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November 29-December 5, 201022 Perio Tribune United Kingdom Edition the restorative course contact: 0845 6046448 website: www.advanceddentaleducation.com the prep course page 21DTß References 1. Siegrist AE, Gusberti FA, Brecx ML, Weber HP, Lang NP. Efficacy of supervised rinsing with chlorhexidine digluconate in comparison to phenolic and plant alkoloid com- pounds. J Periodont Res Suppl 60, 1986 2. Gusberti FA, Sampathkumar P, Siegrist BE, Lang NP. Microbiological and clinical effects of chlorhexidine gluconate and hydrogen peroxide mouthrinses on developing plaque and gingivitis. J Periodontol 15: 60, 1988 3. Svantun B, Gjermo P, Eriksen HM, Rolla G. A comparison of the plaque-inhibiting effect of stannous fluoride and chlorhexidine. Acta Odont Scand: 35:247, 1977. 4. Hefti AG, Huber B. The effect on early plaque formation, gingivitis and salivary bacterial counts of mouth- washes containing hexitidine/zinc, aminfluoride/tin or chlorhexidine. J Clin Periodontol 1987; 14:515 5. Fazi MI. Photographic assessment of the antiplaque properties of sangui- narine and chlorhexidine. J Clin Periodontal 1988; 15:106 6. BASSO ET AL. A modified mouthwash, to reduce the discoloration caused by Chlorhexidine. Dental Cadmos, set 76 (7), 2008. 7. Jones CG. Chlorhexidine: is it still the gold standard? Periodontal 2000 1997: 15: 55-62 8. Bernardi F, Pincelli MR, Carloni S, Gatto MR, Montebugnoli L. Chlorhexidine with an anti discoloration system. A comparative study. Int J Dent Hyg. 2004; 2: 122-6. 9. Addy M, Sharif N, Moran J. A Non-saining Chlorhexidine mouthwash? Probably not: A Study in vitro. Int J Dent Hyg. 2005;3:2:59-63 10. Cortellini P, Labriola A, Zambelli R, Pini Prato G, Nieri M, Tonetti M. Chlorhexidine with an Anti Discoloration System after periodontal flap surgery: a cross-over, randomized, triple-blind clinical trial. J Clin Periodontol 2008; 35: 614-620. 11. Barkvoll P, Rölla G, Svendsen AK. Interaction between chlorhexidine digluconate and sodium lauryl sulphate in vivo. J Clin Periodontol 1989; 16:593-595 12. Carretero Pelaez MA, Esparza Gomez GC, Figuero Ruiz E, Cerero Lapie- dra R. Alcohol-containing mouthwashes and oral cancer. Critical analysis of literature. Med Oral 2004: 9: 120-123, 116-120. 13. Carretero Pelaez MA, Esparza Gomez GC, Figuero Ruiz E, Cerero Lapiedra R. Alcohol-containing mouthwashes and oral cancer. Critical analysis of literature. Med Oral 2004: 9: 120-123, 116-120. 14. Jenkins S, Addy M, Newcombe R: Evaluation of a mouthrinse containing chlorhexidine and fluoride as an adjunct to oral hygiene. J Clin Periodontol 1993; 20: 20-25. 15. Ostela I, Karhuvaara L, Tenovuo J: Comparative antibacterial effects of chlorhexidine and stannous fluoride-amine fluoride containing dental gels against salivary Streptococci mutans. Scand J Dent Res 1991; 99: 378-383.; Meurman JH: Ultrastructure, growth, and adherence of Streptococcus mutans after treatment with chlorhexidine and fluoride. Caries Res 1988; 22: 283-287. 16. Quirynen M, Soers C, Desnyder M, Dekeyser C, Pauwels M, van Steenberghe D. A 0.05% cetyl pyrid- inium chloride/0.05% chlorhexidine mouth rinse during maintenance phase after initial periodontal therapy. J Clin Periodontol 2005; 32: 390-400. 17. Albert-Kiszely A, Pjetursson BE, Salvi GE, Witt J, Hamilton A, Persson GR, Lang NP. Comparison of the effects of cetylpyridinium chloride with an essential oil mouth rinse on dental plaque and gingivitis – a six-month randomized controlled clinical trial. J Clin Periodontol 2007; 34: 658-667. 18. Gunsolley, JC. A meta-analysis of six-month studies of anti-plaque and anti-gingivitis agents. JADA 2006, 137: 1649-1657. This issue of chlorhexidine and dental discolouration is more difficult to resolve, making most CHX mouthwashes inap- propriate for long-term use. However, this major issue looks to have been resolved thanks to the inclusion of an an- ti-discolouration system, known for short as ADS, which is thought to significantly reduce the likelihood of discolouration and taste interference with- out in any way diminishing the plaque-fighting effects of CHX. Recent studies undertaken in 2004,8 20059 and 200810 to assess this claim have shown that not only did a chlorhexi- dine ADS formulation perform better in terms of the stain in- dex14 , but that CHX ADS was just as effective at controlling plaque formation and reducing gingival inflammation in post- operative patients as more tradi- tional forms of 0.2 per cent CHX mouthwashes.15, 16 The efficacy of chlorhexi- dine is also significantly dimin- ished by its interaction with several anionic compounds found in detergents such as so- dium lauryl sulfate (SLS) that are commonly added to tooth- paste.11 This means that in general, patients need to wait for a full 30 minutes after brush- ing before rinsing in order to get the full benefits out of their chlo- rhexidine mouthwash. However, the use of SLS-free toothpaste can help patients get around this issue, even getting a double dose of CHX when using an SLS-free paste containing Chlorhexidine. Many chlorhexidine-based mouthrinses also contain alco- hol, which has been known to cause irritation of the oral mu- cosa, leading to a stinging or burning sensation in the mouth. Currently, over-the-counter brands of mouthwash can con- tain anything between 18- and 26 per cent alcohol. Whilst there have been suggestions of a link between the alcohol content and oral cancer, a critical analysis of literature12 has failed to find evidence of a direct casual link and so far, the studies have been inconclusive. However, the same study also concluded that there is no evidence that alcohol improves the effectiveness of anti-plaque agents.13 As demand for non- alcoholic mouthwashes has increased, the need to develop effective chlorhexidine-based mouthwash products with re- duced negative side effects has become ever greater. Addressing this demand, several manufac- turers have risen to the chal- lenge to develop an alcohol-free chlorhexidine mouthwash. In an effort to rectify the prob- lems associated with chlorhexi- dine, several studies have looked at alternatives such as combin- ing agents (ie sodium fluoride and cetyl pyridinium chloride) with CHX. There is evidence to sug- gest that, when used together in low concentrations, the com- bination of CHX and fluoride provide added benefits to pa- tients, including the prevention of caries and the remineralisa- tion of teeth, and whilst also act- ing as an efficient prophylactic against oral diseases.14 There is also evidence to suggest that this combination is effec- tive in tackling oral pathogens such as streptococcusmutans.15 Another long-term16 study sought to examine the anti- bacterial capacity and side ef- fects of an ethanol-free lower concentration of chlorhexidine (0.05 per cent), combined with 0.05 per cent cetyl pyridin- ium chloride, and found that it had an anti-plaque effect comparable with that of a 0.2 per cent chlorhexidine + alcohol solution, but with reduced sub- jective side effects: slightly less staining and better taste. How- ever, such combinations, whilst effective, do not completely re- move the problem of alcohol and the clear trend away from its inclusion in mouth rinses for a number of reasons, including stinging and burning. Another chemical plaque- control agent that has been studied is essential oils. In a six- month randomised controlled clinical trial,17 a commercially available mouth rinse contain- ing essential oils was compared with an experimental mouth rinse containing 0.07 per cent cetylpyridinium chloride and found both to be effective in re- ducing gingivitis and the propor- tions of periodontal pathogens. Furthermore, a meta-analysis of six-month studies18 found six studies that showed essential oils to be effective as both an anti-plaque and anti-gingivitis agent, comparable with the re- sults achieved by 0.12 per cent chlorhexidine. However, essen- tial oils have the disadvantage of poor substantivity and, in some cases, an unpleasant bitter taste and burning sensation. Conclusion: Although chlorhexidine is the ‘gold standard’ in antimicrobial rinses, in general it is not con- sidered suitable for long-term use due to a number of factors, including discolouration and altered taste sensations, which are likely to make patient com- pliance problematic. DT About the author Following his de- gree in biochemis- try, Howard Tho- mas’s early career was in the pharma- ceutical industry, where he worked for a number of the large multination- als before becom- ing was CEO of Merck for 11 years. After leaving Merck, Howard set up his own company Britannia Health Products. Britannia Health Products developed and launched the world’s first Evening Primrose Oil product (Efamol), which became market lead- er and really established the market for health supplements. Subsequently, Howard introduced Imedeen, a natu- ral product for preventing wrinkles and damage to the skin caused by free radicals and ultra violet light which received tremendous press cover- age as a breakthrough in the preven- tion of premature skin ageing when it was launched. Since1980, Howard has worked with many research groups developing “natural remedies” and has been involved with many health-relat- ed organizations. He set up his own nutritional supplement companies for the human and veterinary markets and also has been director of a number of biotechnology start-up companies in the Cambridge area. Until recently, his principle activity was as Chairman of Life Plus Europe, a successful multi- level marketing company supplying nutritional products on a personal im- port basis throughout Europe. In Jan- uary 2001, he sold that business to the US affiliate and is now taking a much more active role in the management and product development of Oraldent Ltd. Howard is focusing on developing a range of natural products for the den- tal market. The dental market in terms of product development has been ne- glected by companies, yet over 90% of the population has some form of gum disease and suffer form minor to se- vere discomfort.