Download MDA_April_2016

Durinda Mattana, RDH, BSDH, MS
Erin Relich, RDH, BSDH, MSA
Fluoride and Antimicrobials for the RDH
Co-Sponsored by
For details about this life changing event go to:
www.smilemichigan.com/foundation/MissionofMercy.aspx
Register to volunteer at:
www.rsvpbook.com/MDAMOM16
Thursday, June 9:
Friday, June 10:
Saturday, June 11:
Sunday, June 12:
Set Up
Treatment Day
Treatment Day
Tear Down
Main Course Objectives
• Choose appropriate professional and OTC fluoride
therapies based on patients’ caries risk assessment.
• Compare and contrast various fluoride home
products (OTC and Rx).
• Design a fluoride prevention plan for an individual
patient.
• Be familiar with scientific evidence regarding
antimicrobial agents and oral irrigation.
Agenda
• Introduction
– Oral Health Trends/Levels of Prevention
– Evidence-based Care/ Evaluation of Oral Health Products
• Chemical Interventions
– Systemic and Topical Fluorides
– Antimicrobial Rinses/Irrigation
• Patient Cases
Oral Health in America
• Last 50 years = dramatic improvements
• Most Americans expect to keep their teeth for a lifetime
• Disparities exist that affect those with lack of
knowledge/resources, lower SES, and members of
racial/ethnic groups
• Only 60% baby boomers have dental insurance
• Living in a community w/o Fluoride exacerbates oral health
problems
Preventive Interventions:
Fluoride (F) and Sealants (S)
• F Water
– $40 billion saved in reduced OH costs last 40 years
• F more effective on smooth surfaces than on
pits/fissures
• 71% caries can be avoided by use of S (Linders et al,
1993)
Source:
http://drc.hhs.gov/report/2_0.HTM
Dental Caries
• Poverty, certain racial/ethnic groups, & lower education are
associated with decay
• Untreated Dental Decay (2011-2012)
– 5-19 years 17.5%
– 20-44 years 27.4%
• Source: http://www.cdc.gov/nchs/fastats/dental.htm
*Untreated primary tooth decay has risen from 24% to 28%
Source: Trends in Oral Health Status: United States 1988-1994 and 1999-2004
Dental Visits Past Year
• Consistently associated with higher education, higher
income, non-minority status, dental ins. coverage
• During 2013
– Age 2-17 (83.0%)
– Age 18-64 (61.7%)
– Over age 65 (60.6%)
Source: http://www.cdc.gov/nchs/fastats/dental.htm
Tobacco Use
• Strongly linked to oral and pharyngeal cancers/perio diseases
• 90% of oral cancer deaths are linked to tobacco use
• Adults (2013)
– 17.8% smoke cigarettes
• 1 out of 3 cancer deaths related to smoking
• Smoker dies on average 10 years before non-smoker
• Junior/high school students (2011-2014)
– ↓ in cigarette smoking
– ↑ e-cigarettes/hookahs
Source: http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm
Preventive Dentistry
• Safe and effective
measures exist to prevent
2 most common oral
diseases
• Disparities exist
Levels of Preventive Dentistry
Prevent
Primary
Arrest
Deep Scaling
Restoration
Secondary
Periodontal Surgery
Endodontics
Exodontics
Tertiary
Prosthodontics
Interventions
• Steps or measures designed to halt or
significantly alter the current course of an
event (Haynes)
• Chemical, Mechanical and Behavioral
Mechanical
Chemical
Behavioral
Patient Compliance vs. Adherence
• The extent to which a person’s behavior
coincides with medical or health advise
• Knowledge does not equal behavioral change
• Only 10-21% of the population flosses
regularly
Ways to Increase Compliance
•
•
•
•
Set goals with the patient
Attainable and measurable goals
Establish a rapport
Utilize Principles of Adult Learning
– Adults want to solve problems
– Adults don’t want to waste their time
– More???
Stages of Change Model (SCM)
Dev. By James Prochaska and Carlo DiClemente
•
•
•
•
•
•
Precontemplation – denial or unaware
Contemplation – considers change
Preparation – getting ready; experiment w/small changes
Action – making a change
Maintenance – maintain new behavior over time
Relapse – normal process of change
Most people find themselves "recycling" through the stages of change several
times ("relapsing") before the change becomes truly established.
Successful Prevention
• Interventions are:
– Customized to the individual
– Based on preventive needs/wants
– Help shift or keep patient in low-risk category for
specific oral diseases
Evidence-Based Care
What is evidence-based practice?
• National priority in healthcare
– To improve quality, effectiveness and appropriateness
of tx protocols
• Use of current best evidence to aid in
patient care decisions
• Does not replace clinical skills, judgment,
or experience
• Provides another dimension to decisionmaking process
Source:
http://www.usc.edu/hsc/dental/dhnet/onl
ine/ebp.html
Evidence-Based Dentistry
• Best available scientific evidence
• Clinical skill/judgment
• Patient’s needs and preferences
Levels of Evidence
http://ebd.ada.org
Systematic Reviews
ebd.ada.org
Scientific Studies
• PubMed
– National Library of Medicine’s interface to search
MedLine
– Over 14 million citations for dental and biomedical
sciences
– Can print abstract only
– Articles can be printed if subscribed to a database
pubmed.gov
Professional Website
Professional Website
EBD – Practical Considerations
• Type of evidence integrated into practice
should come from sound scientific studies
• Levels of evidence exist (weak to strong)
• Gaps between knowledge and practice exist
• The internet is the main means by which
scientific method is disseminated
Source: http://www.usc.edu/hsc/dental/dhnet/online/e
Oral Health Product
Regulation and Evaluation
•
•
•
•
Federal Trade Commission (FTC)
Food and Drug Administration (FDA)
American Dental Association (ADA)
Canadian Dental Association (CDA)
Sources of Product Information
• Scientific Articles/Studies
– Refereed scientific journals
•
•
•
•
•
Continuing Education courses
Textbooks (not most recent info)
Manufacturer’s Information
Product Labels
Colleagues (experience)
Topical and Systemic
Fluoride Therapies
Fluoride
“Without question the most effective
measures for prevention and control of
dental caries at the present time involve
the use of fluoride in a variety of manners.”
Source: Stookey, G, Caries Prevention, JADA, 1998
Fluoride
• Systemic Nutrient
– Foods
– Water
– Dietary Supplements
– Dentifrices
– Mouthrinses
– Fluoride Products (OTC and Rx)
Fluoride Safety
• Wide margins of safety exist
• Must know: recommended and approved
procedures, potential for toxic effect, be
prepared to administer emergency
measures
Toxicity
• Acute
– Rapid intake of excess dose over short time
• Chronic
– Long-term ingestion of excess amount of
therapeutic level
– Accidental ingestion
– Acute F poisoning is rare
Dental Fluorosis
Chronic Fluoride Toxicity
• Can only occur during tooth
development (long-term
ingestion)
• A form of
hypomineralization,
ameloblasts are sensitive to
F and lay down an irregular
matrix
• Irregularity in the crystal
pattern leads to altered
light reflectance (chalky
area)
Fluorides
• Pre-eruptive
fluoride made available to teeth by way of blood plasma to developing
teeth
• Post-eruptive
fluoride made available directly to the exposed surface of
erupting/erupted teeth
Concentrations of Home Fluoride Products
Product
Fluoride
Concentration
Toxic dose for
22lb/10kg toddler
is
5 mg F ion/kg
bodyweight
Lethal Dose for
22lb/10kg toddler
is
50 mg F ion/kg
bodyweight
Dentifrice
1000 ppm
1.8 oz.
17 oz.
0.05% NaF rinse
230 ppm
0.5 pts.
4.5 pts. (2.2 liters)
905 ppm
2.0 oz.
1.2 pts. (550 ml)
(daily)
0.2% NaF rinse
(daily or weekly)
Author: Michael Gleason, DDS, PhD, UDM School of Dentistry. Department of Biomedical Sciences (modified slightly by
D. Mattana, Feb, 2012)
Fluoride Management
• F products have approval from the FDA and the ADA
• Use only researched amounts and delivery methods
• Instruct patients in proper use of F products
– No more that 264 mg NaF dispensed at one time
– Parental supervision
– Keep out of reach of small children
Pre-eruptive F exposure
• F becomes incorporated into the apatite crystal, reduces
the solubility of enamel on acid exposure
• Greatest effect on pit and fissure caries
• Less effect on proximal surfaces
• Continued post-eruptive fluorides are necessary to
maintain the advantage of systemic F exposure
Post-eruptive Fluoride Exposure
• Topical source throughout life
• Uptake to enamel is rapid first two years after
eruption
Greatest benefit occurs with pre-eruptive and
post-eruptive exposure
Topical Fluoride Action
• Enhances
remineralization of
incipient lesions*
• Inhibits demineralization
• Inhibits bacterial
metabolism
*most significant affect
Topical Fluoride Action
• Enhances remineralization of
incipient lesions
– Demin. occurs in the subsurface
layer
– Demin. enamel has a greater
uptake of F
– White spots will hypermineralize
and harden (harder than
surrounding enamel)
– Forms fluorapatite
Role of Fluoride
• Enhances remineralization
– low concentration, high frequency
Best to have several times per day.
Dentifrice and Fluoridated H2O
• Pre-eruptive and post-eruptive benefit
• Recommend for all patients
Fluoride Sources
•
•
•
•
•
Water
Supplementation
Dentifrices
Professional (including varnish)
Home care gels and rinses
Water Fluoridation
*Adjustment of the natural fluoride
concentration of fluoride deficient water
supplies to the recommended level for
optimum health
Population-based method of primary
prevention
*Definition according to the ADA
Original Studies, 1945
• Research City
– Grand Rapids, MI
– Newburgh, NY
– Brantford, Ontario
• Control City
– Muskegon, MI
– Kingston, NY
– Sarnia, Ontario
Water Fluoridation
• Max. caries reduction with minimum fluorosis
• Most efficient, effective, reliable, and inexpensive means
for improving oral health
• Greatest reduction in caries if fluoride is ingested from 6
months of age
• One of the top 10 public health measures
of the 20th century
Fluoridation Today
• Estimated reduction in caries due to
water F alone (factoring out other sources of
topical fluoride) among adults of all ages is
27%.
Source: Griffin SO. Regnier E. Griffin PM. Huntley VN. Effectiveness of fluoride in preventing
caries in adults. J Dent Res. 2007 May;86(5):410-5.
F in H2O and Root Caries
• Life-long residents in a
community with
optimum F experience
a decline in incidence
of root caries
compared with non-F
community.
Water Fluoridation
• Agents used: sodium fluoride, sodium fluorosilicate,
and fluorosilicic acid (powder form)
• No links between low level fluoride and Cancer,
Kidney disease, GI disturbances, Reproductive
Effects, Immunological disorders, Genetic disorders,
or Bone fractures (1993 National Research Council)
Final Fluoridation Recommendations, 2015
USPHS
■ Updated recommendations for optimal concentration
of water F to a single number, 0.7 ppm for all
communities, rather than the range.
■ Americans have access to many more sources of F
today than when water F was first introduced in the
U.S.
■ Still provides effective level of F to reduce incidence
of dental caries while minimizing the rate of fluorosis.
Optimally Fluoridated Communities
In 2012, 74.6% U.S.
population on public
water systems had
access to F tap water
(Goal for Healthy People 2020 is
79.6%)
In 2012, 67.1% U.S.
population had access
to F water
http://www.cdc.gov/fluoridation/statistics/2012stats.htm
Fluoridated Water in MI
• 90.2% MI population
– Ranked #12 in country (tied for this)
– Kentucky #1 with 99.9%
– New Jersey 14.6%
Source: http://www.cdc.gov/fluoridation/statistics/2012stats.htm
•
•
•
•
Optimal level: 0.7 ppm
Detroit since 1967
Requires no conscious effort
Cost effective
How do you find out about fluoride
levels in water?
• For public water systems: Obtain the
Consumer Confidence Report from the
local water utility.
• “My Water’s Fluoride”
http//apps.nccd.cdc.gov/MWF/Index.asp
How do you find out about fluoride
levels in water?
• About 14% of US residents use
private wells not regulated by the EPA
Safe Drinking Water Act. EPA
suggests all wells be tested for quality
once every 3 years.
Well Water Testing
• Michigan Drinking Water Analysis
Laboratory (517) 335-8184
• FluoriCheck™ Water Analysis Service
from 3M ESPE Omni Preventive Care $14
Bottled Water
• Few have optimal F
levels
• <0.3 ppm in 34 of 39
products tested
• F not regulated in bottled
water
• Patients must be made
aware that they are not
getting fluoride from
bottled water
Effects of H2O Filtration Systems
• Many types exist
• End-of-faucet and pour through pitchers may reduce
the amount of F
• Check with the manufacturer and/or have filtrated
water analyzed
• Reverse osmosis and distillation units remove
significant amounts of F
– Water softeners do not
Source: ADA Fluoridation Facts
Fluoride in Beverages
• “Halo Effect”
• F water used in
bottling juices from
concentrate
• Grape juice
consistently high
• 42% > 1 ppm F
Infant Formula Update
(Jan. 2011)
• Breast milk contains 0.02 ppm F and all types of infant formula
themselves contain a low amount of fluoride (0.11 – 0.57 ppm).
• Infant formula remains a major source of nutrition for many infants.
• Powdered and liquid concentrate formulas are a potential risk factor for
enamel fluorosis (not ready-to-feed).
• The level of fluoride in the water supply used to reconstitute powdered
or liquid concentrate formula determines the total fluoride intake.
Source: Berg J, et al. JADA, 2011.
Formula and Fluoride Content
http://ebd.ada.org/ClinicalRecommendations
Infant Formula Update Cont.
(Jan. 2011)
• ADA recommends continuing to use optimally fluoridated water to
reconstitute infant formula while being aware of the possible risk of
enamel fluorosis in primary teeth.
• Concerned parents should use ready-to-feed formula or reconstitute
powder or liquid concentrate with fluoride-free water (distilled, deionized, purified, demineralized, or produced through reverse-osmosis).
Source: Berg J, et al. JADA, 2011.
Anti-fluoridationists
•
•
•
•
Forced medication
Toxic
No benefit for adults
Carcinogen
Fluorosis
• Most susceptible age: 18-36
months
• Most critical stage:
22-26 months
• By age 6 years (no cosmetically
objectionable fluorosis)
• Corresponds to maturation
patterns
Prevalence of Fluorosis
• Majority in U.S. is very mild
to mild and not considered
an esthetic problem
• Age 12-15 years (comparison from
1986-7 to 1999-2004)
– Very mild = 8.6% (from 4.1%)
– Mild = 28.5% (from 17.2%)
– Moderate & Severe = 3.6%
(from 1.3%)
Source: Prevalence and Severity of Dental Fluorosis in the United States, 1999–
2004, Eugenio D. Beltrán-Aguilar, D.M.D., M.S., Dr.P.H.; Laurie Barker, M.S.P.H.;
and Bruce A. Dye, D.D.S., M.P.H.
Moderate to Severe Fluorosis
1.3% of U.S. Population in 1986-87 to 3.6% in
1999-2004 (Severe = 0.3% in 1986-87)
Among ages 6-49 years >1% = severe
Sources of Fluorides
•
•
•
•
•
Water
Supplementation
Dentifrices
Professional (including varnish)
Home care gels and rinses
Supplementation Update 2010
• ADA Clinical Recommendations (Dec. 2010)
limit the use of fluoride supplements for
children:
– high risk of developing dental caries
– Age 6 months to 16 years only
– primary source of drinking water is deficient in fluoride
Source:
http://jada.ada.org/cgi/content/full/141/12/1480
Rx Dietary Fluoride Supplements
Evidence-Based Recommendations
http://ebd.ada.org/ClinicalRecommendations
Rx Dietary Fluoride Supplements
Evidence-Based Recommendations
http://ebd.ada.org/ClinicalRecommendations
Types of Supplements
• Chewable Tablets
• Drops
• Lozenges
Best to have topical exposure for erupted teeth as well as
systemic benefit.
Safety
• No more than 264 mg.
NaF (120 mg. F) Rx at
once
• Max permitted in one
container
Prenatal Fluoride
• Placenta does NOT act as barrier
as once believed
• No conclusive evidence to show
benefit to primary teeth
• Permanent teeth calcify AFTER
birth
• NOT recommended by ADA
Fluoride Sources
•
•
•
•
•
Water
Supplementation
Dentifrices
Professional (including varnish)
Home care gels and rinses
F in Dentifrices
•
•
•
•
Most in US contain ~1,100 ppm F
No need to change behavior
Daily use enhances remineralization
ADA acceptance
Fluoride Dentifrice
• Brushing with F
toothpaste raises
salivary F levels for a
few hours
• After brushing, F
accumulates in the
residual plaque and soft
tissue surfaces
Types of Fluoride in Dentifrices
• NaF
– directly provides free fluoride
– not in toothpastes containing Ca based abrasives
– in vitro studies show better F uptake than MFP
• MFP
– releases free F when it hydrolyzes on exposure to
phosphate
– in vivo studies show no difference in F uptake or small
advantage for NaF
• SnF
-antimicrobial properties
F in Dentifrices
• 2-3 yr olds swallow 6065% dentifrice
• Use of excessive
amount may be
greatest fluorosis risk
factor
• Touch of toothpaste
Recommended Amount of
Fluoridated Dentifrice
• “Smear” of toothpaste from eruption of first
tooth until 3 years of age (grain of rice)
• “Pea size” for those 3-6 years of age
• Adults use a “ribbon”
•Source: American Dental Association Council of Scientific Affairs. Toothpaste use in young children, JADA
2014;145(2):190-191.
Fluoride Dentifrices
• 17-41% reduction in caries with daily use (F
retained in plaque, soft tissue, enamel and dentin)
• Weak evidence to associate early use of F
toothpaste (before 12 months) with fluorosis (Wong, M.C. et
al, Topical fluoride as a cause of fluorosis in children, 2010)
Concentration of F in Dentifrices
• Caries preventive effects of F
toothpaste increase significantly with
increased F concentrations
– 550 ppm and below showed no statistically
significant effect compared to placebo
– 1,000 ppm and above showed significant
caries reduction
Source: Systematic Review by Walsh, T. et al, 2010
Method of Rinsing
• 3 year clinical study (Chesters
et al – 1992)
• Rinsing in a manner that
removed the least amount of F
resulted in 16% less decay
• Better to rinse with wet TB,
water cupped in hand or from
tap (rather than w/glass of
water)
Frequency of Brushing
• Chesters et al (1992)
– children who brushed
2x/day with F
toothpaste had 22%
less decay than
children who brushed
less often
Fluoride Sources
•
•
•
•
•
Water
Supplementation
Dentifrices
Professional (including varnish)
Home care gels and rinses
In-Office Fluoride
• Promotes remineralization
• Prevents caries initiation
• Replenishes F rich outer layer
• Recommendations from: Professionally-
Applied or Prescription-Strength
Home-Use Topical F Agents, Weyant
RJ et al. JADA, 2013.
http://jada.ada.org/cgi/content/full/137/8/
1151
ADA Clinical Recommendations, 2013
Topical Fluoride for Caries Prevention
• Professionally-Applied and Rx Strength
• Employs caries risk assessment
• Breaks down recommendations into age
groups
– < 6 years old
– 6-18 years old
– 18+ years old
Source: http://ebd.ada.org
Factors that may increase caries risk
(partial list)
•
•
•
•
•
•
•
•
High titers of cariogenic bacteria
Poor OH
Prolonged nursing
Acquired enamel defects
Restoration overhangs
Physical or mental disability
Irregular dental care
Active orthodontic treatment
Professionally-Applied Recommendations
Risk Category
<6 years
6-18 years
18+ years
Non-elevated Risk
May not receive
additional benefit
May not receive
additional benefit
May not receive
additional benefit
Elevated Risk
5% NaF Varnish
@ 3-6 month
intervals
5% NaF Varnish or
1.23 % APF Gel
@ 3-6 month
intervals
5% NaF Varnish or
1.23 % APF Gel
@ 3-6 month
intervals
Source: Weyant, RJ. et al. JADA 2013
Comparison of In-Office F
Gels/Foams
type
strength
pH
uptake
1.23% APF
12,300 ppm
2.0% NaF
9,050 ppm
3.5
rapid
7.0
slow
4 minute gel or foam application
with trays
Gel vs. Foam
Thixotropic Gel
– Heavy, thick
– 50.0 mg per full mouth
treatment
– flowability and
interproximal/occlusal
penetration
Foam
– Light, airy
– 12.5 mg per full mouth
treatment (3/4 less)
– Excellent interproximal
and occlusal penetration
– patient acceptance
Fluoride Foam
• Laboratory data demonstrates foam’s
equivalence to gel in F release
• Only a couple of clinical trials evaluating
its effectiveness
• ADA Report recommends gel or varnish
(does not extrapolate recommendations to
foam)
Professional Tray Application
• Not for children under
age 6
• Prophylaxis not
needed
• Air-dry teeth
• Correct amount of F
• Monitor
• Expectorate
• Avoid rinsing 30
minutes
Fill Trays with Fluoride
• Gel (40% for adults full)
• Foam (full, but NOT
overfilled)
Fluoride Varnishes
• FDA approval as a device
(desensitizing agent or cavity
liners)
• Many products available in U.S.
• Duraphat, Durafluor, Fluor
Protector, Cavity Shield, Vanish
• Viscous gel containing 5% NaF
(2.26% F) in a resin carrier
F Varnish Advantages
Over Gel
• Better patient acceptance
• Less time (I min. vs. 4 min.)
• Safety (less swallowed)
• Less discomfort
F Varnish Studies
• Studies in primary teeth show that FV can arrest active P
& F caries in primary teeth (Autio-Gold, 2001)
• Remineralizes when around enamel lesions (Castellano
et al, 2004)
• Reduces demin. & white areas around ortho brackets
(Demito, 2004)
• F application of choice for desensitization
• ECC Prevention (Weintraub et al, 2005)
Fluoride Varnish Products
• Many available in U.S.
• Viscous gel containing 5% NaF (2.26% F) in
a resin carrier
F Varnish
• 5% Sodium Fluoride Varnish contains 22,600
ppm fluoride
• 1 ml of this suspension contains 50 mg sodium
fluoride, equivalent to 22.6 mg fluoride ion, in
an alcohol-based solution of modified rosins
or natural resins, sometimes sweetened with
Xylitol (Vanish by OMNI)
Dosage Guidelines – Unit doses are 0.50 mg
• 0.25 mg dose (1/2 unit dose)
– Primary dentition only
– Any patient requiring limited tooth surface coverage
• 0.40 mg dose (close to a full unit dose)
– Mixed dentition; Do not use this amount for primary
dentition only
• 0.50 mg dose (full unit dose)
– Only for patients with permanent dentition that require full
coverage
F Varnish Application
•
Wipe plaque
•
0.25, 0.40, or 0.50 dosages
•
Apply thin layer w/brush (all
surfaces of all teeth)
•
No hard foods, drinking hot or
alcoholic beverages, brushing or
flossing for several hours
•
Inform of temporary yellow stain
unless clear product is used
•
Remove with toothbrush following
day
Vanish™ XT Extended Contact
Fluoride Varnish
• Site specific for
enamel and dentin
• Light-cured glass
ionomer
• Two-part
liquid/paste system
• Clicker™ Dispensing
System
F Varnish Safety
• Eventually swallowed, dissolved from the teeth
• For a child,
– 30 mg F used with 1.23% APF gel application
(10 mg usually ingested)
– 7 mg F used with a NaF varnish application
• Gel swallowed in a short period of time
• Varnish swallowed over several hour
• No contraindications for use during pregnancy
F Varnish
• Off-label use
• Clinical evidence of safety and effectiveness
• 1998, 1/2 Rx written off-label
F Varnish Indications
• Young children
• Those unable to
cooperate with tray
application
• Early Childhood Caries
F Varnish Indications cont.
• Root Caries
• Orthodontic Patients
• Uncooperative Patients
Amorphous Calcium Phosphate (ACP)
Products
• Increasingly popular adjunct
• Addresses dentin sensitivity and dental caries
• Various product types
– Prophy paste
– Fluoride varnish
– Toothpaste
– Chewing gum
Amorphous Calcium Phosphate (ACP)
• Evolving technology
• Water-based cream
• Binds to biofilm, soft tissue to deliver calcium
and phosphate to the tooth during acid
challenge
• Used after brushing with fluoride
• One product (MI Paste) contains casein
ACP Technologies
• Recaldent®
– Casein phosphopeptide & ACP
– MI Paste (GC America), Trident Gum
• SeniStat®
– Arginine bicarbonate
– Proclude® and Denclude ® (Ortek)
• NovaMin®
– Synthetic material of calcium, sodium, phosphorus & silica that
contains Ca and PO
– SootheRx ® (3M Espe), Butler NuCare Root Conditioner (Butler)
Varnish with ACP
• No clinical data of increased effectiveness over
F alone when ACP, tricalcium phosphate or
calcium sodium phosphosilicate are added to
F varnish
Source: Rethman et al, Nonfluoride caries preventive agents: A systematic review and evidence-based
recommendations. JADA, 2011
Varnish with ACP
• Lacking “clinical data” of increased
effectiveness over F alone when ACP,
tricalcium phosphate or calcium sodium
phosphosilicate are added to F varnish
Varnish with ACP Studies
•
•
•
•
All effective due to high F content
Claim is greater F uptake
TCP vs. ACP (Schemehorn BR. J Clin Dent, 2011)
CPP, TCP, ACP, CaF, & no added calcium
(Shen P et al. Aust Dent J, 2014)
• Clinically significant?
Comparison of 2 Varnishes
•
•
•
•
•
•
Duraflor™ and Enamel ProR ® Varnish (with ACP)
Demin. around ortho brackets
Invitro study of 72 premolars
No statistically significant difference
Both inhibited demin due to high F concentration
Authors suggest that higher affinity of ACP to F
makes it capable of releasing 4x the amount of F
than conventional varnishes
Source: Nalbantgil et al. European Journal of Dentistry, 2013.
F Varnish Reimbursement
• CDT- 2014 code
• D1206: Topical application of fluoride
varnish on a single visit involving the
entire oral cavity (no need for prophylaxis)
• D1208: Topical application of fluoride
Benefits are defined under the subscriber contract.
Silver Diamine Fluoride (SDF)
•
•
•
•
•
•
•
FDA cleared product (2015)
Class II medical device
38% SDF
Management of dentin hypersensitivity
Professionally-applied
Off-Label use for caries arrest and prevention
Caries Arrest CDT Code: D1354
SDF
• Topical medicament (1 drop per quadrant)
• Used in other countries for decades
• Used to “arrest dental caries” in young
children where there is a shortage of
dentists
Source: Chu, Lo, Oral Health Prev Dent, 2008
Source: Rosenblatt Stamford, Neiderman, J Dent Research, 2009
Figure 1. Clinical photographs prior to and following application of
silver diamine fluoride. (A) Clinical photographs of interproximal
caries lesions in maxillary incisors of a 5-year-old girl. (B) Clinical
photograph of brown staining following a 60-second application of
Cariestop® 12% silver diamine fluoride. Note that only the caries
lesion, not the tooth, is stained.
SDF vs. Fluoride Varnish (FV)
Systematic Review to determine, “Will SDF more
effectively prevent dental caries than FV?”
• SDFs lowest prevented fraction for caries
arrest (96.1%) and prevention (70.3%)
• FV lowest prevented fraction for caries arrest
(21.3%) and prevention (55.7%)
Source: Rosenblatt Stamford, Neiderman, J Dent Research, 2009
SDF Mechanism of Action
• Treats sensitivity & arrests dental caries
• Creates squamous layer on exposed dentin, partially plugging
dentinal tubules
• Kills cariogenic bacteria in dentinal tubules
• F promotes remineralization/silver antimicrobial
• “Zombie Effect”
Source: Horst, Ellinikiotis, Milgrom, J Calif Dent Assoc, 2016
SDF Indications - UCSF
1. Extreme caries risk (oral cancer, ECC)
2. Tx challenged by behavior/medical management
3. Multiple carious lesions that cannot be treated
all at once (stabilize patient)
4. Difficult to tx carious lesions
5. No Access to Care
Source: Horst, Ellinikiotis, Milgrom, J Calif Dent Assoc, 2016
SDF Procedure - UCSF
•
•
•
•
•
Plastic lining for counter (stains)
Petroleum jelly on lips and gingiva (tatoo)
Isolate tongue and cheek with gauze/cotton rolls
Dry lesion
Bend microsponge, immerse in SDF, remove excess
on side of dappen dish
• Apply and allow to lesion to absorb 1-3 min.; may reapply
• Rinse with water
Key factor is repeat application over many years.
Source: Horst, Ellinikiotis, Milgrom, J Calif Dent Assoc, 2016
SDF Contraindications
• Allery to silver
• Pregnancy
• Breast Feeding
Read article: Horst, Ellinikiotis, Milgrom, J Calif
Dent Assoc, 2016
Fluoride Sources
•
•
•
•
•
Water
Supplementation
Dentifrices
Professional (including varnish)
Home care gels and rinses
Topical F Self Care Indications
• Adults and adolescents at moderate or high
risk for caries
• H & N irradiation
• Sjogren’s syndrome
• Orthodontic patients
• Patients with xerostomia
Topical F - Self Care
APF
NaF
SnF
Gels
1.1%
1,000 ppm
1.1% 5,000 ppm
0.4%
1,000 ppm
Rinses
(NeutraCare,
(TheraFluor Prevident)
Phos-Flur)
0.044%
0.2% 900 ppm
NaF and
(Fluorinse)
APF
440 ppm
0.05% 230 ppm
PhosFlur
(Act)
Dentifrices NA
Rx Strength
(Stop, Take
Home, GelKam)
0.1% 250 ppm
(PerioRinse)
0.63 Stannous
0.02% 90 ppm
(Listerine Smart
Rinse)
0.22-0.24%
0.45%
1,000 – 1,500 ppm 1,000 ppm
Topical F - Gels
0.4% SnF
1.1% NaF
1,000 ppm
5,000 ppm
3.5 pH
7.0 pH (neutral)
Reduces caries,
Evidence Anti-cariogenic,
desensitizing, some promotes
data on anti-plaque remineralization
properties
Application Daily brush applied after dentifrice
w/o rinse or custom trays
method
Adverse
effects
Extrinisic stain; Not Not for < age 6
for < age 6
Gel or Paste Products
• 0.04% SnF
• 1.1% NaF
Topical F Gel Indications
Patient
Selection
0.4 % SnF
1.1% NaF
1,000 ppm
5,000 ppm
OTC
Rx
 Caries
control and
plaque control
of primary
concern
 Esthetic
restorations
(porcelain,
resin, glass
ionomer)
 Titanium
implants
 Dentinal
 Root caries
hypersensitivity  Reduced
salivary flow
1.1% NaF (5000 ppm)
Colgate® Prevident® Gels and Pastes
1) 5000 Brush-on Gel (original gel in tray or brush-on 1x/day)
2) 5000 Plus (original toothpaste)
3) *5000 Booster Plus (tri-calcium phosphate)
4) *5000 Enamel Protect (5% Potassium Nitrate)
5) *5000 Sensitive (5% Potassium Nitrate)
6) *5000 Dry Mouth (SLS-free)
*Liquid Gel for better dispersion
PreviDent®
SLS free
Dispersion
Paste Form
5% KNO3
5% KNO3
0.2% NaF Rinse
Topical Rinses
0.05% NaF (Act)
• 230 ppm
• OTC
• Daily Use
• Not for <6 years
0.2% NaF (Fluorinse,
Prevident)
•
•
•
•
900 ppm
Rx
Daily
Not for <6 years
Prescription-Strength
Recommendations
Risk Category
<6 years
6-18 years
18+ years
Non-elevated Risk
May not receive
additional benefit
May not receive
additional benefit
May not receive
additional benefit
1.1% NaF or APF
Gel or Paste twice
daily OR 0.2%
NaF rinse at least
weekly
1.1% NaF or APF
Gel or Paste twice
daily OR 0.2%
NaF rinse at least
weekly
Elevated Risk
Source: Weyant, RJ. et al. JADA 2013
Topical Fluoride Updated Recommendations
Patient Case
•
•
•
•
Lynn, 24 year-old graduate student
Takes Zyrtec daily for allergic rhinitis
Brushes 2x day with F dentifrice
Presents with one new interproximal
lesion
1. Caries risk?
2. Professional Fluoride?
3. Homecare Fluoride?
Patient Case
•
•
•
•
•
Bill, 82 year-old retired business owner
Lives in non-fluoridated area
Brushes 2x day with F dentifrice
Many restorations; no new lesions today
Generalized gingival recession on posterior
teeth with several exposed root surfaces
1. Caries risk?
2. Professional Fluoride?
3. Homecare Fluoride?
Limited Prescriptive Authority Bill (in MI)
for the Dental Hygienist (HB 5374)
“A Dental Hygienist may prescribe any of the following for a
patient:
A. Any fluoride in the form of a tablet, lozenge, drop, or similar
method of oral dosing.
B. Any topical sodium fluoride or stannous fluoride anti-caries
treatment in the form of a toothpaste, gel, rinse, varnish,
prophy paste, or similar method of application.
C. Any topical or subgingival anti-infective.” (Think Peridex –
not Arestin)
* Taken from the Legislative Service Bureau 03295’15 Draft 4
Topical Antimicrobial
Agents and Irrigation
Antimicrobial Rinses
Discuss agents in terms of products available, mechanism of
action, effectiveness, side/adverse effects:
– Chlorhexidine
– Essential oils
– Sanguinarine (Viadent – not in use much today)
– Quaternary ammonium compounds (CPC)
– Stannous Fluoride (SnF)
– Oxygenating agents (Hydrogen Peroxide)
– Sodium Benzoate & sodium lauryl sulfate (detergents)
– Triclosan (Colgate – controversial)
– Chlorine Dioxide/Zinc chloride
Rationale
• Periodontal disease and dental caries are
bacterial infections (biofilm is the basic etiologic agent)
• Mechanical measures are difficult for patients
Mechanical Therapies and
Plaque Control
Prevention remains the
primary method used to
arrest or prevent dental
diseases and maintain oral
health
Mechanical Interventions
• Sc/Rp gold standard for the treatment of
periodontal diseases
• TB and interdental cleansing are effective in
reversing gingivitis
General Indications for Adjunctive Use of
Antimicrobial Interventions
• Patients unable or unwilling to perform
adequate OH procedures
• Impaired manual dexterity
• Systemically compromised
• Have just undergone oral/perio surgery
Topical Antimicrobial Delivery
Methods Used by the Patient
• Rx rinses
• OTC rinses
• Dentifrice
Depth of Delivery
•
•
•
•
Mouthrinsing (>1 mm)
Toothbrushing (1-2 mm)
Flossing (2-3 mm)
Home Irrigation (50-90% depth of the pocket)
– Standard
– Subgingival
Topical Antimicrobial Agents
Studies have NOT documented
effectiveness of topical chemical
plaque control agents in the
treatment of periodontitis
Terms
• Bacteriocidal – capable of destroying bacteria
• Bacteriostatic – inhibits growth and multiplication
of bacteria
• Substantivity – ability of an active agent to be
retained in oral tissues and released over an
extended period of time w/o losing potency
• Inhibitory dosage – lowest possible concentration
to achieve maximum effect
Substantivity
– First generation – agents that have antimicrobial
activity
– Second generation – agents that have
antimicrobial activity and proven substantivity
– Third generation – agents that target specific
bacteria or bacterial products that are essential to
disease development (none available today)
Substantivity
First Generation Second
Generation
Third
Generation
Peroxides,
Phenolic
compunds,
Sanguinarine
Futuristic
Products, none
commercially
available today
CHX, controlled
release agents
Pharmacological Principles
What is the effect on oral flora and
associated disease?
Pharmacological Principles
Is the effect clinically significant?
Pharmacological Principles
Are there adverse effects on oral
flora?
Pharmacological Principles
Does it adversely effect hard/soft
tissue?
Pharmacological Principles
Do usage properties support
compliance?
ADA Seal of Acceptance
•
•
•
•
•
•
•
Council on Scientific Affairs
Voluntary/5 years
All advertising monitored
Consumers look for seal
Demonstrated safety and efficacy
OTC products only!
Three agents have ADA seal for control of
plaque and gingivitis
ADA Seal for Chemotherapeutic
Agents for the Control of Gingivitis
• To make a plaque control benefit MUST
also demonstrate significant effects against
gingivitis
Topical Antimicrobial Agents
•
•
•
•
Chlorhexidine (CHX)
Essential oils (EO)
Sanguinarine
Quaternary
ammonium
compounds (QAC)
– Cetylpyrdinium
(CPC)
• Stannous Fluoride
(SnF)
• Oxygenating Agents
• Sodium benzoate
and sodium lauryl
sulfate (SLS)
• Triclosan
• Chlorine Dioxide
Method of Rinsing
Must be vigorous for the entire
recommended time, avoid water
afterwards.
CHX – Gold Standard
•
•
•
•
•
•
•
•
Chlorhexidine digluconate 0.12%
Bisbiguanide
Cationic (+)
Rx Product
Highly effective agent
PerioGard®/Peridex®
First used in Europe 0.2% (1970s)
FDA approved in 1986 (0.12%)
CHX – Mechanism of Action
• Binds to bacterial cell membranes and
damages the surface
• Increases cell permeability, promotes leakage
CHX – Mechanism of Action
• Ability to bind to soft tissue (30% retained 812 hours)
• Second generation
• Broad spectrum antimicrobial agent (bacteria,
yeasts, viruses)
CHX – Side Effects
•
•
•
•
•
•
Staining*
Increased supragingival calculus*
Altered taste sensation
Reversible desquamation
Transient swelling of salivary glands
Rare hypersensitivity
CHX – Staining
• Two Theories:
– CHX interacts with chromogens in
foods/beverages
– Series of chemical reactions between sugars
and amino acids (maillard or non-enzymatic
browning reaction like apples/potatoes)
Strategies to Reduce CHX Staining
– 3 /4 month recall appt.
– Powered Toothbrush
• 75% reduction over 4 weeks
– Whitening Dentifrice
• Use simultaneously with CHX use
CHX – Published Research
• Effectiveness clearly demonstrated (not for caries)
• Most effective antimicrobial agent
• 45-61% reduction of plaque & 27-67%
reduction in gingivitis
• Anti-candida effect
• Effective against gram+ / gram– /yeast
CHX
•
•
•
•
•
•
11.6% alcohol; pH = 5.5
Alcohol-free formulation
Detectable in saliva 8-12 hours later
Available only by Rx
Both alcohol & alcohol free are FDA approved
Patient Instructions: 2x/daily 30 second rinsing
with ½ ounce
• Wait 30 minutes between use of CHX and
dentifrice
Chlorhexidine Rinses - Uses
• Gingivitis (problems with long-term use)
• Candida Infections (dentures)
• Used in tx. of apthous ulcers/stomatitis, NUG &
HIV/AIDS oral care
• Pre-Procedural
– SBE, implant, and oral surgery patients
• Post –Operative (oral/perio surgery)
– Tongue piercing after-care
Phenolic Related Essential Oils
•
•
•
•
Thymol, menthol, eucalyptol and methyl salicylate
Oldest product (1865 - Lister)
ADA approved
Listerine and over 60 generics
Essential Oil Products
*Both ANTISEPTIC name brand & generics have the ADA seal!
Essential Oils – Mechanism of Action
•
•
•
•
•
Alters bacterial cell wall
Can “extract” LPS
Anti-inflammatory properties
Thymol - principal antibacterial component
Low substantivity (first generation), effectiveness
related to duration of contact
Essential Oils – Side Effects
• Burning
• Bitter taste
• Possible staining
Rare staining
Lower alcohol
content 21.6%
Not the same efficacy
EOMW with and without Alcohol
• Evaluated antiplaque effect of a new alcohol free EOMW with
respect to a control EOMW with alcohol
• 30 volunteers, 3-day period
• Double-blind, randomized, crossover clinical trial
• The EOMW with ethanol shows a better inhibitory effect of
plaque regrowth in 3-days
• The EOMW w/o alcohol seems to have a less inhibiting effect
on the plaque regrowth than the traditional alcoholic solution
Source: Marchetti E et al, Trials, 2011.
Phenolic Essential Oils – Published
Research
•
•
•
•
20 - 56% reduction in supra plaque
25 – 36% reduction gingivitis, Sharma 2004
Anti-candida effect
Most recent studies – Listerine vs. Flossing
Listerine as Effective as Floss?
• Two unsupervised studies (Sharma, 2002 and
Barouth, 2003)
• Purpose: to compare effectiveness of rinsing
with an antimicrobial rinse to flossing in
inhibiting plaque and gingivitis
• All subjects brushed 2x/daily with either
flossing, OR rinsing with EO or placebo
Listerine as Effective as Floss?
• Results showed that 2x/daily rinsing with EO
was “as effective” as flossing once daily on
plaque and gingivitis
• Authors state that Listerine is not a
replacement for flossing
• No added benefit for those that floss regularly
• Judge Chin Ruling in 2005 – Ads for Listerine
were explicitly and implicitly false
Essential Oils (EO)
•
•
•
•
•
•
21.6 – 26.9% alcohol
pH 4.2
30 second rinse 2/3 ounce AM and PM
First generation (low substantivity)
ADA acceptance
Decreases plaque and increases wound
healing 7 days (oral surgery)
EO vs. CHX Systematic Review
• Meta-analysis of long-term studies (>4weeks)
• CHX-MW provided significantly better effects regarding
plaque control, however no significant difference was found
with respect to reduction of gingival inflammation
• Conclusion: Long-term (>4 weeks), EO-MW appears to be a
reliable alternative to CHX-MW with respect to controlling
gingival inflammation
– Consider differences in calculus formation favoring EO-MW and the
lack of difference in gingival bleeding
Source: Van Leeuwen MPC, J Periodontol, 2011.
Quaternary Ammonium Compounds
• Products: Viadent®,
Scope®, Cepacol®, Clear
Choice®, Crest Pro-Health
Rinse®
• 0.045% - 0.07%
cetylpyridinium chloride
(CPC)
QAC – CPC
Mechanism of Action
• Initial attachment is strong (+ ion)
• Released from binding site more rapidly than
CHX
• Increases cell wall permeability
• Decreases cell metabolism
• Decreases ability to attach to tooth
QAC – CPC
Side Effects
•
•
•
•
Slight tooth staining
Burning sensation
Gum irritation
Apthous ulcers
CPC – Published Research
• 24% reduction of gingivitis
• 14% reduction gingivitis
• Placebo and CPC group (no
difference)
• No ADA seal
CPC
• Products vary from alcohol free to 18%
alcohol
• pH 5.5-7.0
• Dentifrice abrasives/flavoring agents
alter activity
• 30 min between rinsing/brushing
• Substantivity in the oral cavity of 3-5
hours.
Mechanism of action
1. Positively charged CPC interacts
with negatively charged bacteria
2. CPC solubilizes bacterial
membrane
3. Key bacterial components escape,
killing bacteria
4. CPC remains in oral cavity for long
periods
Bioavailability comparison
Scope
Crest Pro-Health Rinse
• 0.045% CPC
• 0.07% CPC
• Greater level of
emulsifier; binds more
CPC
• Lower level of emulsifier;
~2x more available CPC vs.
Scope
• Cosmetic – good breath • Therapeutic  plaque,
gingivitis, breath
Comparison: Mouthrinses
Essential Oils
Crest® Pro-Health™
CPC
Chlorhexidine
Scope®
Cēpacol®
BreathRx®
LISTERINE® Antiseptic
Ingredient(s)
Interaction with
Toothpaste
Tooth Staining
Peridex®
Four essential oils: eucalyptol,
menthol, methyl salicylate, and
thymol
Cetylpyridinium chloride (CPC),
a quaternary-ammonium salt
Chlorhexidine (CHX)
ADA Seal of Acceptance*
No CPC-containing mouthrinse
carries ADA Seal of Acceptance for
plaque and gingivitis reduction
*Rx products no longer carry the
ADA Seal of Acceptance
Up to 56.1% supragingival plaque
reduction, and gingivitis reduction
by up to 35.9%, even in hard-toreach areas1-10
Not all clinically tested CPC
formulations have demonstrated
supragingival plaque and
gingivitis reductions11-13
Up to 64.9% in supragingival
plaque reduction and up to 60% in
gingivitis reduction when used
along with brushing14-16
No
Yes; toothpaste can significantly
reduce the antimicrobial activity of
CPC† 18-20
Yes; toothpaste can reduce the
antimicrobial activity of CHX‡ 22
Does not promote significant tooth
staining or calculus
formation1,2,7,10
Significant increases in objectionable
tooth stain†17,21
CHX is linked to tooth staining,
tartar increases, and permanent
discoloration of aesthetic
restorations23
ADA Acceptance
Plaque/
Gingivitis
Viadent® Advanced Care
All trademarks, registered or otherwise, are the property of their respective owners.
*Advanced LISTERINE® Antiseptic does not carry the ADA Seal of Acceptance.
†Based on studies examining mouthrinses formulated with CPC. There are no published studies examining interaction with toothpaste/tooth staining in
Crest® Pro-Health™, Scope®, Cēpacol®, BreathRx®, or Viadent ® Advanced Care.
‡Based on a published study examining a mouthrinse formulated with chlorhexidine.
Stannous Fluoride (SnF)
• Products: 0.4% Gel or
0.454% toothpaste
• Home fluoride gel or
toothpaste
SnF - Mechanism of Action
• Tin ion alters bacterial cell aggregation and
metabolism
• Bacteria retain tin ion
• Antibacterial effect
SnF – Side Effects
• Stain and metallic bitter taste
0.4% SnF brush-on gel
SnF – Published Research
 ADA seal for antiplaque/antigingivitis
 Long-term use shows better results in
reducing gingivitis
 Desensitizing properties
 Reduction in plaque
SnF Gel
• Brush on gel and swish one minute and
expectorate
• Consider ortho patient
• More anti-plaque than sodium fluoride
Oxygenating Agents
• Peroxyl
• Hydrogen Peroxide
Oxygenating Agents – Mechanism of
Action
• Inhibits anaerobic bacteria
• May have short-term anti-inflammatory
properties
• Research does NOT support its use
Oxygenating Agents – Side Effects
•
•
•
•
•
Question of safety
Black, hairy tongue (filiform papillae)
Tissue injury
Co-carcinogen
Delayed wound healing
Oxygenating Agents – Published
Research
• No added benefit over Sc/Rp
• Patients should be informed of side-effects
Sodium Benzoate & Sodium Lauryl
Sulfate (SLS)
• Plax – no antibacterial
properties
• Pre-brushing rinse
• Detergents only
• Disparity in the research
• No ADA Seal
• 8.7% alcohol
Triclosan & PVM/MA
Copolymer
• Active ingredient = 0.3% Triclosan
• Active ingredient is more effective in
combination with a 2.0% copolymer of
polyvinyl methyl ether and maleic acid
(trade name = Gantrez)
• Triclosan found in Dial soap, deodorants
• Colgate Total toothpaste– has ADA seal for
plaque/gingivitis reduction
Triclosan
• Broad spectrum antibacterial agent
• PVM/MA = greater uptake to enamel and
buccal epithelial cells
• Compatible w/ingredients in oral products
• Was only available in Europe and Canada
Product that was available in
Canada before the U.S.
Triclosan – Mechanism of Action
• Primary site of action is in bacterial
cytoplasmic membrane
• Prevents essential amino acid uptake causing
cell leakage of contents
Triclosan – Side Effects
• No development of resistance
• No adverse effects on soft/hard tissue
• Has an anti-calculus effect from the copolymer
(supragingival)
• May also add anti-tartar ingredient
(pyrophosphate)
Triclosan – Published Research
•
•
•
•
29% reduction in gingivitis
17-25% reduction in supragingival plaque
47.6% fewer sites with severe gingivitis
No development of resistant organisms
Triclosan
Over the last few years, the chemical known as
Triclosan has come under scrutiny as
potentially harmful. Should we be concerned?
What does the evidence say?
Source: http://www.dentistryiq.com/articles/2014/04/the-triclosancontroversy-what-are-the-facts.html (04/24/2014 by Dianne Glasscoe
Watterson, RDH, MBA)
Triclosan Controversy
 Cochrane
Systematic Review analyzed 30 studies
containing 14,835 subjects that were published
between 1990 and 2012.
The United States Food and Drug Administration,
which regulates many consumer products for
safety, has published that “there is clear evidence
that triclosan provides a benefit.”
Source: http://www.dentistryiq.com/articles/2014/04/the-triclosancontroversy-what-are-the-facts.html (04/24/2014 by Dianne Glasscoe
Watterson, RDH, MBA)
The FDA website lists some things
consumers should know:
Triclosan is not known to be hazardous to humans.
The FDA does not have sufficient safety evidence to
recommend changing consumer use of products that
contain triclosan at this time.
Consumers concerned about using hand and body
soaps with triclosan should wash with regular soap
and water. Consumers can check product labels to
find out whether products contain triclosan.
Source: http://www.dentistryiq.com/articles/2014/04/the-triclosancontroversy-what-are-the-facts.html (04/24/2014 by Dianne Glasscoe
Watterson, RDH, MBA)
Chlorine Dioxide (CLO2)
• 2001 study showed reduction in S. mutans
and lactobacilli numbers, but not candida
albicans
• Reduces Volatile Sulfur Compounds (VSCs)
• Small study group (33 subjects)
• ProFresh® and Closys® products
Halitosis
• For disease-free people, the assumption is that the
malodor is from overgrowth of oral microorganisms
that produce volatile sulfur compounds (VSCs).
• Toothbrushing and tongue hygiene reduce
microorganisms mechanically.
• Chemical control includes Essential Oils, CPC,
Chlorine Dioxide, etc. but long-term effects have not
been adequately studied
• Many products are part of a system of rinses,
toothpastes, etc.
JADA Report on Oral Malodor
http://jada.ada.org/cgi/content/full/134/2/209
Chlorine Dioxide Products
CloSYS Alcohol-Free
Oral Rinse
Alcohol-Free • CPC-Free
• GLUTEN-FREE
Chlorine Dioxide
• 2004, Mohammed; pilot study showed
effectiveness of 0.8% topical ClO2 in the
management of chronic atrophic candidiasis
• 2002, Borden et al; daily use of 4 mouthrinses
were compared over 4 weeks (Placebo, EO,
CPC, & CD/Zn). The CD/Zn (chlorine dioxide plus
zinc) rinse was the only one that reduced oral
malodor from baseline after 2-4 weeks use.
Chlorine Dioxide
• 2010, Shinada: A randomized, double blind,
crossover, placebo-controlled trial among 15 males,
who were divided into 2 groups. Subjects were
instructed to rinse with the experimental mouthwash
containing ClO2 or the placebo mouthwash, without
ClO2, twice per day for 7 days. After a one week
washout period, each group then used the opposite
mouthwash for 7 days. After rinsing with the
mouthwash containing ClO2 for 7 days, morning bad
breath decreased as measured by the OM and
reduced the concentrations of VSCs.
Summary
• Many agents
available
• All are adjuncts to
conventional
therapy
• Patient Education
• Documentation
Agent Review
–
–
–
–
–
–
–
–
–
–
Essential oils*
Chlorhexidine
Sanguinarine
Zinc chloride
Quaternary ammonium compounds (CPC)
Stannous Fluoride (SnF)** - Crest Pro health toothpaste
Oxygenating agents
Sodium Benzoate & sodium lauryl sulfate
Triclosan** - Colgate TOTAL toothpaste
Chlorine Dioxide
*ADA Seal for the reduction of plaque and gingivitis in
mouthrinse
**ADA Seal for the reduction of plaque and gingivitis and
bad breath in a dentifrice
Oil Pulling
•
•
•
•
What is it?
Known as "kavala" or "gundusha“
Clinical Data?
No evidence for use in U.S.
Irrigation
Supragingival and
Subgingival
Terminology
• Supragingival – point of delivery coronal
to the gingival margin (90·); patient
delivered
• Marginal – point of delivery is angled
apically to the FGM
• Subgingival – point of delivery is in the
sulcus/pocket; patient or professional
application
Rationale for Irrigation
• Used in periodontal disease to flush away
bacteria
• LPS is loosely adherent
• Non-specific reduction of microbes
Penetration
• Mouthrinsing = 4% pocket depth
• Supragingival irrigation = 29-71% of
shallow pockets & 44-68% of moderately
deep and deep pockets (usually 3-4 mm
or ½ probing depth)
• Subgingival irrigation = 75-93% pocket
depth
Supragingival Irrigation
Direct the tip toward the
interdental area at 90’ – water
deflects subgingivally
Supragingival Irrigation – Hydrokinetics
and Water Pressure
• Pulsating stream of water with compression
and decompression phases
• Decompression facilitates displacement of
debris and bacteria
• 80-90 psi can be tolerated by human gingival
tissues
Supragingival Irrigation
Technique
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2x daily use; Start at lowest pressure setting
Hold at a right angle to long axis of tooth
Aim jet across proximal papilla (10-15 seconds)
Trace along gingival margin to the next
interproximal papilla (hold 10-15 sec.)
• Should use the full reservoir
• Use from buccal and lingual surfaces
• Not a substitute for toothbrushing and flossing
Supragingival Irrigation Results
• Inferior to toothbrushing (as a monotherapy)
• Improved periodontal status when used in
addition to toothbrushing for pts. with poor
OH, gingivitis and/or periodontitis; no benefit
for those with good OH
• Greatest benefit for those who perform
inadequate interproximal cleansing
Source: AAP Position Paper, Nov.
2005
Supragingival Irrigation vs. Rinsing with
Medicaments
• Irrigation with water compared to mouthrinsing with 0.12%
CHX – one study showed equivalent results while other shortterm studies showed CHX rinsing to be superior (consider side
effects of CHX)
• Delivers medicaments more effectively interproximally than
with rinsing
• No conclusive data to show one method is superior to the
other
Source: AAP Position Paper, Nov.
2005
Supragingival Irrigation with
Medicaments
• Consistent improvements for gingivitis
patients when compared with irrigation
with water or mouthrinsing with
medicaments
• Lower concentration of medicaments were
used (0.02% or 0.06% CHX)
Source: AAP Position Paper, Nov.
2005
Likely Candidates for Supragingival
Irrigation?
• Those with inadequate oral hygiene
• Orthodontic Patients
• Gingivitis Patients
• Others?
AAP Position Paper, Nov.
2005
Specialized Tips for Marginal or Subgingival
Irrigation
• Soft rubber tip
• Ideal for deep pockets,
furcations
Technique for Subgingival Irrigation
•
Lowest pressure setting only
•
Dental professional determines areas
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Can place at the gingival margin or up
to 2mm below
•
Once tip is placed unit is turned on &
allowed to flow for 5-6 sec.
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Off, reposition to next area
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Tongue Irrigation Tip
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Patients that benefit: Diabetic
(reduction of pro-inflammatory
mediators), Implant
Maintenance patients
Professional Subgingival Irrigation
• Methods of delivery
– Hand-held Syringe - cannula with an
end or sideport
– Jet irrigator with cannula
– Ultrasonic
– EMS Air Polishing unit
• Limiting factors
– Calculus
– Lateral dispersion
• SC/RP should precede
-CDT code: 04921 per quad
Professional Subgingival Irrigation
• Low irrigation forces should be utilized to
avoid projecting bacterial into tissues
• No difference in end port or side port cannula
• Attempt to insert the tip at least 3mm
Subgingival Irrigation - Monotherapy
• Pathogens were reduced after one application
but returned to baseline at 1-8 weeks
• Should be used as an adjunct to SC/RP, not as
a monotherapy
Professional Subgingival Irrigation
When used with the PERIOFLOW®-capable devices and
nozzles, the AIR-FLOW®
PERIO powder's extra-fine
grains remove harmful biofilm
and bacteria in subgingival
pockets of up to 5mm.
Made from glycine rather than
sodium bicarbonate, AIRFLOW® PERIO powder is
gentle on the tooth surface.
Source: www.hufriedy.com
Professional Subgingival Irrigation
Modern air-polishing devices (AIR-FLOW®) and their specific
powders for subgingival application are becoming increasingly
significant in the context of maintenance therapy. However,
before they can be introduced into routine everyday practice,
science must provide sound evidence of the safety, efficacy and
endurance of new methods compared with a variety of other
procedures – from a clinical as well as ethical viewpoint.
Please Note: The following studies show a wide range of use.
AIR-FLOW® PERIO devices are only approved for use in
pockets up to 5 mm in the United States; 10 mm in Canada.
https://www.hufriedy.com/products/ind
ex.php/mastercontrol/index/file/id/326
Limitations to Subgingival Irrigation
with Medicaments
• Short half-life of injected solutions (13 min.)
• Minimal dispersion (use circumferentially)
• CHX reduces quickly when introduced
subgingivally; Contact with blood inactivates CHX
• Gingival crevicular fluid flows outward
• Little contact time with sub-gingival microflora
Limitations to Professional
Subgingival Irrigation with
Medicaments
• A single episode of in-office subgingival
irrigation to enhance Sc/RP does not
improve clinical healing
• Multiple irrigations may help refractory
sites (torturous pockets, furcations)
– Use of CHX at-home 1x/daily in furcations and
refractory sites has shown gingival
improvements
Ultrasonic Debridement With and Without
Antimicrobial Agents as the Irrigant
• Several short-term studies compared water
and CHX delivered through an ultrasonic
unit
• No significant differences between irrigants
in CAL, reduction of probing depths or BOP
Conclusions
• Supragingival and marginal irrigation plays a
role in the treatment of gingivitis and
maintenance of periodontal patients
• No data to support a single episode of
subgingival irrigation or multiple in-office
irrigation appointments (no benefit beyond
Sc/RP)
Putting it into Perspective
• Mechanical Therapy is effective for the
majority of patients with mild to moderate
chronic periodontitis
• Subgingival Irrigation (1x) usually does not
provide any reduction of inflammation,
probing depths or gain of CAL beyond that
achieved with debridement
Source: Mechanical debridement provides definitive treatment for
patients with mild to moderate periodontitis, Greenstein, G., 2000,
JADA
CASE #1
Patient Profile: Patient is a 35-year old White Caucasian male.
Chief Complaint: "My gums are sore and bleed when I brush.“
Dental History: He had a prophylaxis two years ago and has not returned
for dental care since.
Medical History: The patient reports a history of sinus infections and
occasionally seeks medical care. He is currently taking (Sulfamethoxazole)
Septra® and reports he is in good health.
Periodontal Examination:
The patient presents generalized moderate gingivitis and localized gingival
recession on mandibular molars.
Supplemental Information:
Patient reports TMJ discomfort and bilateral clicking sounds occur upon
opening and closing.
Health Behaviors:
Patient uses a power toothbrush once daily.
Patient does not floss daily.
CASE #2
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Patient Profile: 57-year old White Caucasian male, 6’1” and weighs
190 lbs. He is currently in an alcohol rehabilitation program.
Chief Complaint: “I have bad breath and a dry mouth with a bad taste
all the time. My partial denture does not fit.”
Dental History: His last dental appointment was to fabricate a
mandibular removable partial denture. He has not had his teeth cleaned
in the past 6 years. After completing his dental work, he lost interest in
maintaining his teeth.
Medical History: Patient was diagnosed with prostate cancer 5 years
ago and underwent chemotherapy and radiation treatments lasting 9
months. He has a family history of cancer, hypertension, depression,
cardiovascular disease and alcoholism. He has numerous allergies to
pollen, dust, bee stings, cats, shellfish and Penicillin. He was recently
diagnosed with gout and arthritis in each knee. He experiences
frequent asthmatic attacks. His daily medications are: 81 mg aspirin,
(Fluoxetine hydrochloride) Prozac®, (Aripiprazole) Abilify®,
(Dutasteride) Avodart®, (Aloprim) Allopurinol®, (Naproxen) Aleve®,
(Valsartan) Diovan®, (Lovastatin) Mevacor®, (Indomethacin) Indocin®,
(Albuterol sulfate) Proventil®, (Ipratropium bromide) Atrovent®. His
blood pressure was recorded at 155/95.
CASE #2 CONTINUED….
Extraoral Examination:
Submandibular, sublingual, and cervical lymph nodes are palpable and
tender.
Supplemental Information:
Patient questions why he consistently has a bad taste and a dry mouth.
Health Behaviors:
Patient brushes with a hard bristled toothbrush once daily and is uncertain
whether he uses a fluoridated toothpaste.
He has never used floss.
He has rinsed with a phenol mouthrinse daily for several years.
Bleeding Index: 35%
Plaque Score: 40%
Questions?
Questions?
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[email protected]
Thank you!