Perio Notes

Perio Notes
Lecture 1: Perio probing
perio probe is single most important instrument to dx perio disease
• What can it do?
• Measure pocket depth
• measure width of attached gingiva
• assess bleeding points
• assess topography of epithelium
• measure size of lesion
• measure gingival recession
• What is it composed of
• Handle, Shank, Working end
• woking end composed of thin tapered rod, blunt tip, no cutting edges, and
marks in mm
Nabor Probe detect and measure furcations
Probe: 3mm markings, tip should stay in contact with tooth and be sub-gingival
working end should be parallel to long axis of tooth(except in col, some angle
here)
• 10-15 grams of pressure
• healthy - probe stops at junctional epithelium
• diseased - probe into connective tissue
• Measure: base of pocket to gingival margin
• 6 measurements: MF, mid-facial, DF, ML, mid-lingual, DL
• Record bleeding on paper chart by circling site red
• Calculating the Bleeding Index: total number of bleeding surfaces/total surfaces
• remember total surfaces=#of teeth * 6
Pocket Depth vs. Attachment Level
• Pocket depth = base of pocket to gingival margin
• Attachment level = CEJ to base of pocket
• Recession= attachment loss - pocket depth
• See examples (maybe look for some on internet)
Anatomy of Periodontium
Parts of Perio
• Gingiva
• Periodontal Ligament (PDL)
• Cementum
• Alveolar Bone
Marginal (Free) Gingiva

• Portion of gingiva surrounding neck of tooth
• not attached to tooth
• soft tissue wall of gingival sulcus
• Interdental papilla:part of marginal gingiva that fills the interdental space
Free gingival groove AKA free marginal groove
• Shallow depression dividing free from attached gingiva
• only seen in 50% of patients
Attached Gingiva
• Portion of gingiva that extends apically from free gingiva to mucogingival junction
• bound tightly to underlying bone
Gingival Sulcus - pocket, where we probe
Junctional Epithelium
• Collar like band of non-keratinizing epithelia cells
• form the base of the sulcus(pocket)
• .25-1.35 mm in length
Gingival Col
• Saddle like depression
• between facial and lingual papilla
• non-keratinized
Alveolar Mucosa
• freely movable - not bound to bone
• non-keratinized
• not designed to withstand forces of mastication
Mucogingival junction - sclloped line dividing keratinized gingiva from alveolar mucosa
Measuring amount of attached gingiva
• Measuring keratinized gingiva
• gingival margin to mucogingival margin
• subtract sulcus(pocket) depth
• attached = keratinized - pocket depth
• varies: 1-9mm
• Greatest(thickest): Lingual of man molars, facial max ant
• Least(thinnest): Man first premolars
Gingival fibers
• Brace marginal gingiva against tooth
• provide rigidity(withstand mastication)

• unite marginal gingiva to cementum
Cementum
• Calcified structure that covers the anatomic root
• inorganic content: 40-50%
• Anchors tooth to bone via PDL
PDL
• Collagenous connective tissue - surrounds root of tooth
• attaches tooth to alveolar process
• Four Properties
0. Supportive: anchors tooth to bone
1. Formative: Helps maintain biologic activity of bone/cementum
2. Nutritive: supplies nutrients, removes waste via blood/lymph
3. Sensory: transmits tactile pressure and pain
Alveolar Process
• Portion of maxilla/mandible that supports the socket of teeth
• Alveolar bone proper
• Thin layer surrounding root and gives attachment to PDL
• lamina dura in radiograph, AKA cribriform plate
• supporting alveolar bone
• Surrounds alveolar bone proper
• gives support to sockets
• Compact = cortical
• Cancellous or trabecular = spongy
Healthy Gingiva
• Color = coral pink
• contour = marginal gingiva follows scalloped line around each tooth
• knife edge margin
• papilla just fill embrasure
• Consistency = firm / resilient
• Surface texture = stippling (May or MAY NOT be there)
• least reliable parameter
Color influences: Inflammation, Vascularity, keratinization, pigmentation
Unhealthy Gingiva
• Color: Bright Red(acute) to bluish red(chronic)
• Contour: rounded, rolled, blunted, flat, crater, bulbous
• Consistency: spongy, edematous to fibrotic
Gingival description (know which is good, which is bad)

• Location: general vs. local
• Severity: slight, moderate, severe
• Location: papillary, marginal, diffuse
• Color: Coral Pink, red, bluish red
• Contour: knife-edge, enlarged, bulbous, cratered
• Consistency: firm and resilient, edematous, fibrotic
• WNL is not acceptable
Dentin hypersensitivity
Defined
• Short transient pain due to exposed dentin
• usually occurs in response to stimuli (thermal, tactile, osmotic, chem)
• Can occur after dental procedure, more likely to be self-limiting
• cannot be attributed to some other pathology
• What is required?
• Dentin exposure
• tubule open from pulp to oral cavity
Hydrodynamic theory
• Brannstrom and Astron proposition
• opening of tubules => movement of dentinal fluids
• movement indirecty stimulates the extremities of plural nerves, causing pain
• exact mechanism of stimulation not understood
Pain dependent on
• Age (peak at 30, majority 20-40)
• Gender (females>males)
• Situation
• Past dental experience
• Patient expectations
Some Causes
• Gingival recession and tooth wear (erosion)
• Most common sites: buccal-cervical sites of premolars and canines
• DH most commonly caused by recession
• Removal of smear layer also initiates
• Periodontal therapy are 2-3 times more likely
• 73-98% perio patients
• self-limiting - tubules will occlude
• bleaching
Management
• plaque control is paramount
• soft brush, less aggressive brushing

• desensitizing toothpaste
• professionally applied agents
• No cure-all product
Desensitizing toothpastes
• Active ingredient: KNO3 most common
• others: Strontium chloride, sodium citrate, sodium fluoride, stannous fluoride
• 2-3 weeks of use required before improvement
• Max relief 8-12 weeks
• Patience compliance critical
• do not rinse after brushing - only spit
Potassium Nitrate
• Action: Does NOT occlude tubules by crystals (like other agents)
• Inc concentration extracellular K around nerve-fiber,
• causes depol, prevents re-pol
• not enough evidence to show effectiveness
Others still used: NaF, stannous fluoride
• obliteration of tubules through precipitation of CaPO4 onto dentin
• Abrasives may contribute through creation of smear layer
• use LESS water and do NOT rinse
• prescription level: 1.1%
Crest Pro-health: Stannous Fl, obliterates tubules
Professional
• Fl treatments/varnishes: creates barrier of CaF crystals
• can be dissolved over time through saliva
• benefits from varnish base
• crystals in tubules(60-70um) are more difficult to remove
GLUMA 5% gluteraldehyde, 35% HEMA and water: occlude tubules and decreases fluid
flow
Colgate Pro-Relief: 8% Arginine and Calcium Carbonate - occludes tubules
Inflammatory Periodontal Diseases
Perio Disease: Any pathologic process that affects the periodontium
Plaque-related inflammatory perio disease
• gingivitis - inflammation of gingiva
• Chronic periodontitis - progressive inflammation, involves: BONE, PDL, GINGIVA
• Classification
• Gingivitis

• chronic periodontitis
• Aggressive periodontitis
• Periodontitis as a manifestation of systemic disease
• Necrotizing periodontal disease
• Abscesses of the periodontium
• Periodontitis associated with LEO
• Degree of Destruction = Severity of local factors X Freq of Energy X Duration of
Injury X Host response
Gingivitis (Case Type I)
• Gingival erythema
• No bone loss
• Bleeding on probing
• increases pocket depth (3-5mm)
• Increase in GCF
• NO PAIN
Periodontitis
• Apical migration of JE, Bone loss
• Bacteria associated
• Aa - Aggregatibacter actinomycetemcomitans
• Pg - Porphyromonas gingivalis
• Pi - Prevotella intermedia
• Tf - tannerella forsythia
• Td - Treponema denticola
Gingivitis CAN be reversed; Periodontitis CANNOT be reversed
• Gingi always preceeds Peri; but gingi does not always become peri
• no single indicator to diagnose periodontal disease or health
Early Periodontitis (Case Type II)
• Mild bone loss (50% bone loss
• Attachment loss > 5mm, pocket depth > 7mm
• Furcations involvement, mobility likely, suppurtation - pus feeling

• Pain more likely
Case Type V
• Refractory periodontitis
• uncommon periodontal diseases: aggressive periodontitis (LJP, RAP)
• RAP - rapidly advancing periodontitis
• LJP - localized juvenile periodontitis
Radiographs and probings needed to properly dx
Etiology
• Primary: PLAQUE - always
• Secondary
• Local
• Overhangs, poor crown margins
• Calculus, furcations
• crowded teeth, ortho
• large carious lesions
• Food impaction, smoking
• Xerostomia
• Systemic
• Smoking
• diabetes
• immune-compromised
• aging
• stress => ANUG
• Nutritional deficiencies
• medications
Classifications of Pockets
• Gingival Pocket - pseudo-pocket, false pocket
• Pocket caused by hyperplasia; coronal movement of gingival margin
• No apical migration of JE and No bone loss
• Periodontal Pocket: pocket caused by bone loss due to apical migration of JE
• Suprabony - bottom of pocket is coronal to the crest of the alveolar bone
• Infrabony - bottom of pocket is apical to crest of alveolar bone
Tooth Deposits
Non-mineralized - pellicle, plaque, materia alba, food debris
mineralized - calculus
Acquired Pellicle
• Thin, structureless, forms over teeth/restorations/calculus
• a glycoprotein from saliva or GCF subgingival

• fills mico voids
• reforms immediately after removal
• 1 week to completely form into mature stage
• Significance
• Nidus (niche) - place for bacteria to attach
• serves as nutrient source
• protective barrier
• calculus attachment
Dental Plaque
• Dense, non-calcified, ORGANIZED mass of bacterial colonies in a gel-like intracell
matrix - not random bacteria
• Buzz word: bacterial biofilm
• Biofilm
• Cooperating communities of back
• micro-colonies - surrounded by protective matrix creating differing environ
• Microorg communicate via chemical signals
• resistant to Ab, antimicrobials, host response
• Factors influencing plaque build-up
• Mechanical removal
• availability of nutrients
• undisturbed environment
• interaction between bacteria and host immune response
• RESULT: bacteria accumulate in sheltered environ => disease
• Plaque Formation
• initial formation: 2 hours
• gram positive aerobic and facultative organisms
• actinomyces and streptococcus
• 47-85% cocci in first 4 hours
• isolated colonies in proximal surfaces, fissures, sulcus, irregularities
• 2 days to double in mass (visual at this point)
• white, grey, or yellowish
• secondary colonizers - not on clean tooth
• Pi, Pg, Capnocytophaga species, spirochetes, motile rods
• gram negatives and anaerobic bacteria
• initiators of dental caries and perio ds
• Intracellular plaque matrix
• matrix that surround the bacteria with the biofilm
• inorganic and organic components from bacteria
• Major components: polysac from metabolism of CHO
• Minor components: salivary glycoproteins
• Dental Plaque metabolism
• Energy source (sucrose) introduced
• Production of Acid, Intracell polysac (E storage), Extracell poly sac

• Extracell polysac:
• glucans - dextrans - sticky, help anchor/stabilize plaque mass
• fructans - levans - energy source
• Plaque CANNOT be removed by water spray
• matures => more resistant to mechanical removal
• Anaerobic glycolysis results in pH from 7 -> 4.5 (tooth demin)
• Bacteria look for foor, go subgingival
• Host defends itself via inflammatory response and gingivitis inititiated
Materia Alba - not plaque, very different
• UNORGANIZED - soft mixture of saliva proteins, bacteria, desquam epi cells
Food Debris - not plaque, we floss away plaque
Dental Calculus
• Major role in inflammatory perio diseases
• KEEPS PLAQUE CLOSE contact with gingiva
• Calculus not the problem, its the plaque under
• Primary issue: Calculus prevents removal of plaque; not being a mechanical irritant
Supragingival Calculus
• coronal to gingival margin
• white or whitish yellow
• hard, cake-like consistency
• more common: Lower anteriors and buccal of max molars (next to salivary gland
ducts)
Subgingival Calculus
• Below crest if marginal gingiva, not visible clinically
• detect: explorer and radiographs
• dense, dark brown to greenish black (blood and bacteria)
• flint like, firm attachment
Mineralization
• Percipitation of Ca and PO4 from saliva and GCF
• some Mg, Zn, Fl, carbonate
• Not all plaque mineralizes, but plaque destined to mineralize does so within a few
days
• mineralization - starts extracellularly first, then produced intracell
• Occaisionally begin within the cells and spread to intracell matrix
• Four Main Crystalline forms:
• Hydroxyapatite
• whitlockite
• octacalcium phosphate
• brushite

• General Rule: subgingival calculus: 60% min, supra: 30% min
• mineralization starts between day 1-14 of plaque formation
• Not all plaque mineralizes
• Mineral source: supra:saliva, sub:GCF and exudate
Fluorides
Systemic: Water fluoridation, supplements, food/beverages
Topical: Water fluoridation, fluoride products, in-office treatments, food/bev
Mechanism
• Systemmic: ingested and incorporated in enamel during development
• Topical: promote remin, prevent demin, inhibit glycolysis in microbes
Benefits of water fluoridation
• 30% reduction in
• caries for primary dentition
• children/adolescent perm dentition
• coronal caries / root caries
• Most cost effective preventative dental programs
Optimum level of fluoridation: 1 ppm (min caries and min flurosis)
Topical Fluoride
• Mode of Action
• Fl deposition in enamel maturation phase
• Highest conc in outermost portion (5-10um)
• Fl ion substituted into hydroxyapatite crystal - stable, more compact bond
• DOES NOT CAUSE FLUOROSIS (only occurs through systemic)
• Acidic or high conc Fl forms CaFl2; neutral Fl fluoroapatite
• initial deposition not permanent - rapid loss in frost 24, continues over weeks
• Each professional application increases amount of permanently bound Fl
• Fluorhydroxyapatite: most desirable form
• Calcium Fluoride (CaFl2): Fl source for remin
• Benefit of topical related to frequency of treatment
• no benefit for sound enamel, regardless of type of treatment
• Professional applications: 8% Stannous Fl, 2% NaF; 1.23% Acidulated Phosphate
Fl (APF)
• no difference in efficacy; stannous no longer used
• 8% Stannous Fl
• Forms stannous fuorophosphate and CaF
• Acidic, Bitter, metallic taste
• Stains clothes and teeth (brown)
• prepared immediately prior to use

• liquid and messy
• 2% NaF (neutral)
• Results in fluoroapatite and CaF
• gels and foam - ready to use
• Absent of taste
• No stain or tissue irritation
• 1.23% Acidulated Phosphate
• Results in fluorohydroxyapatite and CaF
• gel and foam - ready to use
• stable in plastic
• No irritation or discoloration
• Can etch ceramic or porcelin
• Use NaF for
• composites
• porcelain crowns, veneers
• exposed root surfaces
• glass ionomers
• Indications
• High caries activity
• sensitive or exposed roots
• Deteriorating restorations
• Overdentures
• xerostomia - Hx of head/neck radiation, meds
• Newly erupted teeth -really good uptake here
• Absence of other fluoride exposures
• Why? everyone benefits, no risks to topical
Professional Treatments
• NaF Neutral
• 9000ppm, pH 7.0
• slow uptake - requires 4 minutes to reach 1000ppm
• 4 minutes application
• No side effects
• APF
• 12,000 ppm, pH 3.5
• Rapid uptake - 12,000 ppm within 1 minute
• 4 minutes application (yes, even though uptake is rapid)
• May etch porcelain or composite
Gel vs Foam
• uptake is comparable between the two
• Foam requires less material, decrease chance of swallow
Fluoride Toxicity

• Probable Toxic dose (PTD) based on weight
• 5mg F/kg of body weight
• if less than PTD consumed, give Ca, Al, Mg products in office
• over PTD - same as above plus hospital observation
• over 15mg F/kg - same as above, but call 911
• Signs and symptoms
• Nausea, vomiting, diarrhea, abdominal cramps
• Increased salivation, dehydration
• Treatment
• time is everything, blood levels reach max 30 to 60 min from ingestion
• Milk and eggs or other Ca, Mg, Al
• binds Fl
• Coats membranes of GI preventing burns
• Fluids also help to dissolve
• Do not induce vomiting, but patient will often vomit anyway
Application
• Ribbon into tray - DO NOT OVERFILL (may ingest)
• Pt - upright; dry teeth
• place tray then saliva ejector
• instruct pt to chew slightly
• 4 minute application regardless of which used
• do not leave unattended
• After: expectorate excess Fl, no eat or drink for 30 minutes
Fluoride Varnish
• 5% NaF (26,000ppm)
• FDA: use for dentin hypersensitivity, not reducing caries (ADA does endorse this)
• Can by applied every 6 months to prevent caries in high risk population
• Application
• apply thin layer (.5 mm)
• Post op - forego brushing soft diet that evening
• may discolor teeth and restorations, but not permanent
Fluoride prophy paste: does not replace fluoride application
• prophy removes about .1-1.0 micron of Fl-rich enamel
• At best, Fl in prophy replaces what it removed
• not approved as a Fl treatment
Fl in Dentifrice (toothpaste)
• 1000ppm
• NaF with compatible abrasive is most effective
• Fluorosis/toxicity risk if swallowed

Additional Fl products
Home Fluoride
• Prescription: 1.1% NaF gel
• OTC: .4% stannous (gel)
• OTC: 225ppm NaF some 100ppm
Caries Reduction protocol:
• Pts in high risk category: CHX 1/day for one week, for 6 months - I dunno
• CHX after dinner , Fl at bedtime
• Low risk: OTC mouth rinse for maintenance
Plaque Control and Oral Hygiene aids - not comprehensive details, but important
points
Oral health cannot be attained or preserved with plaque control
Toothbrush
• Bristle shape
• End rounded vs. blunt cut
• round, tapered, or smooth were less abrasive
• Round tip is recommended
• Bristle texture
• Soft: .007-.009 inches
• AVerage life toothbrush - 3 months
• ADA: "Brush regularly"; School: twice a day, 2 minutes each time
• Brushing Techniques
• Bass (modified)
• Bristle angled 45 degrees toward gingival margin
• gently press bristles to enter sulcus and embrasures
• subgingival cleansing and gingival stimulation
• Fones (circular)
• 90 degrees to tooth
• large circles over teeth and gingiva
• easy for children or limited dexterity
• Others: Rolling, Stillman, Charters, Leonard, Horizontal, Smith-modified
• ADA Guidelines for electric toothbrushes
1. Laboratory evidence of electrical safety
2. Clinical evidence of hard/soft tissue safety under under unsupervised
conditions
3. Clinical evidence of plaque and gingivitis when compared to other ADA
accepted toothbrush
4. Evidence of proper labeling and advertising claims
Chocrane review: rotation, oscillation is better than manual toothbrushes at removing
plaque and reducing gum inflammation
Interproximal Plaque Control

• Based on:
• Size of interdental spaces
• presence of furcations
• ortho or fixed appliance
• tooth alignment
• Flossing: remove interproximal plaque, not dislodge food wedged between
teeth
• spool method good for those with less dexterity
• see-saw motion, not pop through
• Platyplus ortho flosser and Super floss - good for getting around brackets
• Interdental brushes (proxy brush)
• large embrasures
• teeth with concavities
• around fixed appliances
• ortho appliances
• furcations (class III, IV)
• Oral irrigators - result in disruption of loosely attached or unattached
supra/subgingival plaque
• not indicated for patients who have effective oral hygiene or no inflammation
• alone not effective at reducing inflammation
• best if combined with toothbrusing
• Cleaning Dentures
• After meals - warm (NOT HOT) water
• Use soap - NOT TOOTHPASTE
• soft toothbrush or denture brush
• Soaking also works - 6 hours
Sweeteners
Xylitol
• Polyol, sweetness similar to sucrose
• 40% few calories (2.4 cal/g)
• From birch trees, corncobs, waste of sugar cane
• Non-acidogenic, thus non-cariogenic
• S mutans and level of lactic acid
• slowly absorbed by GI
• Main side effect diarrhea (occurs at 4-5 times that needed for caries prevention)
• FDA approved since 1960
• First trial (60's): 3 groups: Xylitol, fructose, sucrose for 2 years (125 volunteers)
• Results in DMFT (decayed, missing, filled teeth)
• Xylitol: 0.0 (some lesions of early demin of smooth surface caries)
• Fructose: 3.8
• Sucrose: 7.2
• 1995 trial: large sample group - 1277 over 40 months
• Results: most effective at caries prevention: Xylitol followed by xylitol/sorbitol mix
then sorbitol

• Why does it work?
• not metabolized by S. Mutans, pH not lowered => demin prevented
• Also saliva flow is stimulated, enhances buffering
• Highly toxic to dogs
• How? rapid and severe increase in insulin production leads to hypoglycemia
• only takes .15g/kg to start seeing effects
• Higher amounts (1.4-2.0 g/kg) can cause hepatic failure/necrosis and death
• Therapeutic dose: 6-10 g per day over 3-7 consumptions
• more than this does not see more caries prevention
• less than 3 times a day also not as effective
What doe the ADA seal mean for chewing gum? Basically chewing for 20 min after
eating stimulates enough saliva to help prevent cavities
• Company must show one or more of the following:
2. reduces plaque acids
3. promoting re-min of the tooth
4. reduce caries and/or gingivitis
• Ice cubes: 1.15 g xylitol per cube
• trident .17 gram per piece
• if xylitol is not the #1 lecture
Xylitot lollies - no xylitol
Sorbitol: most common polyol used in US, from plants
• 60% as sweet as sucrose, 2.6 cal/ g
• low-cariogenic (organisms can learn to use sorbitol if sugar supply is depleted)
Mannitol: Polyol from seaweed
• 50-70% as sweet as sucrose, 1.6 cal/g
• non-cariogenic
• non-hygroscopic - used as dusting agent in gum
Intense Sweeteners
• Saccharin
• 200-700 times sweeter than sucrose
• non-cariogenic; non-nutritive
• largest volume / lowest cost sweetener in the world
• Aspartame
• 200 times sweeter than sucrose
• 4 cal/g (negligible due to small amount that is used)
• Sucralose
• 600 times sweeter than sucrose
• non-cariogenic; non-nutritive

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Antimicrobials
11/9/10 2:02 PM
Terminology
• Adverse Effect: harmful to patient
o Side effect(which is different): may be harmful, useful,
beneficial
• Compliance: patients ability, desire, and motivation to use the
product
• Substantivity (know this term): ability of an agent to absorb to
teeth and surfaces and be released at therapeutic levels
o We want this to be high because that means less times the
patient has to use in order to have the effect
Considerations with chemical plaque control
• What effect will it have on oral flora and associated disease?
• Is the effect significant?
• Are there adverse effects on the oral flora?
• Are hard/soft tissues adversely effected?
• Are dental restorative materials adversely effected?
• Do usage and properties support compliance?
• Are the any contraindications to product use?
Delivery systems
• Local: paste, gel, liquid, fibers
• Systemic: antibiotics
Three levels of regulation (prescription and OTC drugs)
• Governmental level: Food and Drug administration
o Evaluates both prescription and OTC
o Therapeutic claims must be backed with proof
o Protects consumers from useless or harmful products
• Professional Level: ADA
o Council on scientific affairs of the ADA
• Consumer Level:
o Advocacy groups
o Federal trade Commission (FTC)
ADA Seal of Acceptance

• Program is voluntary
• Started in 1930 to “help consumers make wise choices”
• Products submitted for seal must have independent, controlled
studies to demonstrate effectiveness and safety
• Seal is found on consumer products
o Professional seal has been phased out
o Professional product review replaces the ADA seal
• Example: ADA seal for antiplaque/antigingivitis agents
o Do not worry about the details
• PER PRODUCT:
o New product submission: 14,500$
o Annual maintenance fee: 3000$
Evaluating product claims – What to look for with the “research”
• Published vs. non-published
• Sponsor
• Peer review
o Not Peer Reviewed
! Journal of clinical dentistry – 800$ per page to publish
(Quick way for industry to publish)
" NOT AS CREDITABLE
o Reviewed:
! JADA
! Jour of Periodontology
! Jour of clinical periodontology
• Length and duration
Alcohol in mouthrinses/mouthwashes
• Used as solvent for active ingredient
o NOT ACTIVE INGREDIENT
• High content can cause hyper-keratotic lesions
• Possible link to oral cancer – inconclusive, heavily debated
Chlorhexidine
• 0.12% CHX
• Peridex, Perio-grad and others

• Cytoplasmic poison – causes rupture of cell membrane allowing
leakage
• Binds to mucins, reducing pellicle formation and inhibiting
colonization
• Binds to bacteria, inhibiting their adhesion onto teeth
• Substantivity: 12-24 hours (only one that’s long enough to merit
mentioning(
• 12% alcohol
• 35-40% decrease in plaque and gingivitis
Alcohol – free chlorhexidine
• .12% CHX
• Alcohol free
• Therapeutically equivalent
• Available only in dental offices
CHX
• Side effects
o Staining
o Altered taste - bad
o Supragingival calculus
o Mucositis
• Dosage: 15ml, bid, 30 seconds each time
• Most effect anti-plaque agent available at this time
• Available with prescription
• FDA approved – no longer carries ADA seal due to change in
program
• CHX on established biofilm will have only superficial effects
• Is more effective when plaque is removed professionally prior to
rinsing
• The biofilm will adapt and protect itself from the effects of CHX
• Inactivated by toothpaste – important to rinse well with water
PRIOR to rinsing or wait 30 minutes before use
• DO NOT rinse with water immediately after rinsing with CHX
• Rec for patients who cannot or will not maintain adequate plaque
control

• Post surgical cases
• Caries protocol cases
Phenolic Compounds – Listerine antiseptic and its generic equivalents
• Active ingrediants: Essential Oils (GOT TO KNOW It)
o Thymol
o Eucalyptol
o Methyl salicylate
o Menthol
• Org formula: 26.9%, cool mint 21.6%
o Twice as much alcohol as CHX
• Alters cell membranes causing leakage and cell death
• 18-25% decrease in plaque and gingivitis
o about half as effective as CHX (good to know)
• low substantivity
• Does it replace floss???
o NO!!! Benefit is in conjunction with brushing and flossing
• Side Effects
o Bad taste
o Burning sensation
o Tooth staining (?) – not a big issue, but one study tried to
show it
• Dose: Rinse with 20ml, bid, for 30 sec
• Before ADA seal – use with minor cuts and infectious dandruff
Listerine Zero
• Introduced in 2010
• Claims:
o “4 essential oil formula”
o “for patients who want/need alcohol-free rinse”
• BUT ITS NOT Listerine antiseptic without alcohol
o It’s a cosmetic rinse – freshens breath
• Essential oils is for flavoring – not a therapeutic concentration

Cetylpyridinium Chloride – CPC (breath freshners, not antimicrobial)
• Ingredient in cosmetic mouthwashes
• Quaternary Ammonium compound
• Marginally effective in reduction of plaque / gingivitis
• Little to no substantivity
Pro-Health Rinse
• .7%CPC
• no alcohol
• studies show plaque and gingivitis reduction comparable to Listerine
• Mechanism of action: ruptures cell wall; also may alter bacterial
metabolism and inhibit cell growth
• Pro-health night – same product, different flavor
CPC vs CHX
• CPC binds to tooth structure and plaque, but not as strongly as CHX
• CPC is rapidly released from binding sites so it is not as efficacious
as CHX
Viadent – former active ingredient was sanguinarine (blood root plant)
• Mid to late 90’s, higher than normal incidence of leukoplakia seen
• Sanguinarine determined to be the cause
• Pts were 8-11 times more likely to develop leukoplakia
• Lesions seen in former users – 5 years after use
• Risk was highest in patients who used both mouth rinse and
toothpaste
Viadent – Now, new formulation without sanguinarine
• Active ingredient: cetylpyridinium chloride (CPC)
• Neutralizes malodor
• No ADA seal
• Cosmetic
Plax
• Marketed as pre-brushing rinse

• Ingredients: surfactants(detergents), sodium bicarbonate, glycerin,
alcohol (7.5%)
• Claims unsubstantiated with sound research
• “the data provided do not support the use of PLAX dental rinse as
part of an oral hygiene”
Listerine Whitening pre-brushing rinse
• Ingredients: water, 8% alcohol, hydrogen peroxide, sodium
phosphate, sodium laurel sulfate
• DOES NOT CONTAIN essential oils
• DOES NOT REDUCE plaque and gingivitis
• Doesn’t really whiten teeth either
Crest Whitening Rinse
• Not marketed to professionals
o Doesn’t really whiten or kill bacteria or protect from future
stains
Triclosan – poor man’s CHX
• Broad-spectrum antibacterial agent
• Widely used in soaps etc
• Anti-bacterial action not effected by sodium lauryl sulfate (SLS)
• Found in mouth rinses in Europe
• Found in some toothpastes in US
• Mild to moderate reduction in plaque and gingivitis
• Considered safe and effective for use in toothpastes and mouth
rinses
When do we recommend a mouth rinse
• Determine need (caries, periodontal)
• Caries Risk (OTC fluoride, Rx fluoride, or caries reduction protocol)
• Patients who are unable to mechanically remove plaque
• Patients who, despite their best attempts, need adjunctive
measures
• Patients with ANUG
• Pre/post periodontal surgery

• Patients undergoing disease control therapy
ADA has always stressed the importance of good oral hygiene by advising
consumers to:
• Brush your teeth twice a day with an ADA accepted fluoride
toothpaste
• Clean between teeth daily with an ADA accepted floss or an ADA
accepted inter-dental cleaner
• Eat a balanced diet and limit between meal snacks
• Visit your dentist regularly for professional cleanings and oral
exams
• In addition to the basic oral hygiene recommendations, consumers
should be aware of the oral health benefits of other ADA accepted
procedure, such certain kinds of mouth rinses and toothpastes
The council wants consumers to know that:
• Use of an ADA accepted antimicrobial mouth rinse or toothpaste
helps prevent and reduce plaque and gingivitis
• Use of an ADA Accepted fluoride mouth rinse helps prevent and
reduce tooth decay
RECAP
Therapeutic:
• Peridex (CHX)
• Listerine antiseptic
• Crest pro health (.07% CPC)
Cosmetic
• Listerine zero or whitening
• Viadent, Scope, Cepecol, Lavoris
• Crest Whitening

Dentifrices
11/9/10 2:02 PM
In the beginning…
• A little history on toothpaste
o Earliest ref = 4 th century
! Iris flowers, strawberries, bones
o 18 th century
! Burnt bread, charcoal, dragons blood, cinnamon, burnt
alum
Early Dentifrices
• Toothpowders
o 1 st on market for general use in 19 th century
o primarily water, soap, flavor
o home versions: chalk, pulverized brick, salt
o pulverized charcoal also recommended for use
o many of these did more harm than good
• Toothpastes
o Became available thanks to lead packaging
! Plastic was used after WWII
! Pump introduced in 1984 by Colgate
! Separate stripes by Lever Bros (still used by some)
! Mentadent used separate chambers for H 2 O 2 and baking
powder – mostly a gimmick
o Fluoride first added in 1914
! 30’s ADA said not good
! 50’s they changed and said it was good
o By 1970: $355 million market
! By 2012 expected to reach $12.7 billion worldwide
• Dentifrices today: Powders, Pastes, Gels
o Gels and pastes use same ingredients
o Gels have more thickening agents vs pastes
o Both equally effective
What’s in Toothpaste?
• Fluoride
• Abrasive (20-40%)
o Types

! Silicas
" Silicon Dioxides, Aluminum oxides
! Carbonates
" Sodium bicarbonate, Chalk (calcium carbonate)
! Phosphate
" Calcium pyrophosphate, dicalcium phosphate
dehydrate
o Dulls teeth requiring a polishing agent to be added (restore
luster)
! Aluminum, calcium, tin, zirconium
! Chalk and silica can both polish and abrade
o Dependent on
! Hardness of abrasive
! Size (slides have mm, I think its µm)
" Smaller (1mm) = polish
" Larger (20mm) = abrasive
! Shaper
! If done wrong:
" Brushing technique
" Pressure on brush
" Hardness of strokes
• Humectant (20-40%)
o Purpose: Maintain moisture, prevent evaporation and
hardening, extends shelf life
o Requires use of preservative to prevent bacterial growth
o Top humectants:
! Sorbitol, mannitol, glycerol, propylene glycol
• Binder (2%)
o Thickening or binding agents to stabilize formula
! Prevents solids from settling out
o Examples: Natural gums, synthetic cellulose, seaweed colloids
• Foaming agent (1-2%)
o Soaps
! Used in early toothpastes as a cleansing agent
" Foaming aided in loosening/removing debris
! Disadvantages:

" Irritation to mucosal membrane
" Nauseating taste difficult to mask
" Incompatibility with other ingredients like calcium
o Detergents
! SLS – sodium lauryl sulfate – MOST WIDELY USED
! Stable and compatible with other ingredients
! Some antimicrobial properties
! Flavor easy to mask
! Low surface tension
" Allows flow of dentifrice over teeth
" Neutral pH
! May cause irritation especially if patient has oral
mucosal disease like herpes or allergies
" Some dentifrices marketed as low SLS for this
reason
" SLS free: Biotene, pro-namel/reg Sensodyne
• Flavoring agent (2%)
o This is the main reason we use to pick our dentifrice
! Product appeal linked to flavor
o Flavor needs to be pleasant, immediate, last for a reasonable
amount of time
o Synthtic flavors (majority used): Spearmint, peppermint,
wintergreen, cinnamon, vanilla, citrus
o Essential ois: thymol, menthol, eucalyptol, methyl salicylate
• Sweetners (2%)
o Early Sweetners:
! Sugar and honey – lower pH, cariogenic
o Non-cariogenic sweetners:
! Saccharin, cyclamate, xylitol
! Sorbitol, mannitol, glycerin (also in humectant list)
ADA stipulations
• Must contain fluoride
• Cannot contain sugar
Therapeutic dentifrice – therapeutic agent – 5%

• Anti-caries
• Anti-hypersensitivity
• Anti-gingivitis
Anti-Caries
• First accepted therapeutic by ADA in 1960
o Stannous fluoride – issue was it stained teeth
• Fluoride- most common used therapeutic agent
• Most OTC toothpastes are 1000ppm
o Aim extra strength – 1500ppm
• Types of fluoride
o Sodium Fluoride (NaF) – 0.22% at 1100ppm
o Sodium monofluorophosphate (MFP) – 0.76% at 1000ppm
! Colgate
o Stannous Fluoride (SnF 2 ) 0.4% at 1000ppm
! Crest
• Not all fluorinated toothpastes have anti-cavity effects – need
certain amount
o Max ppm established by FDA – 1450ppm
o Crest clinical is 1415ppm
• Stannous fluoride
o Activity against caries, plaque, gingivitis
o Used in Crest Pro-Health
! Stabilized stannous fluoride – 0.454%
! Sodium hexamataphophate
! Research shows superior efficacy in
" Antimicrobial
" Plaque acidogenicity
" Gingivitis/ gingival bleeding
" Calculus control
! Approved for multiple benefits
Anti-hypersensitivity
• Potassium nitrate – penetrates dentinal tubules causing
depolarization of neurons and preventing repolarization

• Strontium Chloride and Sodium Citrate – blocking of exposed dental
tubules
• ADA seal for anti-hypersensitivity effects
Anti-gingivitis
• Stannous Fluoride – Crest Pro-Health
• Triclosan – broad spectrum antibacterial agent – Colgate
• Essential Oils – Listerine total care (same stuff that’s in their
mouthwash, just more concentrated)
Baking Soda Toothpastes
• Contains:
o Small amount of bicarbonate
o Silicate
o Standard fluoride compatible abrasives
• ADA seal (if it has it) is NOT due to baking soda
• Not any more effective than regular toothpaste
Cosmetic
• Purpose is to clean and polish the teeth
• Tartar control toothpaste (not recognized by ADA)
o Crystalline growth inhibitors interrupt process of
mineralization
o Soluble pyrophosphates
o ADA seal NOT awarded for anti-calculus claim
o Does NOT change tooth color
• Whitners
o May 1998: guidelines for whitening product implemented
o Controls stain through
! Physical method – abrasives (intermediate level)
! Chemical method – surface active agents or bleaching
agent/oxidizing agent
" NO Bleaching agent in USA toothpastes
! Polishing or chemical agents that remove stain
" Hydrated silica, titanium dioxide, hydrogen
peroxide, carbamide peroxide

! Whitening toothpaste may carry seal for removal of
surface stain
• Biotene and similar Products
o Contains beneficial bio-active enzymes found in saliva
! Helps to maintain oral environment
! Helps provide protection against dry-mouth
o Contains NO sodium lauryl sulfate (SLS)

11/9/10 2:02 PM
3 types of staining:
• Stain may adhere directly to the tooth
• Stain is contained within the plaque and calculus
• Stain is incorporated in the tooth structure
Classified by location
• Extrinsic – occurs on external surface of the tooth
• Intrinsic – occurs within the tooth
Classified by source
• Exogenous – originate from sources outside the mouth
o Can be intrinsic or extrinsic
• Endogenous – originate from withing the tooth
o ALWAYS INTRINSIC
Stains are not considered etiologic factors for any dental disease. Therefore
removal is for esthetic purposes only.
Extrinsic Stains
Yellow stain
• Dull, yellowish discoloration of plaque
• Common in all ages
• Associated with presence of dental plaque
• Usually related to poor oral hygiene
• Etiology: usually food pigments
Green stain
• Light or yellowing green to a very dark green
• Embedded in plaque
• Usually found on facial cervical third of maxillary anteriors
• Often covered with layer of gray debris or material alba
• Dark green stain may become incorporated into tooth surface
• May occur at any age, but primarily childhood
• Etiology: poor oral hygiene, chromogenic bacteria and gingical
bleeding

Black line stain
• Forms along cervical third near gingival margin
• Continuous or interrupted fine line, about 1mm wide with no
thickness
• Appears black at base of pits/fissures
• Composed of microorganisms embedded in intermicrobial substance
(gram positive rods, primarily actinomyces)
• Attached via pellicle-like structure
• All ages, more common in children and women
• Tends to reform after removal
• Predisposing factors: ?, natural tendency
Tobacco stain
• Light brown to dark leathery brown/black
• Usually diffuse staining of dental plaque; may be incorporated into
calculus
• Heavier deposits (especially from chewing tobacco) may become
intrinsic
• Usually cervical 1/3, pits and fissures, frequently on lingual
• Composition: tar products
• Predisposing factors: natural tendencies
Other brown stains
• Stannous fluoride
• Foodstuffs
• Anti-plaque agents
• Betel leaf
Orange or red stain
• Usually appear at cervical third
• More frequently on anterior teeth rather than posterior
• Rare
• Etiology: chromogenic bacteria
Intrinsic stains
• Pulpless teeth (yellow-brown to gray to brown to bluish-black)

• Drugs (tetracycline)
• Restorative materials
• Imperfect tooth development (hypoplasia, fluorosis, genetics)