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Definition

 Mouth washes are the solutions intended for


cleaning,refreshing and deodorizing mouth and also may
be used as therapeutic acids in treatment of
gingival/mucosal diseases.
 All mouth washes are liquids usually in the dominantly
aqueous form but many products may be prepared in the
solid/liquid concentration which are diluted with water just
for use.

 Alcohol/glycerol concentration have all been described as


mouth washes/preparations.
Mouth washes are broadly classified as
Astringent Mouth wash.
Antiseptic Mouth wash.
Buffered Mouth wash.
Deodorizing Mouth wash.
Therapeutic Mouth wash.
Astringent Mouth wash:
These shrink and protect the inflamed oral mucosa and
also serve the purpose of flocculating and precipitating
protein aqueous material so that it can be removed by
flushing.
Action Of Ingredients
1. ZnCl2:is an astringent,is also a powerful alkali used as
astringent mouth wash.ZnCl2 1-2% is used for
application to some fowl smelling wounds and ulcers and
10% as obtundant in dentistry.
2. ZnSO4:Astringent mouth wash is an astringent,it may be
given internally in doses upto 220mg thrice a day to
assist wound healing and used as astringent lotion for
indolent ulcers 0.25%.
3. Dilute HCl:ZnCl2 contains oxychlorides which give
turbidity to preparation,this makes it clear.
4. CHCl3 water:Flavoring agent.
5. Water:vehicle
Uses:It is used for removal of proteinaceous debris from
mouth and for stomatitis.
Antiseptic Mouth wash
Primary purpose is to remove & destroy bacteria found
in large nos. in oral cavity,infections of
mouth,deodorizing mouth.
 These are mouth washes that contain antiseptic
compounds and are intended for use to remove or
destroy bacteria that are normally found in large nos. in
oral cavity.hence these may be used in following
conditions:
1. Before and after tooth extraction.
2. Glossitis.
3. Infections-gingivo-stomatitis.
4. Palatal Ulceration.
5. Healing of wounds,preventing of wounds and other
sequele after gingivectomy.
Antiseptics used in mouth washes
 Phenolic compounds:These phenolic antiseptics have
bacteriocidal effects against a large no. of
microorganisms and microbiocidal effects may be
produced by surface acting agents.
a. Phenol-Exerts mild local anaesthetic effects on oral
mucous membrane.Used in 0.1-1% concentration.
b. B-Napthol-Used in concentration of about 0.3-0.5% in
solution of alcohol or water.
c. Thymol-0.1% solution is used.
d. Hexyl Resorcinol-0.3-0.5% solution is used.
e. Hexachlorophene-0.02% is used.
 Other Antibacterial compounds:
a. Benzoic acid-Exerts antibacterial effect in the oral cavity
and is quite innocuous to the mucous membrane and
tooth structure but does not have a disagreeable taste.
b. Potassium chlorate-has been employed for oral
infections.but may be absorbed by tissues to produce
haemoglobinurea.
c. Tyrothycin &Granicidin-These are sufficiently stable in
aqueous solution to permit their use in mouth washes.
d. Boric acid-is used in concentration of 2-4%.
e. Cetyl Pyridinium Chloride-Effective against wide
spectrum of bacteria and fungi and effective over a wide
range of pH.
f. Hydrogen peroxide-Treatment of NUG & inflammations.
Action of Ingredients
 Hexyl Resorcinol-Antiseptic.
 Glycerin-Sweetening agent and weak antiseptic.
 Clove oil-Flavoring agent,counter irritant and analgesics.
 Ethyl alcohol-Increases solubility of hexyl resorcinol.
 Water-vehicle.
 Ascorbic acid-Antioxidant,reducing agent.
Buffered/Alkaline Mouth wash
These are mouth washes alkaline in nature & are helpful
in reducing stringy saliva & making mucous less viscid
and also help to liquefy the viscid mucous in the mouth
by dispersion of proteins.
Action of Ingredients:
 NaCl-makes solution iso-osmotic.
 NaHCO3-renders the mucous less viscous and reduces
stringy saliva & mucous by dispersion of proteins.
 Peppermint oil-Flavoring agent.
 Chloroform water-Flavoring & preservative agent.
Uses:As mouth washes when there is stringy saliva &
thick mucous in the mouth,bal oral hygiene infections.
 Commercial mouthwashes rinses contain an active ingredient
to reduce the no. of oral microorganism,a flavoring agent,an
astringent,ethyl alcohol,& water.The active ingredient may
or may not have therapeutic qualities,but usually it provides
a temporary benefit through mechanical reduction of oral
microorganisms.The astringent(e.g.,citric acid,zinc
chloride)provides an invigorating sensation in the mouth,&
the flavoring agent provides the pleasant taste.The ethyl
alcohol acts as a solvent.(11% and 27% alcohol).
 Therapeutic mouthwashes are available for control of dental
caries,bacterial plaque,& gingivitis. Mouthwashes do not
have a therapeutic effect on sub gingival periodontopathic
microorganisms because they do not penetrate subgingivally.
 Antibacterial mouth rinses are recommended for use prior to
& during professional oral hygiene care.Pretreatment rinsing
can reduce the no. of microorganisms in the oral cavity &
hence reduce aerosol contamination occurring during dental
hygiene care procedures.
 A term that helps in evaluating chemotherapeutic oral
rinses is substantivity.Substantivity is the ability of an
active agent to be retained in the oral cavity & to continue
to be released over an extended period of time without
losing its potency.
 Oral antimicrobial rinses are divided into first-generation
agents & second-generation agents.
 They are antibacterial,but they have less sub-stantivity.
 Second-generation agents have antibacterial activity plus
proven substantivity.
 Chlorhexidine has high substantivity.
Classification

 Depending upon their antimicrobial efficiency & relative


substantivity,they are categorized as follows:
I Generation agents - Antibiotics,Phenols,Quaternary
ammonium compounds & Sanguinarine.These reduce the
plaque by about 20-50% & their efficiency is limited by
their poor retention in the mouth.
II generation agents - Bisbiguanides:These reduce plaque
scores by 70-90% more effectively retained by oral tissues
& released slowly.
ENZYMES ANTIBIOTICS PHENOLS

Mucinase Penicillin Thymols

Dehydrated Vancomycin Triclosan


pancreas
Lactoperoxidase Kanamycin

Mutanase Erythromycin

Dextranase Nidamycin

Hypothiocyanite
QUATERNARY BISBIGUANIDE METALLIC
AMMONIUM S SALTS
COMPOUNDS
Benzethonium Chlorhexidine Zinc(mentadent P)
chloride
Benzalkonium Alexidine Copper
chloride
Domiphan bromide Bispyridine Zinc

Herbal Extracts – Sanguinarine.


Amino Alcohols – Octaperol,Decaperol.
Other surfactants – Sodium Lauryl Sulphate.
Classification of Antiplaque
agents
I. Cationic surfactants
1. Bisbiguanides –
Chlorhexidine,digluconate,Alexidine,Octanidine
Action : Antimicrobial.
2. Quaternary Ammonium Compounds –
Cetyl pyridinium chloride,Benzalthonium
chloride,Benzalkonium chloride,Domiphen
bromide,Pyrimidine derivatives-e.g.Hexatidine
Uses : Mouthwashes.
II. Phenolic Compounds
1. Zisterine –
Thymol-0.06%,Eucalyptus-0.04%,Methyl salicylate-
0.06%,Methanol-0.04%
2. Triclosan –
3. Resorcinol –
Action : Antimicrobial,anti-inflammatory.
Products : Mouth rinse,Toothpaste.
III. Herbal Extracts – Sanguinarine.
IV. Heavy metal Salts – ZnCl2,CuS04,Stannous
fluoride,Amine Fluoride.
Action : Antimicrobial.
Products : Toothpaste,mouth rinse,gels.
V. Enzyme
Protease,Lipase,nuclease,Dextranase,Mutanase,Glucose
oxidase,Aminoglucosidase.
Action : Plaque removal,antimicrobial.
Products : Toothpaste.
VI. Anionic Surfactants
1. Amino alcohols – Octaperal,decaperol.
Action : Plaque matrix inhibition.
2. Detergents – Sodium Peroxyborate,Hydrogen peroxide.
Action : Antimicrobial,Plaque removal.
Product : Mouth rinse.
VII. Antibiotics
Penicillin,Vancomycin,Spiromycin,Kanamycin,Niclomycin.
Action : Antimicrobial.
Chlorhexidine(Hibitane)
 It is a cationic chlorophenyl bisbiguanide with bacteriostatic &
bacteriocidal action.It is an antiplque agent.The most common
preparation is with digluconate salt because of higher water solubility.
 Composition-Chlorhexidine
gluconate,Alcohol,Glycerine.Saccharine,Flavoring agent.
 Mechanism of Action-
• Chlorhexidine adsorbs to the surface of oral tissues including teeth & is
taken slowly as it is released slowly in its active form.Approximately
30% of 10ml solution of 0.2% Chlorhexidine bonds to oral surfaces.
• The cationic chlorhexidine molecules binds to anionic compounds such
as free sulphate,carboxyl or phosphate groups of pellicle & salivary
glycoproteins & thereby reduce the absorption of proteins to tooth
surface required for formation of dental pellicle.
• Coating salivary bacteria with chlorhexidine molecules also alters the
mechanism of adsorption of bacteria to tooth surfaces.
SITE MECHANISM SEQUENCE
OF ACTION OF ACTION
1.On dental plaque Chlorhexidine Impaired pellicle
blocks acidic formation.
salivary glyco-
proteins which
reduce absorption
of hydroxyapatite.
2.On bacterial It is absorbed on Reduced ability of
capsule extra cellular bacteria to bind to
polysaccharides of surface.
bacterial capsule.
3.On plaque mass It inactivates Impaired
glycosyl adherence.
transferase.
Antibacterial Activity
 Chlorhexidine has wide spectrum of activity for encompassing gram
+ve & gram –ve bacteria.It is also effective against
Staphylococci,Streptococcus mutans,salivarius E-Coli,salmonella.
 At physiological pH chlorhexidine has a large dicationic molecule with
positive charge distributed over the nitrogen atoms on either side of
haemotoxyline bridge.
 The cationic chlorhexidine molecule is rapidly attracted to negatively
charged bacterial cell surface with specific & strong adsorption to
phosphate containing compounds.
 This alters the integrity of bacterial cell membrane & chlorhexidine is
attracted towards the inner cell membrane.
 Chlorhexidine binds to plaque on inner membrane & causes leakage of
low molecular weight compounds such as I2 ions.
 This implies that the structural changes by low levels of chlorhexidine
are minor compared with gross damage caused by increased
concentration of agents.
 Retention in the mouth
 Chlorhexidine is an effective antiplaque agent primarily
because of its retention in the mouth.
 After a mouth rinse of 10ml 0.2% aqueous soln of
chlorhexidine for 5 min. approximately 30% of the drug is
retained in the mouth.

 Modes by which chlorhexidine inhibits plaque formation:


 The effective blocking of acidic group of salivary
glycoproteins will decrease their adsorption to
hydroxyapatite & formation of acquired pellicle.
 The bacterial adherence to the tooth surface may be
reduced by the adsorption of chlorhexidine to the extra-
cellular polysaccharides of their capsule of glycocalyx.
 Chlorhexidine may compete with Ca++ for acidic
agglutination factors in plaque.
 Adverse Effects
 Discolouration of teeth.
 Brown extrinsic strains are formed on tooth surface.
 Painful desquamative lesion of oral mucosa.
 Transient impairment of taste specially salty taste.
 Uses
 Immediately after periodontal surgery.
 During post operative period after removal of periodontal
dressing as mechanical plaque control will not be possible
effectively.
 In patients whom mechanical plaque control is impaired like
in point with fixed orthodontic appliances,inter maxillary
fixation,physically & mentally handicapped patients.
 In poorly motivated patients.
 To control plaque accumulation.
 Medically compromised patients.
Uses(contd….)
 As antiseptic cream.
 Used as subgingival irrigation after scaling & polishing in
patients with periodontal pockets.
 Used as prophylactic rinse in dental treatment like scaling &
extraction.
 Used in gingivitis,periodontitis,acute necrotising ulcerative
gingivitis,HIV,Candidiasis infection.
 Instrument sterilization.
 Surgical scrub.
 Pre surgical skin cleaners.
 Chlorhexidine is used as prophylactic rinse in dental
treatment like scaling,extraction and as alcohol in ultrasonic
scalings.
 Contraindication
 In patient known to be hypersensitive to chlorhexidine
gluconate.
 Precautions are advised for use in pregnancy,nursing
mothers & in children under 18.

 Therapies used
 Short term therapy – 2 teaspoons in a cupful of water twice
daily for 8-10days(10ml of 0.2% chlorhexidine)
 Long term therapies – 1 teaspoon of chlorhexidine in 1%
dilution for 15-20days.Patient is instructed to rinse his
mouth and not to eat or drink for ½-1 hour.
Stannous Fluoride
 Stannous fluoride(SnF2) has more antiplaque properties
than sodium fluoride(NaF).
 It is the stannous ion,not the fluoride that has greatest
antimicrobial effect.Tin from the stannous ion enters the
cell,clogs the metabolism,and affects the growth and
adherence properties of the bacteria.
 Numerous animal and clinical studies demonstrated that
stannous fluoride reduces dental plaque and some have
also indicated a decrease in gingivitis.
 Several 0.4% stannous fluoride gels carry the ADA Seal of
Acceptance for anticaries activity and safety.
Phenolic Compounds(Essential
Oils)
 Listerine has received the ADA Seal of Acceptance ,an agent for
reduction of bacterial plaque and gingivitis.
 Listerine is a mixture of three phenolic-derived essential oils –
thymol,menthol, and eucalyptol,which is combined with
methylsalicylate.
 The mechanism of action appears to be related to alteration of
the bacterial cell wall.This product has a low substantivity and
is safe.
 Adverse effects reported have been a burning sensation,bitter
taste,and a possible staining of teeth.
 Studies indicate that bacterial plaque can be reduced by 25 to
28% and gingivitis can be reduced by an average of 30%.
Sanguinarine
 Sanguinarine, a benzophenathridine alkaloid,is an alcohol
extract from the root of the plant Sanguinaria canadensis.
 It is marketed as a mouth rinse and a dentrifrice.
 The activity os sanguinarine is attributedits ability to
interfere with bacterial glycolsis and bind to plaque to
prevent adherence of microorganisms.
 Sanguinarine is retained for about 2 to 4 hours in the
mouth.It is less effective than chlorhexidine and no side
effects are observed.
 However, a consistent degree of efficacy has noy been
documented.
 Effectiveness is enhanced when both the mouth rinse and
the dentifrice are used.
Quaternary Ammonium
Compounds
 Quaternary Ammonium Compounds have been evaluated
an average plaque reduction of 35% less than baseline
scores has been reported.
 Cepacol and Scope are well-known representatives of this
group with concentrations of 0.05 and 0.045%
cetylpyridinium chloride(CPC).
 The mechanism of action is related to increased bacterial
cell wall permeability that favors lysis,decreased cell
metabolism,and a decreased ability for bacteria to attach to
tooth surfaces.
 They alter surface tension and have a low substantivity.
Oxygenating Agents
 Several products containing oxygenating agents are
available.
 The American Academy of Periodontology has published a
review of oxygenating agents.
 Long term studies have shown no beneficial effects on
reductions in bacterial plaque and gingivitis when
compared to controls.
 Safety is an issue with hydogen peroxide.Chronic use of
hydrogen peroxide has been to cause serious side effects
including carcinogenesis,tissue damage,hyperkeratosis.oral
ulcerations,hyperplasia,and black hairy tongue syndrome.
 Short-term use of oxygenating oral rinses is intended for
oral wound cleansing.A soothing effect has been reported.
Prebrushing Rinses
 Plax is a prebrushing mouth rinse containing sodium
benzoate and other nontoxic surfactants.It contains 7.5%
alcohol.
 Short-term studies have shown some reductions in
bacterial plaque,however, a number of investigations have
shown effect no plaque reduction when compared to a
placebo.
 Reductions in gingivitis have not been documented.
 Sodium content contraindicates use for clients on sodium-
restricted diets.