Effect of Chlorhexidine Varnish on Mutans

Streptococci in Plaque and its effect on Gingival

status in Patients undergoing Orthodontic treatment
-An In-vivo study



Dissertation submitted to
THE TAMILNADU DR. M.G.R MEDICAL UNIVERSITY
in partial fulfillment for the Degree of
MASTER OF DENTAL SURGERY



BRANCH - V

ORTHODONTICS

FEBRUARY 2005


CERTIFICATE

This is to certify that this dissertation titled, EFFECT OF
CHLORHEXIDINE VARNISH ON MUTANS STREPTOCOCCI IN PLAQUE
AND ITS EFFECT ON GINGIVAL STATUS IN PATIENTS UNDERGOING
ORTHODONTIC TREATMENT- AN IN VIVO STUDY, is a bonafide
record of work done by Dr. MITHUNA VASUDEVAN under my guidance
during her postgraduate study period between 2002-2005.

This dissertation is submitted to THE TAMILNADU DR. M.G.R MEDICAL
UNIVERSITY in partial fulfillment for the award of the degree of Master of Dental
Surgery in BranchV Orthodontia

It has not been submitted (partially of full) for the award of any other degree
or diploma


Guide:

Dr. Ashwin Mathew George, M.D.S Dr. N.R. Krishnaswamy, M.D.S
Reader Professor and Head
Department of Orthodontics Department of Orthodontics
and Dentofacial Orthopedics and Dentofacial Orthopedics
Ragas Dental College Ragas Dental College
Chennai Chennai




Dr. S. Ramachandran
Principal
Ragas Dental College
Chennai


CONTENTS


S.No. Title


1. INTRODUCTION


2. REVIEW OF LITERATURE


3. MATERIALS AND METHODS


4. RESULTS


5. DISCUSSION


6. SUMMARY & CONCLUSION


7. BIBLIOGRAPHY


















INTRODUCTION
The orthodontic patient due to the presence of brackets ,bands,
arch wires, springs and other orthodontic components is hampered in
maintaining adequate oral hygiene. Decalcification and periodontal
problems are common iatrogenic side effects of orthodontic treatment.
Orthodontic appliances provide opportunities for the collection
and retention of food and debris and also protect the plaque from the
actions of brushing, mastication, and salivary flow. The increased food
retention permits luxuriant bacterial growth
Decalcification or white spot formation during orthodontic
treatment has been a problem since the introduction of fixed appliances.
White spot formation represents an unaesthetic side effect of orthodontic
treatment. Enamel decalcification results from an imbalance between the
demineralization and remineralization of enamel. The white spot lesion
is considered to be the precursor of enamel caries. Plaque retention
surrounding orthodontic appliances leads to enamel demineralization
caused by organic acids, produced by bacteria in the dental plaque
Significant increase in salivary and plaque levels of streptococcus
mutans is seen as early as the first week after placement of the
appliance. These organisms are associated with the initiation and
development of caries and especially colonize retentive tooth sites.
As a number of persons with significant carious and periodontal
challenges are candidates for orthodontic treatment there is a need for
combating this double menace of decalcification and gingival
inflammation . The practice of orthodontics is constantly in search of
new techniques and materials that benefit both the patient and the
clinician Therefore it would be of great clinical benefit if a chemical
agent could be used during the active phase of orthodontic treatment to
reduce the bacterial plaque accumulation, thereby improving the
gingival conditions and possibly reducing the incidence of caries and
periodontal disease in these patients
Although topical administration of various mouth rinses during
treatment minimizes these problems, patient compliance to perform
adequate oral hygiene and delivery of rinses at home is often poor. A
mechanism whereby protection could be delivered to the oral cavity
independent of patient cooperation would certainly benefit both patient
and orthodontist.
Chlorhexidine is one of the most widely used broad spectrum
antibacterial or antiseptic agents in dentistry. Chlorhexidine mouth
rinses have proven to be very effective in the maintenance of plaque
control and gingivitis without developing resistant organisms in the oral
flora. Unfortunately some of the side effects of using chlorhexidine
mouth washes that limit its wide spread use among patients include
brown staining of the teeth, the difficulty in completely masking its taste
when used as a rinse, a dulling of taste and epithelial desquamation.
Therefore a way to overcome the adverse side effects of
Chlorhexidine mouth rinses would be to use a local delivery system
which limits its action to just the area required. It has also been
suggested that chlorhexidine combined with thymol in a varnish could
has the following effects: a desensitizing effect on the teeth, lowering
the bacterial activity in plaque while maintaining an ecologic balance
and excellent adsorption to the tooth surface and good tolerance by the
patient.
The aim of this study was to evaluate the effect of chlorhexidine
varnish on streptococcus mutans in plaque as well as to evaluate the
effect of the varnish on gingival health. A varnish containing a
combination of 1% chlorhexidine and 1% thymol Cervitec (Ivoclar
Vivadent, Liechtenstein) was evaluated in a split mouth design in order
to facilitate comparison with the opposite untreated quadrant. The
clinical relevance of this study would be the evaluation of an agent for
the dual purpose of combating both decalcification and gingival
inflammation in orthodontic patients.
REVIEW OF LITERATURE
DECALCIFICATION and STREPTOCOCCUS MUTANS

Shannon Ira (1981)
62
stated that decalcification and caries
around and under orthodontic bands has long been recognized as
problems of clinical significance and the orthodontic patient is at
advanced risk in this respect. The recommendation of this study was
that all orthodontic patients should use daily the 0.4% SnF2 gel or the
0.1% SnF2 mouthrinse . Shannon and West showed that there was an
overall reduction of decalcification for all patients who used the gel
daily; irregular users received very little protective benefit, It was clear
that patient compliance in an imposed program of prevention is crucial,
and that benefit is directly related to the degree of cooperation shown by
the individual patient.
According to Gorelick, Geiger, and Gwinnett (1982)
29
white
spots or areas of decalcification are carious lesions of varying extent. It
was found that individual teeth, banded or bonded, exhibited
significantly more white spot formation than was found in the control
group. In the bonded teeth the study revealed that the mandibular
posterior (15 per cent) and maxillary anterior (14 per cent) teeth had the
highest incidence of white spot formation. The maxillary lateral incisors
had the highest incidence of decalcification (21 per cent), which was
almost three times as frequent as that found for the central incisors. The
maxillary and mandibular canines and premolars had a high incidence of
white spots and, when related to the control group, the increase for these
teeth was disproportionately high.
Mizrahi (1982)
45
performed a cross-sectional study carried out to
determine the prevalence and severity of enamel opacities in patients
before and after orthodontic treatment. The results showed that there
was a significant increase in both the prevalence and severity of
decalcification following completion of orthodontic treatment. This
study showed that orthodontic treatment with multibanded appliances
contributed to the development of new areas of enamel demineralization
and to an increase in the severity of enamel opacities
Mizrahi (1983)
46
carried out another cross-sectional study to
determine the prevalence and severity of enamel opacities occurring on
different surfaces of the dentition as well as the distribution of these
lesions on individual teeth following orthodontic treatment. The results
showed that following orthodontic treatment there was a significant
increase in the prevalence of enamel opacities on the vestibular and
lingual surfaces of the dentition. The increase was significantly greater
on the cervical and middle thirds of the crown. Among individual teeth,
there was a statistically significant increase in the prevalence and
severity of enamel opacities on the maxillary and mandibular first
molars, the maxillary lateral incisors, and the mandibular lateral incisors
and canines. The increase was greatest on the cervical and middle thirds
of the vestibular surface of these teeth.
O'Reilly and Featherstone (1987)
53
determined quantitatively
(1) the amount of demineralization and (2) the ability of commercially
available products to inhibit or reverse orthodontically related
demineralization. The study demonstrated that measurable
demineralization occurred around orthodontic appliances after only 1
month and this demineralization can be completely inhibited and/or
reversed by the use of commercially available fluoride products. They
also suggested that considerable mineral loss can occur without being
observed by the clinician emphasized the importance of early and
constant preventive therapy if demineralization is not to continue
gaard, Rlla, and Arends (1988)
48
performed a clinical trial to
investigate carious lesion development associated with fixed orthodontic
therapy. Specially designed orthodontic bands for plaque accumulation
were attached to premolars scheduled to be extracted as part of an
orthodontic treatment. Visible white spot lesions were seen within 4
weeks in the absence of any fluoride supplementation. Both
microradiographic and SEM examinations showed surface softening of
the enamel surface. Enamel demineralization associated with fixed
orthodontic therapy is an extremely rapid process caused by a high and
continuous cariogenic challenge in the plaque developed around
brackets and underneath ill-fitting bands. Careful inspection of the
appliance at every visit and preventive programs are therefore required.
gaard, Rlla, Arends, and ten Cate (1988)
49
conducted
clinical experiments to investigate the effect of fluoride on carious
lesion development and on lesions established during fixed orthodontic
therapy. The remineralizing capacity of saliva was found to be rapid in
the absence of any fluoride. Although white spot lesions may
remineralize and even disappear, most of the emphasis should be
directed against prevention rather than treatment of carious lesion
development during treatment with fixed orthodontic appliances
gaard (1989)
50
In the present study the prevalence of white spot
lesions on the vestibular surfaces was recorded in 19-year-olds
subjected to and not subjected to orthodontic treatment. On the average,
5.7 years had elapsed since orthodontic appliances were removed. The
median white spot score was significantly higher in the orthodontic
group than in the untreated group. The orthodontically treated subjects
also had more teeth with white spot lesions than the untreated subjects..
The present study showed that white spot lesions after orthodontic
treatment with fixed appliances may present an esthetic problem, even
more than 5 years after treatment.
Rosenbloom and Tinanoff ( 1991)
57
evaluated salivary
Streptococcus mutans levels in patients before, during, and after
orthodontic treatment. S. mutans levels were significantly elevated
during active treatment. Such an alteration in the oral flora may be a
factor in the increase in enamel decalcification (white spot lesions) often
seen during orthodontic therapy. However, when sampled 6 to 15 weeks
into the retention phase of treatment, the microbial levels decreased
significantly to levels comparable to age-matched untreated controls. In
addition, patients who were no longer wearing any retention appliances
had S. mutans levels similar to those subjects sampled in the retention
phase of treatment as well as to subjects in age-matched control groups.
The findings of the study suggest that orthodontic treatment does not
result in any long-term elevations of S. mutans levels.
Geiger, Gorelick, Gwinnett, and Benson (1992)
30
this study was
designed to identify the effect of a self-administered fluoride rinse and
to evaluate the effect of procedures designed to influence patient
compliance with the rinsing regimen. Only 12% of patients were judged
excellent compliers, and more than 50% complied very little or not at
all.
The more closely patients adhered to the daily use of the sodium
fluoride rinse, the more likely they exhibited a decrease in the
occurrence of white spot lesions.The efforts to improve compliance with
the rinse protocol were, however, unrewarded.Despite educational
efforts and supply of rinse free of charge, only 13% of the patients
complied fully with its use, thus suggesting further investigation into
methods to improve motivation and compliance.
Matasa (1995)
40
suggested that microbes accumulate on
restorative materials. Among these, Mutans streptococci are known to
cause secondary caries at the margins of composite restorations as well
as directly attacking the enamel.
The colonies of Streptococcus mutans develop fast, aggressively
attack the adhesive. Microorganism accumulation on adhesives can
possibly be culprits for premature debonding and eventually caries and
diseases.
Eliades, Eliades, and Brantley( 1995)
25
the authors concluded
that Stainless steel presented the highest critical surface tension and
total work of adhesion, indicating an increased potential for
microorganism attachment on metallic brackets. The lowest surface
tension values were obtained from the polycarbonate and ceramic
alumina material. Accordingly, reduced plaque-retaining capacity is
expected from the polycarbonate and ceramic alumina brackets relative
to the stainless steel appliances.
John R,Prabhu NT, Munshi AK,(1996)
37
examined whether the
commonly prescribed short term antibiotic therapy for the treatment of
acute infections in children affects the levels of salivary streptococcus
mutans over a period of time. Another aim was to find out if there was
any co relation in the quantification of salivary streptococci using
culture and staining methods. 20 children between the ages of 3-12 who
reported for the treatment of acute bacterial infections were the subjects
of this study. Salivary samples were collected before and after the
initiation of the antibiotic therapy.a significant decline was seen in the
level of streptococcus mutans for a period of 12 weeks.
Andr Fournier et al (1998)
28
suggested that metallic
orthodontic brackets have been found to induce specific changes in the
buccal environment such as decreased pH, increased plaque
accumulation, and elevated S. mutans colonization. Thus, metal brackets
impose a potential risk for enamel decalcification.
Ali Y A, et al (1998)
1
attempted to correlate the caries status
(caries free, caries average, rampant caries) with cfu counts and
Snyders test. The Streptococcus mutans was isolated from saliva
samples using MSB agar and cfu was determined for each individual.
The saliva was also drooled into a bottle containing Snyders agar and
the color change was noted after 24, 48, and 72 hours after incubation at
37 degrees C. It was found that in general the subjects with low caries
experience had low cfus, while the individuals who had average caries
experience had moderate levels of cfus and those with rampant caries
had high levels of cfu of streptococcus mutans. Thus a definite
correlation was established between caries experience, cfu of
streptococcus mutans and Snyders test.
Bader JD et al (2001)
6
presented a systematic review of periodic
scientific literature to determine the strength of the evidence for the
efficacy of professional caries preventive methods applied to high risk
patients. Seven studies reporting 11 evaluations of preventive
interventions conducted on teeth with orthodontic bands were reviewed.
In the short term studies titanium tetra fluoride, sodium fluoride varnish,
plaque removal by swabbing and prophylaxis, and a combination of
fluoride and chlorhexidine rinse all showed a significant decrease in the
mean depth of demineralization or percent of sites with
demineralization. Among long term evaluations, fluoride based
interventions all resulted in significant reductions in percentage of
demineralization or number of initial lesions in subjects. The authors
judged the evidence for efficacy to be insufficient, for any given method
given the small sample sizes, low quality scores and small number of
studies per method.
According to AKL Wan et al (2002)
71
although a few growth
media are available for the selective isolation of cariogenic bacteria
S.mutans, it is still unclear as to which is the most efficacious. This
study compared the selectivity and sensitivity of five different media for
growing a laboratory strain of S.Mutans and for enumerating S.mutans
from teeth of a group of young children aged 2-10 years.
Mitis Salivarius (MS) agar was one of the first media to be
developed as a specific media for culturing streptococci species. Later it
was used to identify the S.Mutans on basis of its unique colony
morphology. However extensive serial dilution was needed and false
negatives and underestimations were possible. With the addition of
0.2U/ml of Bacitracin and 20% sucrose to MS media lead to an
improved media MSB with a high selection of S.mutans. Tryptone-
Yeast-Cysteine-Sucrose-Bacitracin (TYCSB) was the most sensitive and
selective of all media but it is an expensive media and is laborious to
make.
Policy on Use of a Caries-risk Assessment tool (CAT) for
Infants, Children and Adolescents.
54
Originating Council: Council on
Clinical Affairs, Adopted 2002.
The American Academy of Pediatric Dentistry (AAPD)
recognizes that caries risk assessment is an essential element of
contemporary clinical care for infants, children and adolescents. A
practical tool for assessing caries risk in infants, children and
adolescents has been so far lacking. The table in this article is a first step
towards incorporating available evidence into a concise practical tool to
assist both dental ad non dental health care providers in assessing the
risk for caries development in infants, children and adolescents. Each
childs ultimate risk classification is determined by the highest risk
category where a risk indicator exists. i.e. the presence of a single risk
indicator in any area of the high risk category is sufficient to categorize
the child as being at high risk.
Wearing dental or orthodontic appliances is a clinical condition
indicative of high risk according to the AAPD.
CHLORHEXIDINE
Balanyk, Sandham (1985)
7
developed two microbial varnishes
to be applied to the teeth for the eradication of streptococcus mutans
infection. One of them contained chlorhexidine acetate and the other
erythromycin base as the microbial agent. Both varnishes contained
Sumatra Benzoin as base. Both varnishes were shown to be highly
effective against S. mutans and to be compatible with the benzoin base.
When applied to extracted teeth both dried to form a tough adherent and
transparent layer. Dried samples of the varnish when suspended in a
frequently changed buffer released their microbial agents at low but
bactericidal levels for at least 12 days. After the first day the
chlorhexidine varnish showed zero order kinetics.
HJ Sandham, et al (1991)
59
evaluated in a randomized double
blind clinical trial the ability of a Chlorhexidine containing varnish to
reduce salivary levels of Mutans Streptococci in 51 adults. The
varnishes applied once weekly for 4 weeks ,were held in place with a
covering layer of either of two polyurethane sealants. After treatment
there was a highly significant difference between the groups due to the
dramatically lower level of organisms in Chlorhexidine treated groups
compared with their respective placebo controls and to the prophylaxis
only group. There was a highly significant reduction of mutant
Streptococci regardless of the type of sealant used. By contrast the group
receiving only prophylaxis showed no decrease in mutans Streptococci.
Sandham, Nadeau, Philips, (1992)
60
applied Chlorhexidine
Dental varnish the teeth of 26 children 10 to 17 years of age in an
attempt to limit the increase in colonization by Mutans Streptococci that
normally accompanies the placement of fixed Orthodontic appliances
and to asses the acceptance of the application procedure. Despite the
insertion of appliances in the month following the varnish application
the numbers of detectable salivary mutans Streptococci in the children
were found to remain significantly lower than baseline values for seven
months. No significant difference in effectiveness was observed
between varnish formulations containing 10 or 20 percent Chlorhexidine
acetate or between children of different ages or past caries experience.
The lack of drop outs and the results of a questionnaire indicated that the
acceptance of the treatment by children was excellent. This study
indicate that chlorhexidine varnish therapy was acceptable to the
children and was effective in suppressing oral mutans streptococcal
levels for long period, even when used prior to the placement of fixed
orthodontic appliance
R Grenier (1993)
32
evaluated the effect of the antimicrobial agent
Chlorhexidine on Proteolytic degradation. Chlorhexidine was found to
prevent degradation of type I collagen by Porphyromonas gingivalis
cells. The mechanism of inhibition of Proteolytic degradation appears
to be associated to an electrostatic chlorhexidine-protein interaction.
Recently it has been demonstrated that chlorhexidine reduces plaque
accumulation as a result of both immediate bactericidal action during
application as well as a prolonged bacteriostatic action due to its
adsorption to the pellicle coating of the enamel surface. The
Glucosyltransferase from Streptococcus mutans which may be important
in dental plaque formation may be sensitive to chlorhexidine. In addition
the phosphoenol pyruvate phosphotransferase of this micro organism is
also inhibited by chlorhexidine.
S Twetman, A Hallgren, Petersson.(1995)
67
evaluated the effect
of an anti bacterial varnish Cervitec on the levels of mutans Streptococci
in plaque adjacent to bonded Orthodontic brackets was evaluated in 18
children using a split mouth technique with a placebo varnish control.
Both varnishes were applied on four occasions during a three month
period and plaque was subsequently collected between one week and six
months after the onset of treatment. The result showed a more frequent
growth of mutans Streptococci in the dental plaque collected from
placebo treated quadrants as compared with test quadrants on sampling
occasions. The proportion of mutans Streptococci within the Plaque
Microflora was significantly lower on the test sides than on the opposite
sides at the one week and one month examination. In conclusion this
study suggests that topical application of Cervitec varnish can
effectively suppress mutans Streptococci levels in plaque adjacent to
orthodontic appliance. It should be considered as a targeted preventive
action for patients undergoing Orthodontic treatment.
C Van Loveren, et al .(1996)
70
in an invitro demineralization
model investigated the protective effect of two Chlorhexidine varnishes
Cervitec and EC40 was compared with that of Fluor Protector, a varnish
containing chloride. The demineralization model comprised of an
acidogenic Streptococcus mutans suspension in Agarose placed on
enamel or dentin specimens. The experiment extended over three 22
hours demineralization periods with fresh S.Mutans suspension for each
period. EC40 gave the best protection to both enamel and dentin when
the varnishes were placed next to the specimens and left there during the
experiment. However when the specimens were only pre-treated, enamel
was best protected by the Fluoride varnish. Dentin was at least as well or
even better protected by the Chlorhexidine than by the fluoride pre
treatment. A long term protective effect of the pretreatment with the
Chlorhexidine varnishes was not found. A varnish containing both
fluoride and Chlorhexidine seems to be meaningful since it could give
protection to both enamel and dentin.
Samir E. Bishara, et al (1996)
9
determined whether the
application of .12% chlorhexidine paste as an antibacterial agent
affects the shear bond strength and debonding failure modes of
orthodontic brackets. The results of this study indicated that shear bond
strength was not significantly affected by treating the enamel surface
with various concentrations of fluorides and/or chlorhexidine. Treating
enamel with either chlorhexidine or fluoridated prophylactic pastes does
not significantly affect shear bond strength or bond failure location
during the removal of orthodontic brackets. As a result, the use of
chlorhexidine and fluoridated prophylaxis products to clean the teeth
before acid etching should be recommended as part of the bonding
protocol.
Paul L. Damon et al (1997)
22
determined whether the application
of chlorhexidine varnish to etched enamel affects the shear bond
strength and bracket/adhesive failure modes of orthodontic brackets.
The findings in this study indicate that treating the etched enamel
surface with a chlorhexidine-containing sealant does not significantly
affect shear bond strength or bond failure location during the removal of
orthodontic brackets. As a result, the use of a chlorhexidine-primer
mixture following acid-etching could be recommended as part of the
bonding protocol.
Samir E. Bishara, et al (1998)
10
determined whether the
application of chlorhexidine with or without a sealant, to the etched
enamel will affect the shear bond strength and the bracket/adhesive
failure modes of orthodontic brackets.
The findings in this study indicated that shear bond strength was
not significantly affected when chlorhexidine was applied; (1) over the
bracket and tooth surfaces after the bonding procedure was completed
(2) as a prophylactic paste over the unetched enamel surface before the
bonding procedure is initiated and (3) when the varnish was premixed
with the sealant and applied on the etched enamel surface .On the other
hand, in all the experimental groups in which the chlorhexidine varnish
was applied as a layer on the etched enamel surface or over the sealant,
shear bond strength values and bracket failure rates were of a magnitude
that made them clinically unacceptable.
AH Forgie, et al (2000)
27
The primary aim of this randomized
control clinical trial was to assess the efficacy of Chlorzoin in reducing
the caries increment in caries active adolescents. Secondary aims
included investigating the effect of compliance on caries increment, the
effect of Chlorzoin on mutans streptococci count. 1240 children ages
11-13 assessed to be high caries risk were recruited into this trial. The
results indicated that Chlorzoin had an initial effect in reducing the
Mutants Streptococci levels but had no long term reductions in caries
increment.
L G Petersson, K Magnusson, et al (2000)
56
Compared the
effects of two different dental varnishes on approximal caries incidence
in teenagers with a proven caries susceptibility during a three year
period.. 180 subjects participated and were randomly assigned to equally
sized groups. One group was treated with Fluor Protector a fluoride
varnish ( FV) containing 1% F every third month and the othe
participants were treated similarly every three months with Cervitec (
1% chlorhexidine- thymol varnish) (CV). In total each subject was
treated 12 times during the experimental period. At baseline and after
three years the differences between the two groups were not statistically
significant. In conclusion treatment every three months with either a
fluoride or chlorhexidine/thymol varnish showed a promising effect
with low approximal caries incidence and progression in teenagers with
proven caries susceptibility.
T J Snodgrass, et al (2001)
65
evaluated the ability of an
experimental coating Odyssey to prevent demineralization Ex Vivo was
compared with that of Duraphat a fluoride containing varnish and
Cervitec a chlorhexidine containing varnish. the control group exhibited
the greatest mean lesion depth and the group treated with Duraphat
demonstrated the least lesion depth. There was no significant difference
between any of the Odyssey groups. The chlorhexidine group did not
show any difference in comparison to the control group and the reason
could be that the test only evaluated the effectiveness of the
chlorhexidine varnish to act as a mechanical barrier and did not evaluate
its microbial efficacy.
Bjrn gaard, Samir E. Bishara et al (2001)
51
conducted a
randomized prospective clinical study, with 220 patients scheduled for
fixed orthodontic therapy, to test the hypothesis that application of an
antimicrobial varnish in combination with a fluoride varnish is
significantly more efficient in reducing white spot lesions on the labial
surfaces than application of the fluoride varnish alone The effects of the
antimicrobial varnish on the occurrence of gingivitis and plaque
formation were also studied. The antimicrobial varnish significantly
reduced the number of mutans streptococci in plaque during the first 48
weeks of treatment. This effect did not result in significantly less
development of white spot lesions on the labial surfaces compared with
the group receiving only the fluoride varnish application. There was
however a clear trend that the combination of the antimicrobial and
fluoride varnishes more effectively reduced the increments of new
lesions on the maxillary incisors.
J J De Soet, et al (2002)
24
determined whether a commercially
available 40% chlorhexidine varnish is able to reduce the number of
mutans streptococci and lactobacilli in the saliva in a moderately active
caries population in Surinam. At baseline and every 6 months a 40%
chlorhexidine varnish EC40 was applied. The control group received a
gel that did not contain chlorhexidine. The number of Mutans
streptococci and lactobacilli were evaluated every 12 months and the
study lasted for 30 months. The results indicate that the chlorhexidine
varnish did not decrease the number of mutans streptococci nor did it
prevent caries progression.
Without the elimination of the source of infection in a high
treatment need population a 40% chlorhexidine varnish is not likely top
decrease caries.
Baca P, Munoz et al (2002)
5
conducted a study to determine the
effect of chlorhexidine varnish on the prevention of caries in permanent
first molars. Two groups of children ages 6-7 were followed up in a
clinical trial, a group of 86 children whose teeth was treated with
Cervitec ( chlorhexidine thymol Varnish) and a control group of 95
children. The varnish was reapplied every 3 months and the caries
increment compared at 24 months.Results indicated that the decayed
and filled surfaces in the first molars was higher in the control group
than in the test group resulting in a 48.6% caries reduction.They
concluded that Chlorhexidine- thymol was effective in preventing caries
in permanent first molars.
Sumer M Alaki, Walter J Loesche, et al (2002)
64
The purpose of
this study was to determine if the application of a 1 % chlorhexidine
containing wax on primary molars during the period of eruption of the
permanent first molars could prevent the transfer of certain oral flora,
namely Streptococcus mutans to the permanent molars In one group of 9
children a 1% chlorhexidine wax was painted on the primary molars on
one side of the mouth and a placebo group of 5 children in which a
similar wax but not containing chlorhexidine was painted on one side of
the mouth. The levels of Streptococcus and other oral flora were
compared to that of the opposite side. Since lower Streptococcus mutans
to sanguis ratios are associated with lower caries experience, treating the
primary molars with a wax containing 1% chlorhexidine wax during the
eruption of permanent first molars may be a simple means for shifting
the fissure flora of the permanent molars towards a more favorable
balance.
S Matthijs, PA Adriaens( 2002)
41
stated that of all the chemical
plaque control agents Chlorhexidine digluconate has proven to be the
most effective and safe. Since 1964 varnishes have been used for the
delivery of fluoride and have been reported to be an easy and effective
way to deliver the agent. Based on the initial experiments of Balanyk in
1983, Balanyk and Sandham 1985 Chlorzoin varnish containing 10 or
20% of chlorhexidine acetate was developed. The initial Varnish
prepared by Schaeken and De Haan (1989) has been modified and
commercialized as EC40 varnish containing 40% chlorhexidine,
sandarac and ethanol. In 1990 Huizinga started to report on the use of
Cervitec varnish. In general all three varnishes have a similar effect on
the mutans streptococci in the oral cavity. However none of the
varnishes could maintain a suppression of the mutans streptococci for
greater than 6 months. Therefore repeated varnishes are necessary. For
patients at a high risk for dental caries, varnish application might be a
meaningful preventive approach.
Kulkarni and Damle S G.(2003)
39
evaluated the efficacy of a
0.05% sodium fluoride, 0.12% chlorhexidine and 0.3% Triclosan mouth
rinse in reducing the mutans streptococci in saliva. 60 subjects from the
age 12-14 were selected and equally divided into 4 groups. First three
groups were test groups and the last group was the control group. The
subjects were asked to rinse with one full marked measure of mouth
rinse twice daily for 1 minute each tie. Salivary samples were collected
at baseline and after two weeks and cultured on MSB medium. The
results of the study indicated that the chlorhexidine mouthwash was
more effective in reducing the mutans streptococci count than the other
mouth rinses.
Nurit Beyth, et al (2003)
8
evaluated the effect of sustained-
release chlorhexidine varnish on orthodontic patients. Ten children, ages
10 to 16 years, participated. Bacterial levels of Streptococcus mutans
and Actinomyces viscosus and total counts were evaluated in sputum
samples. These counts were evaluated at 4 stages: before orthodontic
treatment, at least 2 weeks after bonding of the brackets, 1 week after
application of chlorhexidine varnish, and 3 weeks after application of
chlorhexidine varnish. Increases in bacterial levels of S mutans and in
the total bacterial count were detected after the bracktes were bonded.
One week after the sustained-release chlorhexidine varnish was applied,
a significant decrease of total bacterial levels and S mutans was
observed. This decrease persisted for 3 weeks after the first application.
No significant change in A viscosus levels occurred during that period.
The results provide additional evidence that sustained release
chlorhexidine varnish decreases S mutans levels in orthodontic patients
with fixed appliances and therefore might be useful in preventing caries
lesions.
Svante Twetman(2004)
68
examined recent evidence for the effect
of the antibacterial approach to prevent and control caries with special
reference to the use of chlorhexidine.
Four studies dealing with white spot lesions were identified all
performed on patients undergoing orthodontic treatment ( Twetman et al
in 1995: Madlena at al 2000: J enatschke et al 2001;Ogaard et al 2001).
Conflicting results were reported in these studies. While Madlena at al
found a significant reduction in white spot lesions in children with high
risk of caries, no effect could be seen in a Swedish low caries population
according to Twetman. The last two studies were unable to disclose any
benefit any from frequent Chlorhexidine varnish applications in spite of
significant reductions in MS colonization.
Ali Ihya Karaman, et al (2004)
38
determined whether different
types of anti microbial agents with hydrophilic primer applied to etched
surfaces will affect the shear bond strength (SBS) and the bracket
adhesive failure modes of metallic orthodontic brackets. Mixtures
containing a hydrophilic primer Transbond MIP and one of the three
anti microbials were prepared. ( Cervitec in a 1:2 ratio, chlorhexidine
mouth wash and EC40 in a 1:1 ratio) these mixtures were applied on the
etched enamel surfaces and thoroughly light cured for 20 secs, brackets
were bonded and light cured for 40 secs. The Shear Bond Strengthof
these brackets were tested using a Universal Testing machine. Results
revealed a statistically significant difference in the SBS of the groups.
The SBS of control and Cervitec had higher values than the other
applications and had clinically acceptable bond strengths.
FLUORIDE
GM Bounoure et al (1980)
12
enumerated the advantages and
disadvantages of Fluoride Varnish( Duraphat).Among the
disadvantages of this method of applying fluorine are the taste of glue
which the varnish leaves behind, and the delay after application until the
patient is permitted to eat and drink. It is recommended that intake of
any nourishment should be postponed for 12 hours in order to assure the
maintenance of the applied film. This implies doing the painting at the
end of the afternoon. In the case of painting limited areas such as the
incisor sector only, which represents the majority of cases, the patient is
permitted to take liquid nourishment and to chew on the untreated teeth.
Finally, ulcerous gingivitis and tendency to allergic reactions are
contraindications to the use of Duraphat.
Geiger, Gorelick, Gwinnett, and Griswold( 1988)
31
presented
the results of a clinical study in which an experimental preventive
fluoride program was used results indicated that decalcification of the
labial (buccal) surfaces of teeth during orthodontic therapy can be
significantly reduced by the consistent use of a 0.05% sodium fluoride
rinse during treatment. The incidence and severity of white spot
formation are related to the length of time teeth are bracketed. This
suggests the need for a preventive fluoride rinse used continuously
during treatment.. Despite efforts to educate patients and parents, poor
compliance with a preventive fluoride rinse program occurred in 50% of
patients. This suggests the need for more effective methods to change
behavior patterns.
Wei Nan. Wang, et al (1991)
72
compared the tensile bond
strength of orthodontic self-cured resin on teeth rinsed 4 minutes in
1.23% APF with untreated controls. The tensile bond strengths of the
fluoride-treated teeth and the untreated teeth were not significantly
different. The debonding interfaces between resin and bracket base,
within the resin itself, and between enamel and resin were similar in the
two experimental groups. However, greater enamel detachment was
seen within the fluoride pretreatment group. So while fluoride
pretreatment does not significantly affect tensile bond strength, it may
cause enamel detachment after debonding.
S Twetman,L G Petersson, G N Pakhmov( 1996)
69
studied the
caries incidence during a two year period was studied in 4-5 year old
children from three areas with contrasting levels of natural fluoride in
the drinking water and different regimens of topical fluoride regimens.
Higher levels of salivary mutans streptococci were found in children
from low fluoride areas at baseline and at two years. The study
confirmed the close relationship between salivary streptococcus mutans
and caries incidence in pre school children and suggests a caries
reducing effect of topical application of fluoride silane varnish.
Daniel J. Rinchuse, et al (1997)
58
said that the current decline in
the incidence of caries, coupled with an increase in the prevalence of
fluorosis, has led most dentists to prescribe fluoride more cautiously.
The most compelling reason is that dentists do not yet know the optimal
dosage of fluoride, considering the various degrees of fluoridation of
water supplies.
According to the authors it is no longer acceptable to routinely
prescribe fluoride for patients without considering such factors as risk of
caries, age, exposure to background fluoride, compliance, and ability to
apply gels or rinses without ingestion. Because it is so difficult for the
practitioner to judge exactly how much fluoride a patient is ingesting
systematically, the routine prescription of fluoride supplements and
adjuncts to brushing is not recommended.Even the routine application of
fluoride in dental offices is now suspect: it is too infrequent (usually
only semiannual or annual), and the amount of fluoride ingested can be
significant. Office-applied fluoride gels and foams should be reserved
for patients with increased risks of caries and for caries-active children.
D Steinberg, R Rozen, et al (2002)
66
described properties of
potential sustained release varnishes (SRV) containing Amine Fluorides
or Amine Fluorides with stannous Fluorides. The release kinetics
antibacterial properties and anti adhesion properties of two potential
varnishes were tested. Both types of SRV demonstrated a strong anti
bacterial effect on bacteria in bio film. The main advantages of these
SRVs are that they prolong the availability of the drug.
GINGIVITIS IN ORTHODONTIC PATIENTS
Bjrn gaard, Per Gjermo, and Gunnar Rlla, (1980)
52

studied the plaque-inhibiting effect of a dentifrice containing stannous
fluoride/stannous pyrophosphate during treatment with fixed orthodontic
appliances. The test toothpaste was compared with sodium
monofluorophosphate toothpaste and paste without fluoride and tin.
When applied directly on the teeth, the test paste was found to reduce
plaque ,growth significantly for 24 hours It was concluded that because
of its dual action on plaque and teeth stannous fluoride/stannous
pyrophosphate toothpaste may be recommended as supplement to and
not substitute for other forms of fluoride supplementation in this
category of patients .
Peter M. Sinclair, et al ( 1987)
63
evaluated the changes in
gingival health and in subgingival microbial flora associated with fixed
orthodontic appliances.This study found after one year in fixed
orthodontic appliances, with a relatively good standard of oral hygiene
mild gingivitis, particularly on the labial surfaces of bonded incisors
adjacent to the orthodontic attachments, a small but significant increase
in pocket depths adjacent to brackets on incisors , an increase in the
percentage of Streptococci ,no increase in the percentage of potentially
pathogenic Gram-negative organisms frequently associated with
inflammatory periodontal disease and no correlation between changes in
the sub gingival microbial flora and gingival condition.
MJM Schaeken, P De Haan( 1989)
61
evaluated the effect of a
varnish containing chlorhexidine diacetate on the human dental plaque
flora. The invitro release of chlorhexidine from the varnish was
relatively fast on the first day followed by a substantial decrease in the
following three days. In a clinical study 26 volunteers were randomly
distributed over 4 experimental groups. After a dental prophylaxis , the
subjects were treated with a single application of the placebo
varnish,(group I) a fluoride varnish( group II), a chlorhexidine varnish
(group III) a fluoride and chlorhexidine varnish (Group IV). Saliva and
pooled plaque samples were taken at baseline and 1,2,3,4,and 6 weeks
after treatments. Results: no suppression of the total cultivable flora or
S.sanguis was found after the experimental treatments. Applications of
the fluoride varnish did not suppress the level of S.mutans in the
fluoride varnish group. Chlorhexidine varnish suppressed S.mutans up
to 4 weeks after application. After two chlorhexidine treatments the
S.mutans was suppressed more strongly than with a single application.
The need for repeated varnish applications could be based on salivary
S.mutans levels.
Huser, Baehni, and Lang (1990)
34
evaluated the effect of
placement of orthodontic bands on the gingival tissues and the microbial
composition of dental plaque. Plaque index and bleeding scores
increased significantly on banded teeth as compared with control sites.
Probing depth remained within normal values for both test and control
groups. The composition of dental plaque determined by dark-field
microscopy showed significant shifts in the test sites after banding.
Changes consisted of an increase in the percentage of spirochetes,
motile rods, filaments, and fusiforms; conversely, a decrease in cocci
was noted. Bacterial changes were accompanied by clinical signs of
gingival inflammation. Whether gingivitis will progress to a more
advanced form of periodontal destruction is not known. However, these
findings should again draw attention to the importance of prophylactic
programs for patients who are undergoing orthodontic treatment.
Brightman, et al (1991)
21
assessed the effectiveness of a 0.12%
chlorhexidine gluconate mouthrinse, Peridex, on orthodontic patients 11
through 17 years of age with established gingivitis.. The gingival index
(Gl) of Le and Silness, the plaque index (Pl) of Silness and Le, the
Eastman Interproximal Bleeding Index, and staining index were
recorded for each subject. The subjects in the Chlorhexidne group, as
compared with the placebo group, had statistically significant
reductions. Staining was in the moderate range, and it was concentrated
on the mandibular lingual surfaces. Peridex, in combination with
mechanical plaque removal, proved to be an important therapeutic agent
in controlling gingival inflammation, bleeding, and plaque accumulation
in orthodontic patients 11 through 17 years of age with established
gingivitis.
In a study by Morrow, Wood, and Speechley (1992)
43
Twenty-
three adolescent orthodontic patients with gingivitis affecting all banded
first molars volunteered for the study. Three measures associated with
gingivitis (papilla bleeding index, plaque index, and probing depth)
were recorded at four sites for all four molars. A single application of
subgingival irrigation with 0.12% chlorhexidine digluconate or isotonic
saline was performed for 5 seconds at each site. The gingival bleeding
as determined by papilla bleeding index, was virtually eliminated in 4
weeks by a single application of subgingival irrigation with either
chlorhexidine or saline. However, there was no significant reduction in
pocket depth or plaque index. In addition, no significant difference
between the effect of chlorhexidine or saline was found for any of the
outcome measures.
Boyd and Baumrind,( 1992)
13
compared the periodontal status
of bonded and banded molars in 20 adult and 40 adolescent patients
before, during and after treatment with fixed orthodontic appliances. At
pretreatment, no significant differences were found in gingival
inflammation between maxillary and mandibular banded and bonded
molars. During treatment, both maxillary and mandibular banded molars
showed significantly greater gingival inflammation and plaque
accumulation than did bonded molars. Three months after appliance
removal, the maxillary molars that had been banded continued to show
significantly more gingival inflammation and loss of attachment than
did the maxillary molars that had been bonded. When all banded and
bonded teeth were grouped by patient age, mean values for plaque
accumulation and gingival inflammation in the maxillary molar regions
were significantly greater for adolescents than for adults.
In a study by D Zyskind, et al (1992)
78
slow release varnish
containing chlorhexidine was applied prior to the application of
periodontal dressing. The ability of a chlorhexidine varnish to prevent
accumulation of dental plaque under a dressing was compared to that of
a placebo. A week later the dressing were removed the plaque
accumulation was scored. Significantly less plaque was found on the
teeth precoated with chlorhexidine varnish as compared with the control.
The capability of chlorhexidine to absorb to the surface of the tooth
while retaining its antibacterial activity is among the properties
attributed to its role as an antiplaque agent.
Boyd and Chun (1994)
14
determined whether conventional
toothbrushing and twice daily use of a brush-on 0.4% stannous fluoride
(SnF2) gel containing more than 90% available Sn
2+
would be more
effective for controlling plaque accumulation and gingivitis in the
presence of orthodontic appliances than conventional toothbrushing
alone. The results indicated that the SnF2 gel group had significantly
lower scores for plaque index gingival index , and bleeding tendency
than did the control group. They concluded that the use of a 0.4% SnF2
gel containing more than 90% available Sn
2+
is an effective adjunct to
mechanical tooth cleaning in preventing gingivitis in adolescents
undergoing orthodontic treatment with fixed appliances.
P B Imrey, et al (1994)
36
presented suggested revisions to the
American Dental Associations 1985 guidelines for acceptance of anti
gingivitis chemotherapeutic agents. The areas of study design, choice
and quality control of clinical gingivitis measurements, statistical
analysis and minimum strength of effect is addressed. Guidelines for
measurement of gingivitis should be strengthened to elicit reporting of
an 1) index of gingival bleeding coupled with 2) either a purely visually
based gingivitis index or alternatively a comprehensive gingivitis index
that incorporates both bleeding and visual appearance.
R Weiger,et al (1994)
73
studied the effect on local plaque
formation of Cervitec was evaluated in this study. Ten volunteers with
clinically healthy oral conditions were asked to refrain from any kind
of oral hygiene measures for three periods of three days. Undisturbed
plaque formation was measured for the first three days. At the beginning
of the next experimental period the varnish was applied to the surface of
6 vestibular enamel surfaces and removed after an hour. The third
experimental period was initiated 12 weeks after varnish application to
assess potential long term effects. during each period of plaque
formation samples were collected from the vestibular surfaces after 24
hours from teeth 15/25, after 48 hours from teeth 14/24 and after 72
hours on teeth 13/23 and evaluated for total bacterial count and colony
forming units. Results: the microbial vitality of 48 and 72 hour plaque
was significantly reduced after Cervitec application. An inhibitory effect
by Cervitec could not be discerned 12 weeks after varnish treatment.
Gissela Bernal Anderson, et al (1997)
18
compared the short-term
clinical effect of 0.12% chlorhexidine gluconate and placebo
mouthrinses in 30 adolescents undergoing orthodontic treatment.
Subjects were randomized into experimental and control groups.
The data indicate that the use of the CHX, in addition to regular
oral hygiene habits, was effective in reducing plaque and gingivitis in
adolescents undergoing orthodontic treatment.
WA Bretz, M.I Valente, et al (2000)
20
showed that treatment
with a 1% chlorhexidine/1 % thymol varnish has been shown to reduce
indicators of gingival inflammation of subjects undergoing orthodontic
treatment by reducing the amount of inflammatory mediators the
volume of Gingival crevicular fluid and the number of sites that bled on
probing. The aim of this study was to evaluate for 6 months the effects
of a chlorhexidine varnish on the gingival status of adolescents. 110
adolescents 10-15 years old were randomly divided into control (C)
n=53 and test (T) n=57 groups respectively. C and T subjects were
matched at baseline by age salivary levels of mutans Streptococci, caries
scores and by the percent of sites that presented with clinical signs of
inflammation. Subjects in the T group had a 10% chlorhexidine varnish
Chlorzoin applied to their dentition at baseline. Subjects that had >2.5 X
10
5
Cfu of streptococci as measured by the Cariescreen test (a dip Slide
test) received a second application of the varnish one week later.
Evaluation of the subjects was by the Gingival index of Loe and Silness
(GI) Results: over a 6 month period the subjects of the T group had
fewer sites with gingival disease than subjects in the C group.
J P Bernimoulin (2003)
17
stated that Dental Plaque is an adherent
bacterial film and is the main pathological agent for periodontal disease
and caries. The formation of plaque can occur both supra and sub
gingivally and is comprised of a complex mix of bacteria numbering at
least several hundred species. The prevention of gingivitis is largely
governed by limiting the development of the oral biofilm.
Because plaque flora changes as the film matures, an effective
oral antiseptic must be active against wide range of species including
streptococci and other Gram positive organisms, fusobacteria and other
Gram negative bacteria and spirochetes. Additionally an antiseptic
which can penetrate the plaque biofilm would be expected to be more
effective.
In both in vitro and in vivo studies both Essential oils and
Chlorhexidine mouthwashes have shown broad antimicrobial effects,
with the chlorhexidine mouthwash being more effective. Both agents
penetrate the plaque biofilm and are active against biofilm embedded
bacteria. Most importantly the antibacterial effect of both agents was not
limited to the rinsing period, for chlorhexidine suppression of the plaque
microflora was detectable for more than 12 hours after rinsing
SUMMARY AND CONCLUSIONS
Due to the potential food traps caused by the placement of
orthodontic appliances decalcification and gingivitis are some of the
common iatrogenic consequences of orthodontic treatment
The cariogenic environment created by the appliances harbors
Mutans streptococci which are responsible for white spot lesions that are
nothing but the precursor of caries. The accumulation of supragingival
plaque also initiates gingival inflammation which could lead to
periodontal disease with accompanying tissue destruction. Varnishes are
sustained release devices that have been introduced with the aim of
maintaining an ideal drug concentration over long periods of time.
Therefore it would be of great clinical benefit if a sustained
release chemical agent could be used during the active phase of
orthodontic treatment to reduce the bacterial plaque accumulation,
thereby improving the gingival conditions as well as reducing the
incidence of caries and periodontal disease in these patients.
Over the past few years studies on effect of sustained release
chlorhexidine varnishes has sparked interest in its applicability in
orthodontics where it could be used for protection against both
decalcification and gingivitis. Hence this in vivo three month study was
done to investigate the efficacy of a single application of a
commercially available chlorhexidine varnish ( Cervitec) containing
1% chlorhexidine and 1% thymol against streptococcus mutans as well
as its effect on gingival health.
A spilt mouth technique was followed on 15 patients evaluating
the test varnish on two randomly allotted quadrants along with a placebo
on the other two quadrants.
The study group was selected through stringent selection criteria
with an aim of removing as many confounding factors as possible and
establishing standardization to perform the study.
The test sites were the 4 first premolars where the following
parameters were assessed.
1. Plaque index ( Loe and Silness)
2. Streptococcus mutans count in the plaque
3. Gingival index as described by Ramfjord
4. Bleeding Index (modified Mhlemann method)
Evaluation of these parameters was done at three time intervals:
Baseline (T0), one month (T1), and three months (T3) after the
application of the varnish.
Plaque samples from these test sites were inoculated on specific
media for mutans streptococci and bacterial counts were thus obtained.
Gingival health and plaque accumulation was assessed by the
three indices- Plaque Index, Gingival Index and Bleeding Index.
Results indicated that a single application of the Test varnish was
capable of significantly reducing Mutans streptococci count at the first
month in comparison to the placebo group and this difference was
statistically significant. The test varnish had no effect on Mutans
streptococci at the end of three months as there was no statistically
significant difference in the bacterial count between the two groups.
Gingival health was significantly improved by the test varnish
both at one and three month evaluation in comparison to the placebo
group, thus indicating an efficacy in maintaining gingival health for a
longer period of time.
This study proved that sustained release devices like varnishes are
a viable option for a orthodontic patients. Chlorhexidine varnishes are
capable of reducing mutans streptococci and gingivitis thus improving
the overall oral health of the patient.
Side effects that reduce the long term use of chlorhexidine
mouthrinses are not seen in this new delivery system.
Thus this new therapeutic agent in the orthodontists
armamentarium is an effective tool in reducing mutans streptococci and
gingivitis.
Further long term studies are necessary to establish protocols
regarding the varnish concentration and application schedules in
orthodontic populations.
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