;30 Suppl 5:13–6.

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CONCLUSION 64 DEVELOPMENT AND APPLICATION OF EFFECTIVE ANTICARIOGENIC AGENTS USE OF AGENTS TO BE JUSTIFIED FOUNDATION OF PREVENTION FOR MODERN ORAL PREVENTIVE HEALTH CARE EVIDENCE BASED SUPPORTED BY CONCLUSIVE LITERATURE LONG TERM CLINICAL STUDIES GOOD ORAL HYGEINE DIET MODIFICATION Autio -Gold J. The role of chlorhexidine in caries prevention. Operative Dentistry 2008;33(6):710–6 .

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REFERENCES 65 Ismail Al, Hasson H. Fluoride supplements, dental caries and fluorosis. A systematic review. Journal of the American Dental Association 2008;139(11 ):1457–68 . Beazly VC, Thrane P, Rölla G. Effect of mouthrinses with SnF2 , LaCI3, NaF and chlorhexidine on the amount of lipoteichoic acid formed in plaque. Scandinavian Journal of Dental Research 1980;88(3):193–200 . Emilson CG. Potential efficacy of chlorhexidine against mutans streptococci and human dental caries. Journal of Dental Research 1994;73(3):682–91 . Marinho VC, Higgins JP, Logan S, Sheiham A. Topical fluoride (toothpastes, mouthrinses , gels or varnishes) for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2003, Issue 4 . Santos A. Evidence-based control of plaque and gingivitis. Journal of Clinical Periodontology 2003;30 Suppl 5:13–6.

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REFERENCES 66 Wong MC, Glenny AM, Tsang BW, Lo EC, Worthington HV , Marinho VC. Topical fluoride as a cause of dental fluorosis in children. CochraneDatabase of Systematic Reviews 2010 , Issue 1 . Murray JJ, Rugg-gunn AJ, Jenkins GN. Anticaries mechanisms of fluoride. Fluorides in caries prevention. 3 rd Ed. Butterworth- Heinemann 1991.p Eberhard J et al. Chlorhexidine versus topical fluoride treatment for the prevention and management of dental caries in children and Adolescents. Cochrane Database of Systematic Reviews 2012, Issue 7 . Autio -Gold J. The role of chlorhexidine in caries prevention. Operative Dentistry 2008;33(6):710–6 . Tandon S. Preventive control to caries approach: Fluorides. Textbook of Pedodontics . 2nd Ed. New Delhi;Paras Medical Publisher; 2008.p 258-65.

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REFERENCES 67 Rao A. Fluorides. Principles and Practice of pedodontics . New Delhi: Jaypee Medical publishers;2006 p. 204 – 18. Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3 rd ed. New Delhi: Arya publishing house;2007 p 270 – 358. Peter S. Plaque control. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house ; 2007 p 432-51. Roberson TM, Heymann HO, Swift EJ. Cariology : The Lesion, Etiology, Prevention, and control. In: Roberson TM. Sturdevant’s Art and Science of operative Dentistry. 5 th Ed . Missouri: Mosby; 2006 p. 65-134 Osmunson B. Editorial Water fluoridation intervention: dentistry crown jewel or dark hour? Fluoride 2007;40(4):214-221.

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& CHLORHEXIDINE IN THE ROLE OF FLUORIDE PREVENTION OF DENTAL CARIES

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