Final Antiseptics Powerpoint

Antiseptics and Periodontology

DefinitionAn antiseptic is a substance which

inhibits the growth and development of microorganisms. It:

Is a chemical antimicrobial agent Destroys microorganisms & inhibits

their reproduction or metabolism.

Functions For practical purposes, antiseptics are

considered as topical agents:1. For application to skin, mucous

membranes, and inanimate objects.2. In periodontology, applied topically or

subgingivally to mucous membranes, wounds, or intact dermal surfaces

AntibioticsChemical substances that: kill and stop the growth of bacteria. act by interfering with the cell wall &

protein synthesis and nucleic acid metabolism.

are broadly classified as bacteriostatic,

What is the difference between Antibiotics and Antiseptics?

Antibiotics acts against bacteria while antiseptics are effective against a wide variety of microorganisms.

Antibiotics kill and stop the growth of bacteria while antiseptics prevent the growth and development of the microorganisms without necessarily killing them.

Antibiotics are used internally as well as externally, but antiseptics most often used externally.

ClassificationsBis-biguanides

Quaternary Ammonium Compound Phenolics

IodophoresAmine-Alcohols

Oxygenating AgentsNatural Products

Pyrimidines

Bis-biguanides The most common Bis-biguanide is Chlorhexidine.

It binds to different surfaces within the mouth including teeth , mucosa, pellicle and saliva.

Chlorhexidine has been formulated in a number of products including, mouth rinses, gels, tablets, varnishes and chewing gum.

Bis-biguanides Chlorhexidine (CHX) is a broad-spectrum

biocide effective against Gram(+) & bacteria, Gram(-) bacteria and fungi.

Mechanism of action -CHX is a positively-charged molecule that binds to the negatively-charged sites on the cell wall; it destabilizes the cell wall and interferes with osmosis.

The bacterial uptake of the chlorhexidine is very rapid, typically working within 20 seconds. In low concentrations it affects the integrity of the cell wall.

Structure of Chlorhexidine

Anti-plaque Activities

The effective blocking of acidic groups of salivary glycoproteins will reduce their adsorption to hydroxyapatite and formation of acquired pellicle.

The ability of bacteria to bind to tooth surfaces may be reduced by adsorption of CHX to the extracellular polysaccharides of their capsules or gylcocalyces.

The CHX may compete with calcium ions for acidic agglutination factors in plaque.

Without brushing, Chlorohexidine will reduce plaque by 60 % and gingivitis by 50-80% using 10 ml of 0.2% mouth rinse twice daily

Gel-1%, .2% and .12% are now available

Commercially Available Examples

Mouth Rinses› Aqueous alcohol solutions of 0.12% and 0.2% chlorhexidine

rinses.› Also available are alcohol-free chlorhexidine rinses.

Gels › 1% Chlorhexidine gel product is available.

• Corsodyl

• Savacol

Tablets › Lozenges with 2mg chlorhexidine gluconate for

disinfecting the oral cavity . Usually prepared as sugar free , making it suitable for diabetics

Varnishes› Available varnishes cannot maintain a significant

suppression of Strep. Mutans for 6 months. ( repeated application needed)

› Clorzoin, EC40 and Cervitec

Biodegradable Chip› Slow release chip for controlled delivery of

chlorhexidine directly to the periodontal pocket. Chip biodegrades and releases chlorhexidine within the pocket over 7-109 days, used as an adjunct to scaling and root planning.

Quaternary Ammonium Compounds

This is a group of cationic surface active agents that possess the ability to bind with the bacterial cell membrane, that have the ability to affect its permeability with subsequent loss of cell content.

They are bactericidal to both gram positive and gram negative , but are thought to be more effective against gram positive bacteria.

Structure

Formulations

Two of the groups Cetylpyridinium chloride (CPC) usually at 0.05% with and without domiphen bromide and benxethonium chloride at a similar concentration have been used in mouthwahses.

They work by disrupting membrane function, causing leakage of cytoplasmic material and ultimately this leads to collapse of intracellular equilibrium.

Formulations cont’d Mouthrinses combining Cetylipyridium

chloride with Chlorhexidine (CHX 0.05% + CPC 0.05% + Zinc lactate 0.14% or Chlorhexidine 0.12% + CPC 0.05% non-alcoholic formulation) are available and compare well with established Chlorhexidine products.

Both significantly reducing plaque and gingivitis as well as monitoring halitosis with a decreased number of side effects.

Commercially Available Examples

Formulations cont’d A non-degradable osmotic slow-release

dosage form containing 6.6 mg CPC (Mucosal oral therapeutic system) and CPC lozenges Cepacol (each containing 1.6 mg CPC).

Phenols Phenolic compounds are used as both

antispetics and antibiotics. Triclosan, a bisphenol and nonionic

germicide with low toxicity and broad antibacterial activity spectrum, is available in dentrifices and mouthwashes.

Phenolics High killing activity and broad

spectrum of effect against bacteria , spores ,viruses and fungi (10-25 % sporicidal)

250-500ppm-bacteria 300-3000ppm bacterial spores 2000ppm 15-20mins in activate

enterovirus

Structure

Mechanism of Action The mechanism of action is not clearly

understood. Due to its hydrophobic and lipophilic nature, triclosan adsorbs to the lipid portion of the bacterial cell membrane and in low concentrations interferes with vital transport mechanisms.

Inhibitory effect on primary enzymes (cyclooxygenase and 5-lypoxygenase) in the pathways of arachidonic acid metabolism and this leads to a decreased production of proinflammatroy metabolites such a PGE2 and Leukotriene B4

Formulations Tricolosan in dentrifices Since it does not bind well to oral sites due to its

lack of strong positive charge, formulations have been developed to enhance its ability to bind to plaque and teeth. These include:

1. Combinations with Zinc Citrate to take advantage of potential anti-plaque and anti-calculus properties.

2. Incorporation of triclosan in a copolymer of methoxytheylene and maleic acid to increase its retention time

3. Combinations with pyrophosphates to enhance its calculus reducing properties

Commercially Available Examples

Formulations Triclosan in mouthwashes Reduction in plaque and gingivitis

ranges from 24-36% and from 23-46% respectively.

Iodophores 12.5 ppm sanitizing solution. Used to sterilize

instruments Optimal concentration 3.5% beyond which

additional effect negligible Povidone-iodine is most widely used, it is a

complex of elemental iodine and the surfactant povidoneIdophour (active) N-vinyl

pyrolidone

Mechanism of Action Iodination of lipids and oxidation of

compounds (protein and nucleic acid)

Iodophores When used as a component in a rinse with hydrogen

peroxide it can decrease the levels of gingivitis. Can be used as an adjunct to scaling and root planning in

the treatment of periodontitis. Also used as a subgingival irrigation by means of a syringe.

Amine-Alcohols Mode of action- Alcohols denature

proteins by breaking the hydrogen bonds that link oppositely charged hydrogen and oxygen atoms on different parts of the chain-like molecules.

Works best against microorganisms at about 70% concentration, as it is easily absorbed by cells, which allows optimal penetration into the cell.

Structure of Amine-Alcohols Isopropanol is more effective against

bacteria

Delmopinol offers 0.1-0.2%

Oxygenating Agents Most common: Hydrogen Peroxide 3% concentration

It releases nascent oxygen which is highly reactive. It combines with and oxidizes necrotic matter and bacteria.

Oxygenating Agents Sodium peroxyborate / Sodium peroxycarbonate

Available in mouthwash and gel forms .

Sodium peroxyborate products show evidence of efficacy in the treatment of acute ulcerative gingivitis.

Natural Products Sanguainarine: Structure

The mechanism of action is not clearly understood.

Herb and plant extracts have been used in oral hygiene products for years.

Sanguinarine and zinc toothpaste and mouth rinses have shown some antimicrobial action.

But Studies show that these products increase the likelihood of developing oral precancerous lesions.

Natural Products

Detergents Sodium lauryl sulfate (SLS) is one of the

most widely used synthetic detergents in dentrifices.

In general, surface active agents are thought to lower the surface tension and penetrate and loosen surface deposits, emulsify or suspend the debris, which the abrasive in a dentrifice removes from the tooth surface.

Sodium lauryl sulfate is an anionic molecule with a high affinity for protein molecules.

Detergents cont’d Concentration in dentrifices usually range from

0.5-2.0% It may have an antagonistic effect with CHX.

This is due to an ionic attraction of CHX, a cationic bis-biguinide symmetrical molecule, to SLS, a molecule with an anionic nature and a high affinity for protein molecules.

Recommended time between brushing with a SLS containing dentrifice and a CHX rinsing is 30 mintues, if a reduction in anti-microbial effect is to be avoided.

Relate the application of antiseptics to concepts of

bacterial biofilm and plaque hypotheses.

Basic Plaque FormationThe mechanisms of plaque formation include: Adsorption of proteins and bacteria to form a film

on the tooth surface. The effect of van der Waals and electrostatic

forces between microbial surfaces and the film to create reversible adhesion to the teeth.

Irreversible adhesion due to intermolecular interactions between cell surfaces and the pellicle.

Secondary colonizers attach to primary colonizers by intermolecular interaction.

The cells divide and generate a biofilm.

Antimicrobials used in periodontal treatment can be divided into two main groups: Agents directed against supragingival

plaque development Agents directed against subgingival

bacteria.

SUPRAGINGIVAL PLAQUE CONTROL

Terminology Plaque Inhibitory Effect- reducing plaque to levels

insufficient to prevent the development of gingivitis. Anti-Plaque Effect- one which produces a prolonged

and profound reduction in plaque sufficient to prevent the development of gingivitis.

Anti-Gingivitis- an anti-inflammatory effect on the gingival health not necessarily mediated through an effect on plaque.

Substantivity- the ability of drugs to adsorb on to and bind to soft and hard tissues. It is affected by the concentration of the medicine, the pH and temperature and the length of time of contact of the solution with the oral structures.

Bisbiguanide Antiseptics – They kill a wide range of microbes by damaging the cell wall.

Chlorhexidine The anti-plaque properties of Chlorhexidine has much

greater effects than other antiseptics of similar or greater antibacterial activity.

Probably due to the adsorption of the dicationic Chlorhexidine molecule on to the oral surfaces and its release at bacteriostatic levels for prolonged periods.

Chlorhexidine is a synthetic antimicrobial agent effective in vitro against Gram-positive and Gram-negative bacteria, yeasts, fungi, aerobes and anaerobes.

A study by Noiri et al(2003) investigated the effects of Chlorhexadine and P. Gingivalis in artificial biofilms in an intraoral device.

Chlorhexidine reduces the adherence of Porphyromonas Gingivalis to epithelial cells by affecting the bacterial outer membrane and was therefore effective in reducing the viability of P. Gingivalis biofilms.

It’s antibacterial action is due to an increase in cellular membrane permeability followed by coagulation of the cytoplasmic macromolecules.

It has been shown to be an effective anti-plaque and anti- gingivitis agent.

When used as an adjunct to normal oral hygiene practices, it is more effective in reducing plaque accumulation on a clean tooth surface than in reducing pre-existing plaque deposits.

Thus, Chlorhexadine mouthwash should be given to patients only after the necessary periodontal treatment has been performed.

Chlorhexidine has high substantivity since it maintains effective concentrations for prolonged periods of time thus suitable for inhibiting plaque formation.

Quaternary Ammonium Compounds

Cetylpyridinium Chloride (CPC) Although they have greater initial oral retention and equivalent

antibacterial activity to Chlorhexidine, they are less effective in inhibiting plaque and preventing gingivitis.

This may be due to the rapid desorption of the compounds from the oral mucosa.

It has also been found that the antibacterial properties of these compounds are reduced once adsorbed on to a surface, which may be related to its monocationic nature.

The cationic group of each molecule bind to the receptors on the mucosa producing mucosal retention but because of the monocationic nature of these molecules, there are few unattached sites available for antibacterial function.

A CPC pre-brushing mouthrinse used as an adjunct to mechanical oral hygiene has not been found to have a beneficial effect on plaque accumulation (Moran and Addy 1991).

Conventional use, according to Jenkins et al (1994), compared plaque inhibitory effect of 0.05% and 0.1% CPC and 0.05% Chlorhexidine and control mouthrinses used twice daily for four days with non-brushing.

The 0.1% CPC had lowest plaque scores and produced limited but statistically significant inhibitory plaque growth but 0.05% CPC and Chlorhexidine had too low a total dose to yield an effect.

The short duration of the study made it impossible to detect anti-plaque effect on gingivitis.

A slow release system with CPC has been tried to increase the retention time of CPC in the mouth. This showed no change on the efficacy of the CPC.

A study by Sheen et al 2001 showed that toothpaste use before and particularly after mouthrinses, significantly reduce tooth staining and plaque inhibitory effects. Thus antiseptics should best be used about 2-3 hours after tooth brushing.

Phenolic Antiseptics They may be used alone or in combinations, in mouthrinses or

lozenges for a considerable time. When used at higher concentrations relative to other

compounds, they have been shown to reduce plaque accumulation(Lusk1974).

Listerine® has been shown to have moderate plaque inhibitory effects; possibly due to poor oral retention. It has some anti-inflammatory effects which may reduce the severity of gingivitis.

Thus it has been accepted by the American Dental Association to be used as aid in home oral hygiene measures.

A study by Moran 1995 compares the effects of Listerine ® on 4-day plaque regrowth during abstinence from mechanical oral hygiene, from Chlorhexidine and anti- adhesive mouthwashes.

0.2% Chlorhexidine mouthwash was more effective than Listerine ® which in turn was more effective than anti-adhesive mouthwash.

Pyrimidine-Hextidine

It has some plaque inhibitory activity but this is low in comparison with Chlorhexidine.

It’s substantivity is between 1-3 hours which accounts for the plaque inhibitory effect of Oraldene®.

It can cause oral ulcerations with concentrations more than 0.1%.

Hextidine combined with zinc improves its plaque inhibiting activities by acting synergistically with it.

Iodophores- Povidone-Iodine

Appears to have no significant anti- plaque activity when used as 1% mouthwash.

The absorption of significant levels of iodine is unsatisfactory for prolonged use within the oral cavity and may cause iodine sensitivity.

Triclosan A non ionic antiseptic which lacks the staining effect

of cationic antiseptics. Moderate plaque inhibitory effect when used with zinc

as a mouthwash or toothpaste, due to possible synergistic effects.

Triclosan itself has little or no substantivity but oral retention can be increased by combination with copolymers of methoxylene and maleic acid.

May act as an anti-inflammatory agent in mouthrinses and toothpaste. This depends on its ability to penetrate the gingival tissue and the nature of the solvent in the mouthwash formulation.

Shown to reduce gingival inflammation better than mechanical brushing alone(Saxton 1986).

Oxybenzone A phenolic compound similar to triclosan. Tested in vitro for its ability to inhibit prostaglandin E2

(PGE2) following oxybenzone exposure. Aids in reducing gingivitis.

Amine Alcohol-Delmopinol

Amine Alcohols like Octapinol Hydrochloride has shown to inhibit plaque accumulation and reduces gingivitis ( Colleart 1992).

Limited substantivity compared to Chlorhexidine and inhibits salivary bacteria for only 30 minutes as compared to several hours for Chlorhexidine(Moran 1992).

It may be plaque inhibitory since it interferes with plaque matrix formation and reduces bacterial adherence. It also inhibits the growth of dextran producing streptococci. Thus producing loosely adherent plaque that is more easily removed upon mechanical brushing.

Thus should be used as pre-brushing mouthwash.

Salifluor An effective anti-plaque agent but the mechanisms

for it being an effective anti-microbial and anti-inflammatory agent is not fully understood.

Further studies need to be done before released for clinical usage.

Natural Products - Sanguinarine

Contains the chemically reactive iminium ion, which appears to be retained in plaque for hours after its use.

Sanguinarine mouthwashes has significant plaque inhibitory effects but no effect on gingivitis. Toothpastes used without mouthwash, have shown no detectable plaque inhibition or anti-inflammatory effects. This may be due to the other components of the toothpaste binding to the chemically reactive site of the sanguinarine molecule.

Oxygenating Agents Hydrogen peroxide, buffered sodium peroxyborate

and peroxycarbonate in mouthwashes have beneficial effects on acute ulcerative gingivitis, possibly by inhibiting anaerobic bacteria.

There is some retardation of plaque growth and is useful against the development of obligate anearobes in formation of gingivitis and periodontitis.

SUBGINGIVAL PLAQUE CONTROL

They are applied locally into the periodontal pocket via slow release agents and are an adjunct to scaling and root planing.

Gingival crevice and periodontal pockets are not reached by chemical agents in mouthwashes or toothpastes, whose main activity occurs with supragingival plaque and not really in treatment of gingivitis and periodontitis.

Recently there has been local drug placement of antibiotics and antiseptics into the periodontal pocket.

Chlorhexidine Most common antiseptic to be used via pocket

irrigation using 5ml syringe and blunt needle in either a liquid or gel form.

It may be delivered via slow release agents but these are not commercially available.

Comparative studies have shown that Chlorhexidine is not as effective as opposed to tetracycline or metronidazole(Joyston- Bechal 1986) in changing the bacterial microflora and reducing gingivitis.

However, it does not allow for bacterial resistance and may be suitable for repeated use.

Chlorhexidine pocket irrigation is useful as an adjunct to scaling and root planing deep pockets, especially when there is marked inflammation.

Applications of Antiseptics in Periodontology

Antiseptics, delivered via rinsing and irrigation, have been shown to be effective in controlling gingivitis, but not periodontitis. The agents generally are not retained at the site long enough for their antimicrobial effect to provide a measurable benefit to pocket depth and/or attachment levels. They are best used for short periods of time to efficiency and to minimise side effects.

Chlorohexedine As an adjunct to oral hygiene and professional prophylaxis of periodontal

patients. Improving oral hygiene and gingival health of medically and physically

handicapped groups. In patients with intermaxillary fixation where oral hygiene is difficult. Medically compromised patients predisposed to oral infections with

particular reference to oral candidiasis. In patients with oral complications associated with cancer chemotherapy

(stomatitis, mucositis) chlorohexidine. In patient receiving fixed appliance orthodontic treatment. High risk caries patients Treatment of Candida associated infections Oral malodour management Immediate preoperative ultrasonic scaling Post-op periodontal surgery and root planing In patient with recurrent oral ulcerations Well-localized acute periocoronitis Acute necrotizing ulcerative gingivitis Acute periodontal abcess

Essentials Oils Supports gingival health around implants After periodontal surgery in the early postoperative phase. Reduces bacteremia following ultrasonic scaling Reduces malodour for up to 3hrs.

Iodophores Used as plaque disclosing agents Severe gingivitis to reduce bacteremia Post-op scaling and root planing in medically compromised patients As an adjunct to mechanical scaling in periodontal infections

Discuss the side effects of antiseptics and

methods of minimizing the side effects.

TOOTH, TONGUE & DENTURE STAINING <10%

Possible causes:1. Degradation of the CHX molecule

to release parachloroaniline2. Catalysis to Maillard reactions3. Protein denaturation with metal

sulfide formation4. Precipitation of anionic dietary

chromogens5. Exacerbated by smoking, heavy

plaque and calculusBy-products bind to the surfaces of tooth, denture & tongue and cause brown pigmentation.

Bis-Biguanides

MINIMIZATION OF EFFECTS

1. Addition of different products such as peroxiborate, polyvinyl pyrrolidone or sodium metabisulfate, ascorbic acid and an anti-discolouration system to CHX in order to reduce brown pigmentations.

2. Limiting the intake of foods and beverages (tea, red wine & coffee) during treatment with CHX especially if it’s just the CHX formulation present in agent.

3. Brushing of teeth with conventional toothpaste just before use of CHX mouth rinse.

4. Clean denture with denture cleanser before use of CHX.5. Removal of stains by scaling and in this regard ultrasonic scaling is the

most effective method.6. Severely restriction of CHX use in patients with visible anterior

composite and glass-ionomer restorations.7. Reduction of the concentration of CHX.8. Use for short periods. No longer than 2 weeks. 9. It is also worth stating that chlorhexidine formulations which donot

stain are ineffective in inhibiting plaque.

HYPOGEUSIA <10%1. Reduced ability to taste2. Concerns only salt and bitter,

not sweet and sour.3. Thought to involve blockage of

taste receptors for affected taste modalities.

4. Will last for days after interruption of mouthrinses.

MINIMIZATION OF EFFECTS

1. Usually diminishes with continued use.

2. Chlorhexidine concentration in mouthwashes till 0.12% and mucosa exposure not exceeding 60" twice a day, seem the best procedure to protect tastes in clinical practice.

3. Used after meals for better food appreciation.

4. Addition of flavour agents.5. Do not rinse with water

after use to avoid washing away of flavour masking agents.

IRRITATION OF MUCOSAL MEMBRANES (<1%)

1. This includes burning, epithelial desquamation, erythema and peeling.

2. Rare

MINIMIZATION OF EFFECTS1.Burning will ease after continued use.2.Dilution of the mouthwash using 5ml water with 10ml mouthwash, freshly mixed, will often allow continued use of the mouthwash.3.Discontinue use if ulceration and peeling present.

TOOTHACHEPeridex has caused mild to moderate toothache, which often resolved spontaneously and required no further treatment.

HYPERSENSITIVITY REACTIONS 1. Includes allergic reactions or

anaphylaxis.2.  Persons may experience urticaria,

dyspnea, and anaphylactic shock.3. Very RARE.4. Usually due to accidental ingestion of

the chlorhexidine formulation.

MINIMIZATION OF EFFECTS1. Discontinue use.2. Seek medical attention

immediately.3. Do not give to teens or

children.4. 3-5mls of 1:1000 epinephrine

given to avoid death from AS.

PAROTID GLAND SWELLING1. Swelling of the parotid glands

during the use of oral chlorhexidine has been reported.

2. Very RARE

ENHANCED SUPRAGINGIVAL CALCULUS FORMATION (Varied)

1. Thought to be due to precipitation of salivary proteins onto tooth surface, thereby increasing pellicle thickness &/or inorganic salts precipitation on pellicle layer.

MINIMIZATION OF EFFECTS

1. Discontinue use.2. Spontaneous resolution has

occurred on discontinuing treatment.

MINIMIZATION OF EFFECTS

1. Studies indicate need for biofilm disruption prior to the start of CHX mouthrinses in order to reduce side effects. Is currently debatable.

TOOTH STAINING1. All CPC formulations produced tooth

staining and this was worst with the CPC lozenges.

2. Agents are categorized as cationic, which favors their attraction to tooth surfaces and bacterial plaque.

3. Clearance of the Cetylpyridinium chloride is rapid from oral cavity. Appears to last only 3-5 hours due to either loss of activity once adsorbed or rapid desorption. Thus CPC frequency of use must be doubled to 4 times daily to ensure adequate efficacy. However this results in an increase in tooth staining.

Side effects can also include oral ulceration and a mild burning sensation of the tongue. Quaternary ammonium compounds may also have a lingering bitter taste. 

MINIMIZATION OF EFFECTS1. Use of mouthrinses with

combination formulations of CHX (0.05, 0.12%) and CPC (0.05%) have shown reduced staining and other side effects.

2. Brushing of teeth with conventional toothpaste just before use of CPC mouth rinse.

3. Clean denture with denture cleanser before use of CPC.

4. Removal of stains by scaling and in this regard ultrasonic scaling is the most effective method.

5. Other side effects are mild and transitory.

6. Flavouring agents added to mask bitterness.

QUATERNARY AMMONIUM COMPOUNDS

Triclosan is generally non-toxic to humans. However the FDA had stated evidence from studies which show that triclosan may cause photoallergic contact dermatitis (PACD), which occurs when the part of the skin exposed to triclosan is also exposed to sunlight.

Concern that widespread triclosan use is leading to antimicrobial resistance.

The disadvantage of Listerine is its high alcohol conc. (21.6-26.9%) which, may exacerbate xerostomia. Side effects also include transient tingling/burning sensation and bitter taste.

MINIMIZATION OF EFFECTS

1. Side effects are of Listerine are transient and usually disappear quickly after use.

2. Ensure proper removal of triclosan containing dentrifices from skin surfaces that may be exposed to sun.

3. Discontinue use.

Phenolics & Essential Oils

Povidone-iodine may give rise to allergic reactions, including itching, burning, and reddening and blistering in the area of application, so a patient's history of allergy to iodine or shellfish must be evaluated. Prolonged iodide intake can inhibit thyroid hormone synthesis and cause goiter, myxedema, or hyperthyroidism.

Transient hyperthyroidism

MINIMIZATION OF EFFECTS

1. Povidone-iodine should not be used in patients with

thyroid dysfunction; pregnant woman, infants, or

in routine patient self-care as it may lead to iodine

induced hypothyroidism.

Iodophores

Pyrimidines: Hexetidine Side effects are usually mild. Very rare hypersensitive rxns; very rare, transient changes in taste; erosive effects on enamel; staining of tooth & composite restorations; erythema, slight epithelial desquamation and burning. Concentrations greater than 0.1% will cause oral ulceration.

MINIMIZATION OF EFFECTS1. Discontinue use if any of these side effects occur.

Use of 0.2% delmopinol hydrochloride includes tooth & tongue staining, taste disturbance, transitory numbness of the tongue and rarely mucosal soreness and erosion.

Octapinol has toxic effects. No longer on market.

MINIMIZATION OF EFFECTS

1. Discontinue use.2. Side effects lessen with

continued use.

Amine Alcohols

Salifluor Sanguinarine: No effects

known. Mechanism behind antimicrobial effects are not yet properly understood and as such further studies should be carried on salifluor to determine possible side effects.

Natural Products

Frequent rinsing with 0.2% sodium hypochlorite may produce a brown-black extrinsic discoloration of the teeth.

Irritation of mucous membranes at high concentrations.

MINIMIZATION OF EFFECTS1. Patients are also advised to rinse

orally with 0.2% sodium hypochlorite for 30 seconds, 2 or 3 times per week. This is equivalent to 8 mL (2 reduced teaspoonfuls) of 6% household bleach in 250 mL (a full glass) of water.

2. If irritation occurs, reduce the concentration or discontinue use.

Chlorine Compounds

Oxygenating Agents Chronic use of hydrogen peroxide causes serious side effects such as carcinogenesis, tissue damage, hyperkeratosis, oral ulceration and hyperplasia. To minimize effects use for short periods or discontinue use.

References Periodontics 6th ed. B.M.Eley, M. Soory, J.D. Manson. Antibiotics and Antiseptics in Periodontal Therapy. A. L.

Dumitrescu 2011. http://www.academia.edu/955997/Chemical_Antiplaque_Agent_-

_An_Update http://www.oralscience.com/en/documentation/articles/

periostat/Nonsurgical-Approaches-for-the-Treatment-of-Periodontal-Diseases.pdf

http://www.tufts.edu/med/apua/consumers/personal_home_21_4240495089.pdf

http://www.nature.com/bdj/journal/v186/n6/full/4800090a.html http://medical-dictionary.thefreedictionary.com/Antiseptics  http://www.ncbi.nlm.nih.gov/pubmed/11199690