ANTIMICROBIAL

IN CARIES
CONTROL
 TOOTH BRUSHING

• tooth brushing and other mechanical cleaning

procedures are considered to be the most reliable
means of controlling plaque, provided cleaning is
sufficiently thorough and performed at regular
intervals.
• Tooth brushing is paramount in maintaining good
oral hygiene under the best of circumstances,
however, toothbrushing is able to clean only the
buccal lingual and occlusal surfaces (excluding pits
and fissures); proximal and interdental area are
essentially left untouched.
 TOOTH BRUSHING

• Therefore, the target for modern hygiene programs

or for any regimen attempting to prevent and
reduce the incidence of caries and periodontal
disease must put a major focus on the interdental
and proximal areas of the dentition

Since adequate self-performed mechanical

control of dental biofilms is difficult and often
inadequate, antimicrobials may offer an adjunct.
• Caries is caused by the resident oral microflora.
This flora represents an important line of defense
and protects the host against colonization by
foreign microorganisms.
• Thus the goal is not to eliminate the flora, but to
prevent a shift from an ecologically favorable to
an ecologically unstable biofilm that may lead to
disease.
CHEMICAL AGENTS CAN REDUCE BIOFILM MASS AT
VARIOUS STAGES OF BIOFILM FORMATION OR
MATURATION THROUGH :

1. inhibition of microbial adhesion and colonization

2. inhibition of microbial growth and metabolism
3. disruption of mature biofilms and detachment of
biofilm microorganisms
4. modification of biofilm biochemistry and ecology
STAGES & MECHANISMS OF BIOFILM FORMATION AS
TARGETS FOR INTERFERENCE
 INHIBITION OF
MICROBIAL ADHESION AND COLONIZATION

• Inhibiting microbial adhesion to tooth surfaces will

reduce the accumulation of dental biofilms.
• The salivary pellicle, to which the microorganisms adhere
through specific and non-specific mechanisms, provides
a complex array of binding sites. Thus, the composition
of the pellicle may modulate bacterial adhesion events.
• One approach is to change the surface characteristics
by manipulating the protein film on the enamel, and
thereby reduce bacterial adhesion.
• In vitro studies: agents that reduce the surface free
energy will reduce microbial adhesion to that surface.
 INHIBITION OF
MICROBIAL GROWTH AND METABOLISM

• The majority of agents used to limit or inhibit biofilm

formation are broad-spectrum antimicrobial agents
with bactericidal or bacteriostatic effects.
• They are used according to a non-specific plaque
hypothesis and are formulated to be used as
supplements or mechanical oral cleansing.
• Antimicrobial bind to the microbial membrane :
interfere with normal membrane functions such as
transport → disturb microbial metabolism → may kill
the microorganism.
• Adsorption to microbial membranes may also lead
to alterations in the permeability → leakage of
intracellular components, along with denaturation
and coagulation of cytoplasmic protein contents.
• For several bacteria, communication signals may
be necessary to form structured biofilms.
• Such signals may be involved not only in the
formation of structured biofilms, but also in the
ability of the cells to adapt to adverse enviromental
conditions.
 DISRUPTION OF MATURE BIOFILMS AND
DETACHMENT OF BIOFILM MICROORGANISMS

• Mature community biofilm is the result of a well-

regulated series of processes, each of which may
represent a potential target for biofilm control.
• Approaches to disrupt established biofilms through
the hydrolytic action of enzymes therefore seem
reasonable.
• Experimental results are disappointing >> dental
biofilm matrix contains several types of biopolymers
including a variety of polysaccharides, DNA and
proteins. Therefore, targetting just one of these may
be insufficient. Another barrier is diffusion of the
agent into the biofilm.
• Disturbance of the structural properties of the dental
biofilm during formation could also limit its ultimate mass.
• Example: inhibitory effects on glucosyltransferase activity
could result in more loosely attached deposits.
Research results:
• Chlorhexidine inhibits GTF activity
• Delmophinol reduce the viscosity of glucan synthesized.
• In vivo: frequent applications of CHX and high
concentrations of demolphinol have been shown to
possess biofilm-dispersive activity.
 MODIFICATION OF
BIOFILM BIOCHEMISTRY AND ECOLOGY

• The microbial ecological balance is crucial for the

maintenance of dental health.
• One way to maintain or restore such a balance
could be to replace potential pathogens with
harmless and beneficial microorganisms through
probiotics or replacement therapy.
 PROBIOTIC

• By definition, a probiotic is a live microbial food

ingredient that when ingested in a sufficient quantity
exerts health benefits on the consumer.
• Genetic engineering opens the possibility of designing
new probiotic strains.→ may be enabled to compete
against and to replace known pathogens, while being
non-virulent themselves.
• With probiotics, naturally occuring harmless
microorganisms may exert beneficial action by
occupying colonization sites and competing with the
pathogen for nutrients. They may also produce harmful
metabolites, biosurfactants, or antimicrobial agents that
inhibit biofilm formation by pathogen.
 PROBIOTIC

• Probiotic has been suggested on caries prophylaxis.

• Replacing mutans streptococci with strains that lack
the ability to produce lactate or strains that
produce alkaline products >> limit the pH drop in
dental biofilms.
Research results:
• Children were given milk containing the probiotic
Lactobacillus rhamnosus LGG with meals, five days
a week for 7 months. The results indicated that the
probiotic milk had a protective effect, since a
tendency towards low caries incidence was seen in
one of the age groups.
THE REQUIREMENTS FOR PREVENTION THROUGH
PROBIOTICS TO BE EFFICACIOUS ARE

1. They are able to adhere and become part of the

biofilm
2. There is definite pathogen to interact with or to
replace
3. The probiotic or replacement organisms must not
cause disease themselves
4. They must colonize persistently
5. They must replace or interact with the pathogen
effectively
6. They must possess high degrees of genetic stability
 VEHICLES FOR ADMINISTRATION OF
CARIES-PROPHYLACTIC AGENTS

• Mouthrinses
• Sprays
• Dentrifices
• Gels
• Chewing gum/lozenges
• Various sustained-released formulations or devices
 VEHICLES FOR ADMINISTRATION OF
CARIES-PROPHYLACTIC AGENTS

• The choice of vehicle depends on compatibility

between the active agent and the constituents of
the vehicle.
• The vehicles should provide optimal bioavailability
of the agent at its site of action >> delivery by
dentrifices and mouthwashes result in immediate
high concentrations of the agent.
 MOUTHWASH

Mouthwashes (mouth rinses) are solutions or liquids

used to rinse the mouth for a number of purposes:
• to remove or destroy bacteria,
• to act as an astringent,
• to deodorized
• to have a therapeutic effect by relieving infection
or preventing dental caries

Mouthwashes are manufactured in two forms: the

wash and the spray.
The most common use of mouthwashes:
• Rinsing the mouth with about 20 ml of
mouthwash 2 times each day after brushing.
• The mouthwash is swished or gargled for about
30 seconds and then spat out.
 MOUTHWASH INGREDIENTS

• The active ingredients in mouthwashes are usually

antimicrobial agents that have a temporary reductive
effect on the total number of microorganisms in the oral
cavity.
• Active ingredients in mouthwashes sold commercially:
thymol, eucalyptol, hexetidine, methyl salicylate,
menthol, chlorhexidine gluconate, benzalkonium
chloride, cetylpyridinium chloride, methylparaben,
hydrogen peroxide and domiphen bromide.
• Some mouthwashes contain alcohol which act as a
solvent for other ingredients.
- Alcohol 10-12% act as a preservatives and antiseptic
- Alcohol 27% acts as a carrier for the flavor.
 ANYANWU ET AL.
IHE: LINCOLN UNIVERSITY JOURNAL OF SCIENCE
VOL 2 (1) 2011

Hypothesis :
• Alcohol containing mouthwashes were more
effective against Gram negative bacteria than
non-alcohol-containing mouthwashes.
• alcohol acts as a solvent to remove the outer
membrane of Gram negative bacteria. Since
Gram positive bacteria have no outer membrane,
alcohol would have no effect on them.
Result: do not support the hypothesis
 ADVERSE EFFECTS OF MOUTHWASH USE

The localized oral lesions induced by

mouthrinses
• lesions of the primary irritant type
• lesions generated through activation of
specific immunologic pathways such as type I
and type IV hypersensitivity reactions,
• hard tissue effects (demineralization and
discoloration of thetooth enamel).
ADVERSE EFFECTS OF LISTERINE
ADVERSE EFFECTS OF MOUTHWASH USE

Systemic ill effects of mouthrinses

• alcohol intoxication and poisoning through
wrongful ingestion of mouthwashes.
• Oropharyngeal cancer
 ADVERSE EFFECTS OF CHLORHEXIDINE

• Chlorhexidine, is one of the most routinely

prescribed oral rinses.
• Adverse Effects:
 altered taste sensation
 superficial desquamation of the oral mucosa
 brownish discoloration of the tongue and teeth
 increased calculus formation
 Chlorhexidine has also been associated with
potential anaphylactic reactions