Srinu Chemical Plaque Control

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PRESENTED BY

G.SRINIVAS

2ND YEAR PG

DEPT OF PERIODONTICSDATE: 19/8/11


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Contents

Introduction

Definition

The concept of chemical supragingival plaque control

Chemical supragingival plaque control

Rationale for chemical supragingival plaque control

Approaches to chemical supragingival plaque control

-Antiadhesive agents-Antimicrobial agents

-Plaque removal agents

-Antipathogenic agents


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Contents

Vehicles for the delivery of chemical agents

Chemical plaque control agents

Chlorhexidine mouth wash-toxicology and side effects

-chlorhexidine staining

-mechanism of action

-chlorhexidine products

-clinical use of chlorhexidine

References


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Introduction

Epidemiological studies revealed a peculiarly highcorrelation between supragingival plaque levels andchronic gingivitis ---Ash et al. 1964

Clinical research(Loe et al. 1965) led to the proof that

plaque was the primary etiological factor in gingivalinflammation.


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Definition

Plaque control is the removal of dental plaque on aregular basis and the prevention of its accumulation

on the teeth and adjacent gingival surfaces.


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THE CONCEPT OF CHEMICAL SUPRAGINGIVAL

PLAQUE CONTROL

The use of chemical agents should be as adjuncts & are notreplacements for mechanical methods.

These appear partially or totally ineffective alone.

Many individuals remove only around half of the plaquefrom their teeth even when brushing for 2 minutes (de laRosa 1979).

The adjunctive use of chemicals would overcome thedeficiencies in mechanical tooth cleaning habits.


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Chemical supragingival plaque control

History of oral hygiene products:

The terminology "oral hygiene products" is recent butthere is evidence dating back at least 6000 years thatformulations and recipes existed to benefit oral anddental health (Fischman 1992, 1997).

A considerable number of formulations can beattributed to the Hippocrates(circa 480 BC).


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Alcohol-based mouthrinses were particularly popular

with the Romans and included white wine and beer.

Urine, as a mouthrinse, appeared to be popular withmany peoples and over many centuries.

Cantabri and other peoples of Spain preferred staleurine

whereas Fauchard (1690-1761) in Francerecommended fresh urine.


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Rationale for chemical supragingival

plaque control

Etiology of both gingivitis and periodontitis is dental

plaque and plaque bacteria.

This supports the concept of employing chemicalagents to control plaque.

This is the concept that underlies chemicalsupragingival plaque control.


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Approaches to chemical supragingival

plaque control

Chemical agents, on the other hand, could influence

plaque quantitatively and qualitatively via a number ofprocesses .

The action of the chemicals could fit into fourcategories:

1. Antiadhesive2. Antimicrobial

3. Plaque removal

4. Antipathogenic


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Antiadhesive agents

These would act at the pellicle surface to prevent the initialattachment of the primary plaque forming bacteria.

Acting most effectively on an initially clean tooth surface.


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Prevent the attachment and development of biofilms.

Described as antifouling agents.

Antiadhesion and plaque removal, has been showneffective against plaque and gingivitis (Collaert et al.1992, Claydon et al. 1996).

Amine alcohol & Delmopinol interferes with thebacterial matrix formation.


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Antimicrobial agents

Antimicrobial agents could inhibit plaque formationthrough one of two mechanisms alone or combined.

1. inhibition of bacterial proliferation (bacteriostaticeffect).

2. Bacteriocidal effect whereby the antimicrobial agentdestroys all of the microorganisms either attaching oralready attached to the tooth surface.


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Plaque removal agents

Chemical plaque removal agents has attracted theterminology of "the chemical toothbrush".

There are potential agents, such as the hypochlorites,which might be expected to remove bacterial deposits.

The nearest success was with enzymes directed at boththe pellicle( e.g. proteases) or the bacterial matrices,

e.g. dextranase and mutanase (Kornman 1986).


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Antipathogenic agents

Inhibit the expression of the pathogenicity without

necessarily destroying the microorganisms.

In some respects antimicrobial agents, which exert a

bacteriostatic effect, achieve such results.


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Vehicles for the delivery of chemicalagents

The carriage of chemical agents into the mouth forsupragingival plaque control has involved a small butvaried range of vehicles ( Addy 1994, Cummins 1997).


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Tooth pastes

Ideal vehicle for the carriage of plaquecontrol agents is toothpaste.

The major ingredients may beclassified under the followingheadings:

1.Abrasives 6. Flavors

2.Detergents 7. Actives3.Thickeners

4.Sweeteners

5. Humectants


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The addition of cationic antiseptics to toothpastes is

difficult but chlorhexidine has been formulated into

toothpastes and shown to be effective

( Yates et al. 1993, Sanz et al. 1994).


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Mouthrinses

Mouthrinses are less complexthan toothpastes.

Anionic detergents are includedin some products but, again,cannot be formulated with

cationic antiseptics such ascetylpyridinium chloride orchlorhexidine(Barkvoll et al.1989).


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Ethyl alcohol is commonly used both to stabilizecertain active ingredients and to improve the shelf-lifeof the product.

The proportion of alcohol is usually less than 10% butsome rinses have in excess of 20% alcohol.


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Spray

Spray delivery of chemical plaque control agents hasattracted both researchers and manufacturers.

Sprays have the advantage of focusing delivery on therequired site.

The dose is clearly reduced and for antiseptics such aschlorhexidine this has taste advantages.


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When correctly applied chlorhexidine sprays were aseffective as mouthrinses for plaque inhibitionalthough there was no reduction in staining (Francis

et al. 1987a, Kalaga et al. 1989a).

Chlorhexidine sprays were found particularly useful forplaque control in physically and mentally handicappedgroups (Francis et al. 1987a,b, Kalaga et al. 1989b).


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Irrigators

Irrigators were designed to spraywater, under pressure, aroundthe teeth.

They only remove debris, with

little effect on plaque deposits( Frandsen 1986).


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Chewing gum

Significant benefits to dentalhealth through the use of sugar-free chewing gum.

Unfortunately, chewing gumsalone have little plaque control

benefits particularly at sitesprone to gingivitis ( Addy et al.1982a).


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Varnishes

Though Varnishes have beenemployed to deliver antisepticsincluding chlorhexidine, but thepurpose has been to preventroot caries rather than as areservoir for plaque control.


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CHEMICAL PLAQUE CONTROL AGENTS

The number and variation of chemical agentsevaluated are quite large,

Most have antiseptic or antimicrobial actions and

success has been variable at the extreme.


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The most effective agents inhibit the development ofplaque and gingivitis

Limited to affect established plaque and gingivitis.

Chemical plaque control agents have been the subject

of many detailed reviews since 1980 (Hull 1980, Addy1986, Kornman 1986)


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Persistence of action, sometimes termedsubstantivity(Kornman 1986), appears todependent on several factors:

1. Adsorption and prolonged retention on oral surfaces

including, importantly, pellicle coated teeth.

2. Maintenance of antimicrobial activity once adsorbedprimarily through a bacteriostatic action against the

primary plaque forming bacteria.

3. Minimal or slow neutralization of antimicrobialactivity within the oral environment or slowdesorption from surfaces.


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1. Bisbiguanide antiseptics

2. Quaternary Ammonium Compounds3. Phenolic Antiseptics

4. Hexetidine

5. Povidone Iodine6. Triclosan

7. Delmopinol

8. Salifluor

9. Metal Ions

10. Natural Products

11. Oxygenating Agents


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1. Bisbiguanides (Addy et al1994)

Kills a wide range ofmicroorganisms bydamaging cell wall.

Bisbiguanide antisepticsthat possess antiplaque

activity are: Chlorhexidine

Alexidine

Octenidine


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2. Quaternary Ammonium Compounds

(Mandel 1988)

Have moderate plaque inhibitory activity

Greater oral retention and equivalent

antibacterial activity to chx

Less effective in inhibiting plaque and

preventing gingivitis


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Example of QAC are Benzalconium chloridecetylpyridinium chloride (CPC)

Most effective in 0.05% formulations

Available as CPC rinses and CPC

lozenges (Cepacol)

Causes staining


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3. Phenolic Antiseptics(Mandel 1988)

Used either alone or in combination with mouth rinsesor lozenges

Has moderate plaque inhibiting effects and some anti-inflammatory effects in reducing gingivitis

E.g. is Listerine, which is an essential oil/phenolicmouthwash


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Its lack of profound plaque inhibitory effect is becauseof poor oral retention

Thus, Listerine has moderate effect on plaque re-

growth and some anti inflammatory effect which mayreduce the severity of gingivitis


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4. Hexetidine

Has some plaque inhibitory activity

Oral retention: 1 3 hours, whichaccounts for the low plaqueinhibitory effects

Concentrations > 0.1% can causeoral ulceration

Combining zinc with hexetidineimproves its plaque inhibitingactivity

Product: Oraldene


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5. Povidone Iodine

No significant activity when usedas 1% mouthwash

Can cause iodine sensitivity

Either full strength or equal partsof povidone iodine and water isused for subgingival irrigation.


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6. Triclosan

Non-ionic antiseptic

Has moderate plaque inhibitory effects

Usually used in combination with zinc to increase oralretention


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Acts as an anti-inflammatory agent in mouth rinses

and toothpastes Inhibits cyclo-oygenease and lipooxygenase thus

reducing prostaglandins and leukotrienes

Anti-inflammatory effect depends on its ability to

penetrate into gingival tissues.


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Brushing with a Triclosantoothpaste reduces gingivalinflammation

Effective formulations:

Triclosan/ Copolymer

Triclosan/ Zinc Citrate


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7. Delmopinol

Has plaque inhibiting effects:

Interferes with plaque matrix formation and

reduction of bacterial adherence

Formulations: 0.1% and 0.2%

Possesses anti-inflammatory effects


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Reductions in dextran-producing

streptococci

Side effects:

Transient numbness of tongue

Tooth and tongue staining

Taste disturbances

Mucosal soreness

Erosion


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8. Salifluor

Is a salicylanide which has anti-bacterial andinflammatory properties

Mechanism of action is not fully understood

Experimentally 0.12% is as effective as 0.12%

chlorhexidine.


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9. Metal Ions (Addy et al. 1994)

Zinc, copper, and tin possessplaque inhibitory effect

Copper and tin causes staining

Fluoride compounds such as

stannous fluoride and aminefluoride have plaque inhibitoryeffect .


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Zinc is retained by dental plaque and inhibits itsregrowth without disrupting oral ecology

Zinc has additive or synergistic effect with hexetidine,Triclosan and sanguinarine


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10. Natural Products (Mandel 1988)

1. Sanguinarine

2. Propolis

Sanguinarine: Is retained in plaque for several hours after use and is

poorly absorbed by GIT

Mode of action: inhibition of glycolysis with assistancefrom zinc


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Is an effective plaque inhibitory

agent but less effective thanchlorhexidine

Prevents development of gingivitis

Mouthwash is more effective plaqueinhibitory agent than toothpaste.


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Propolis:

Has an antiseptic, anti-inflammatory, antimycotic andbacteriostatic effect

Not effective as mouthwash


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11.Oxygenating Agents(Addy et al. 1994)

Examples:

Hydrogen peroxide

Buffered sodium peroxyborate

Peroxycarbonate

Inhibits anaerobic bacteria

As obligate anaerobes are important inthe development of gingivitis andperiodontitis, these effects are useful


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Alcohol Content of Mouthwashes

Many mouthwashes contain significant quantities of alcohol,which leads to a number of possible disadvantages:

If accidentally swallowed by young children it cancause alcohol toxicity

Can increase the incidence of oral and pharyngeal

cancer

Reduces hardness of composite and hybrid-resin

restorations


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CHLORHEXIDINE

Chlorhexidine isavailable in three forms,

1.digluconate,

2.acetate and

3.hydrochloride salts.


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Most studies and most oral formulations and productshave used the digluconate salt, which is manufacturedas a 20% V/V concentrate.

Digluconate and acetate salts are water-soluble buthydrochloride is very sparingly soluble in water.


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Chlorhexidine was developed in the 1940s by ImperialChemical Industries, England, and marketed in 1954 asan antiseptic for skin wounds.

Later, the antiseptic was more widely used in medicineand surgery.

Use in dentistry was initially for presurgicaldisinfection of the mouth and in endodontics.


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Plaque inhibition by chlorhexidine was firstinvestigated in 1969 (Schroeder 1969).

The definitive study was performed byLoe andSchiott (1970).

This study showed that rinsing for 60 seconds twiceper day with 10 ml of a 0.2% (20 mg dose)

chlorhexidine gluconate solution in the absence ofnormal tooth cleaning, inhibited plaque regrowth andthe development of gingivitis.


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Chlorhexidine is a bisbiguanide antiseptic,

Being a symmetrical molecule consisting of fourchlorophenyl rings,

Two biguanide groups connected by a centralhexamethylene bridge.


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The compound is a strong base and dicationic at pHlevels above 3.5, with two positive charges on eitherside of a hexamethylene bridge (Albert & Sargeant1962).

Indeed, it is the dicationic nature of chlorhexidine,

making it extremely interactive with anions, which isrelevant to its efficacy, safety, local side effects anddifficulties with formulation in products.


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Safety, toxicology and side effects

The cationic nature of chlorhexidine minimizesabsorption through the skin and mucosa, includingfrom the GI tract.

Systemic toxicity from topical application or ingestionis therefore not reported,

There is no evidence of teratogenicity in the animalmodel.


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Neurosensory deafness can occur if chlorhexidine isintroduced into the middle ear.

In oral use as a mouthrinse, chlorhexidine has beenreported to have a number of local side effects (Flotraet al. 1971).


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Chlorhexidine staining

The mechanisms proposed for chlorhexidine stainingcan be debated (Eriksen et al. 1985, Addy & Moran1995, Watts & Addy 2001) but have been proposed as:

1. Degradation of the chlorhexidine molecule to release

parachloraniline

2. Catalysis of Maillard reactions3. Protein denaturation with metal sulfide formation

4. Precipitation of anionic dietary chromogens.


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O l l i


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Oral mucosal erosionappears to be anidiosyncratic reaction

and concentrationdependent.

Dilution of the 0.2%formulation to 0.1%,but rinsing with thewhole volume tomaintain dose, usuallyalleviates theproblem.

Erosions are rarelyseen with 0.12% rinseproducts used at 15 mlvolume.


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Unilateral or bilateralparotid swelling

This is an extremely rareoccurrence and anexplanation is notavailable


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Taste perturbation where the salt taste appears to bepreferentially affected (Lang et al. 1988) to leave foodand drinks with a rather bland taste.

Chlorhexidine also has a bitter taste, which is difficultto mask completely

Enhanced supragingival calculus formation.


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This effect may be due to the precipitation of salivaryproteins on to the tooth surface, thereby increasingpellicle thickness and/or precipitation of inorganic

salts on to the pellicle layer.

Certainly pellicle forming under the influence ofchlorhexidine shows an early and highly calcifiedstructure (Leach 1977).


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Mechanism of action

Chlorhexidine is a potent antibacterial substance butthis alone does not explain its antiplaque action.

The antiseptic binds strongly to bacterial cellmembranes.

At low concentration this results in increasedpermeability with leakage of intracellular componentsincluding potassium (Hugo & Longworth 1964,1965).


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At high concentration, chlorhexidine causesprecipitation of bacterial cytoplasm and cell death

(Hugo & Longworth 1966).

In the mouth chlorhexidine readily adsorbs to surfacesincluding pellicle-coated teeth.

Once adsorbed chlorhexidine shows a persistentbacteriostatic action lasting in excess of 12 hours(Schiott et al. 1970).


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A more recent study and review suggested that plaqueinhibition is derived only from the chlorhexidine

adsorbed to the tooth surface (Jenkins et al. 1988).

It is possible that the molecule attaches to pellicle byone cation leaving the other free to interact withbacteria attempting to colonize the tooth surface.

It would also explain why anionic substances such assodium lauryl sulfate based toothpastes reduce theplaque inhibition of chlorhexidine if used shortly after

rinses with the antiseptic (Barkvoll et al. 1989).


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A more recent study has demonstrated that plaqueinhibition by chlorhexidine mouthrinses is reduced iftoothpaste is used immediately before or immediatelyafter the rinse (Owens et al. 1997).

Plaque inhibition by chlorhexidine mouthrinses

appears to be dose related (Cancro et al. 1973, 1974,Jenkins et al. 1994).


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Chlorhexidine products

Mouthrinses:

0.2%

0.1%

0.12%

Gel:1% chlorhexidine gel

0.2%, 0.12% are also available

Sprays:


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Sprays:

0.1% and 0.2%

chlorhexidine sprays

Varnishes:

Toothpaste:More recently, a 1%chlorhexidine toothpaste withand without fluoride was

found to be superior to thecontrol product for theprevention of plaque andgingivitis in a 6-month home

use study(Yates et al. 1993).


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CLINICAL USES OF CHLORHEXIDINE

As an adjunct to oral hygiene andprofessional prophylaxis

Postoral surgery including periodontal

surgery or root planing

For patients with jaw fixation

For oral hygiene and gingival healthbenefits in the mentally and physicallyhandicapped


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Medically compromised individuals predisposed tooral infections

High-risk caries patients

Recurrent oral ulceration, Subgingival irrigation

Removal and fixed orthodontic appliance wearers

In denture stomatitis

Immediate preoperative chlorhexidine rinsing and

irrigation


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conclusion

The concept of chemical plaque control may bejustified as a means of overcoming inadequacies ofmechanical cleaning.

Chemical plaque control can augment mechanicalplaque control procedures.

The use of chemical agents should be as adjuncts andnot replacements for the more conventional andaccepted effective mechanical methods.


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References

Lindhe ; Clinical periodontology and implantdentistry; 4th and 5th edition.

Carranza; Clinical periodontology; 9th and 10th edition.

Antimicrobial mouthrinses: overview and update;MandelD; J Am Dent Assoc. 1994 Aug;125 Suppl 2:2S-10S.

Cytotoxicity of Mouthrinses on Epithelial Cells byMicronucleus Test; Ebru Olgun Erdemira, DDS, PhD.

In-vitro evidence for efficacy of antimicrobialmouthrinses;Pauline C. Pana,*; J Dent. 2010 June ;

38(Suppl 1):


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0.2% Chlorhexidine Mouthwash With anAntidiscoloration System Versus 0.2% Chlorhexidine

Mouthwash: A Prospective Clinical ComparativeStudy; Carols Sols,*; J Periodontol 2011;82: 80-85.

Modern supragingival plaque control; Iacono VJ; IntDent J. 1998 Jun;48(3 Suppl 1):290-7.

New agents in the chemical control of plaque andgingivitis: reaction paper; O'Mullane D; J DentRes.1992 Jul;71(7):1455-6.

Clinical and microbiological benefits of strictsupragingival plaque control as part of the active phaseof periodontal therapy; Magda FERES; J ClinPeriodontol. 2009 October ; 36(10): 857867.


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Chemical agents to prevent and regulate plaque

development; DANIELH . FINE; Periodontology 2000,Vol. 8, 1995, 87-107.

Current patterns of oral hygiene product use andpractices; BASHARB AKDASH;Periodontology 2000.Vol. 8, 1995, 11-1 4.

O.O. AKANDE, A.R.A. ALADA; EFFICACY OFDIFFERENT BRANDS OF MOUTH RINSES ON ORAL

BACTERIAL LOAD COUNT IN HEALTHY ADULTS;African Journal of Biomedical Research, Vol. 7 (2004);125 128.


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