ANTI-PLAQUE & ANTI-ANTI-PLAQUE & ANTI-CALCULUS AGENTSCALCULUS AGENTS

PRESENTED BY: PRESENTED BY:

DR. AARTI DR. AARTI CHOPRACHOPRA

Plaque:Plaque: Plaque is defined clinically as a Plaque is defined clinically as a structured, resilient, yellowish-grayish substance structured, resilient, yellowish-grayish substance that adheres tenaciously to the intraoral hard that adheres tenaciously to the intraoral hard surfaces, including removable and fixed surfaces, including removable and fixed restorations.restorations.

Materia alba:Materia alba: refers to soft accumulations of refers to soft accumulations of bacteria and tissue cells that lack the organized bacteria and tissue cells that lack the organized structure of dental plaque and it is easily structure of dental plaque and it is easily displaced with a water spray.displaced with a water spray.

Calculus:Calculus: Calculus is a hard deposit that forms by Calculus is a hard deposit that forms by mineralization of dental plaque and it is generally mineralization of dental plaque and it is generally covered by a layer of unmineralized plaque.covered by a layer of unmineralized plaque.

PLAQUE CONTROLPLAQUE CONTROL

Mechanical plaque control:Mechanical plaque control: With the help With the help of tooth brush, dentrifrices, interdental cleaning of tooth brush, dentrifrices, interdental cleaning aids, gingival massage, oral irrigators.aids, gingival massage, oral irrigators.

Chemical plaque control:Chemical plaque control: With the help of With the help of antiplaque and anticalculus agents.antiplaque and anticalculus agents.

Chemical plaque control – Chemical plaque control – RationaleRationale

Gingivitis & periodontitis are highly prevalent Gingivitis & periodontitis are highly prevalent diseases and prevention of occurrence or re-diseases and prevention of occurrence or re-ocurrence is dependent on supragingival plaque ocurrence is dependent on supragingival plaque control.control.

Mechanical tooth cleaning through toothbrushing with Mechanical tooth cleaning through toothbrushing with tooth paste is the most common method of oral tooth paste is the most common method of oral hygiene practiced.hygiene practiced.

Tooth cleaning is largely influenced by the Tooth cleaning is largely influenced by the compliance and dexterity of the individual.compliance and dexterity of the individual.

The concept of chemical plaque control can be The concept of chemical plaque control can be justified as a means of overcoming inadequacies of justified as a means of overcoming inadequacies of mechanical cleaning.mechanical cleaning.

Uses of antiplaque agentsUses of antiplaque agents

To replace mechanical tooth brushing when this To replace mechanical tooth brushing when this is not possible in situations like:is not possible in situations like:

- - After oral or periodontal surgery during the healingAfter oral or periodontal surgery during the healing period.period. - After intermaxillary fixation used to treat jaw fractures. - After intermaxillary fixation used to treat jaw fractures. - With acute oral mucosal or gingival infections when - With acute oral mucosal or gingival infections when

pain & soreness prevents mechanical oral hygiene.pain & soreness prevents mechanical oral hygiene. - For mentally or physically handicapped patients who - For mentally or physically handicapped patients who

areare unable to brush their teeth.unable to brush their teeth.

As an adjunct to normal mechanical oral As an adjunct to normal mechanical oral hygiene in situations where this may be hygiene in situations where this may be compromised by discomfort or inadequacies:compromised by discomfort or inadequacies:

- - Following sub-gingival scaling & root planing whenFollowing sub-gingival scaling & root planing when gingivae may be sore for a few days.gingivae may be sore for a few days. - Following scaling when there is hypersensitivity - Following scaling when there is hypersensitivity

due to due to root exposure.root exposure. - Following scaling when patient’s oral hygiene - Following scaling when patient’s oral hygiene

remainsremains inadquate.inadquate.

Classification of Antiplaque Classification of Antiplaque agentsagents

1. On the basis of mechanism of action:1. On the basis of mechanism of action:

AntiadhesivesAntiadhesives AntimicrobialAntimicrobial Plaque removalPlaque removal AntipathogenicAntipathogenic

2. On the basis of chemical nature:2. On the basis of chemical nature: Bisguanides:Bisguanides: chlorhexidine, alexidine, octenidine chlorhexidine, alexidine, octenidine Quarternary ammonium compounds:Quarternary ammonium compounds: benzalkonium benzalkonium

chloride, cetyl pyridinium chloridechloride, cetyl pyridinium chloride Phenols and essential oils:Phenols and essential oils: listerine listerine Fluorides:Fluorides: sodium fluoride, stannous fluoride, sodium fluoride, stannous fluoride,

organic amine fluorideorganic amine fluoride Antiseptics:Antiseptics: iodine, povidone iodine, chloramine To iodine, povidone iodine, chloramine To Antibiotics:Antibiotics: penicillin, tetracycline, vancomycin, penicillin, tetracycline, vancomycin,

spiramycin, kanamycin, streptomycin, actinomycin, spiramycin, kanamycin, streptomycin, actinomycin, erythromycin, bacitracin etc.erythromycin, bacitracin etc.

Oxygenating substances:Oxygenating substances: hydrogen peroxide, hydrogen peroxide, buffered sodium peroxyboratebuffered sodium peroxyborate

Enzymes:Enzymes: protease, amylase, mutanase, protease, amylase, mutanase, amyloglycosidase, glucose oxidase and amyloglycosidase, glucose oxidase and amyloglucosidaseamyloglucosidase

Plant alkaloid:Plant alkaloid: sanuinarine sanuinarine Metal ions:Metal ions: Zn, Cu, Sn Zn, Cu, Sn TriclosanTriclosan Other agents:Other agents: salifluor, delmopinol, detergents, salifluor, delmopinol, detergents,

propolis, hexetidine.propolis, hexetidine.

3. On the basis of form:3. On the basis of form: MouthrinsesMouthrinses SpraysSprays IrrigatorsIrrigators Chewing gumsChewing gums VarnishesVarnishes

BisguanidesBisguanides

Several bisguanides possess antiplaque activity, Several bisguanides possess antiplaque activity, including chlorhexidine, alexidine, octenidine. including chlorhexidine, alexidine, octenidine. However chlorhexidine is the most studied and However chlorhexidine is the most studied and used.used.

CHLORHEXIDINECHLORHEXIDINE

Chlorhexidine- the digluconate of chlorhexidine Chlorhexidine- the digluconate of chlorhexidine is a synthetic antimicrobial which was is a synthetic antimicrobial which was developed in late 1940’s.developed in late 1940’s.

Loe & SchiottLoe & Schiott introduced this agent as an oral introduced this agent as an oral antimicrobial agent (0.2%) and have shown that antimicrobial agent (0.2%) and have shown that 5, 2 and even 1 daily rinse prevented plaque 5, 2 and even 1 daily rinse prevented plaque accumulation and development of gingivitis accumulation and development of gingivitis over 21 day period of no oral hygiene.over 21 day period of no oral hygiene.

Clinical studies of several month duration have Clinical studies of several month duration have reported plaque reductions of 45% to 61% and reported plaque reductions of 45% to 61% and gingivitis reductions of 27% to 67%.gingivitis reductions of 27% to 67%.

MECHANISM OF ACTION:MECHANISM OF ACTION: Chlorhexidine is a base and is stable as a salt.Chlorhexidine is a base and is stable as a salt. The most common preparation is chlorhexidine The most common preparation is chlorhexidine

digluconate that is water soluble and at physiologic digluconate that is water soluble and at physiologic pH readily dissociates releasing the positively pH readily dissociates releasing the positively charged chlorhexidine component.charged chlorhexidine component.

Access to the bacterial cell wall is enhanced by the Access to the bacterial cell wall is enhanced by the electrostatic force between positevly charged electrostatic force between positevly charged chlorhexidine cations and negatively charged chlorhexidine cations and negatively charged lipoteichoic acid and other components of bacterial lipoteichoic acid and other components of bacterial cell wall, thereby altering the osmotic equilibrium.cell wall, thereby altering the osmotic equilibrium.

Having gained access to the inner cell membrane, Having gained access to the inner cell membrane, chlorhexidine disorientates its lipoprotein structure chlorhexidine disorientates its lipoprotein structure causing destruction of the osmotic barrier and causing destruction of the osmotic barrier and resulting in the leakage of intracellular resulting in the leakage of intracellular components.components.

At low concentrations of chlorhexidine, small At low concentrations of chlorhexidine, small molecule weight substances such as potassium molecule weight substances such as potassium and phosphorus will leach out, exerting a and phosphorus will leach out, exerting a bacteriostatic effect.bacteriostatic effect.

At high concentrations of chlorhexidine, At high concentrations of chlorhexidine, bactericidal effect occurs due to precipitation bactericidal effect occurs due to precipitation and coagulation of cytoplasm.and coagulation of cytoplasm.

Bactericidal effect is thought to be less Bactericidal effect is thought to be less important than the bacteriostatic effect, important than the bacteriostatic effect, provided by the slow release of chlorhexidine. provided by the slow release of chlorhexidine.

Chlorhexidine is more effective in preventing Chlorhexidine is more effective in preventing plaque accumulation on a clean tooth surface plaque accumulation on a clean tooth surface than in reducing pre-existing deposits.than in reducing pre-existing deposits.

In addition to antibacterial properties, In addition to antibacterial properties, chlorhexidine also reduces bacterial chlorhexidine also reduces bacterial colonization on tooth surface by 3 mechanisms:colonization on tooth surface by 3 mechanisms:

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

2.2. The ability of bacteria to bind to the tooth The ability of bacteria to bind to the tooth surface may also be reduced by the adsorption surface may also be reduced by the adsorption of chlorhexidine to the extracellular of chlorhexidine to the extracellular polysaccharides of their capsules or polysaccharides of their capsules or glycocalyces.glycocalyces.

3.3. Chlorhexidine may compete with Calcium ions Chlorhexidine may compete with Calcium ions for acidic agglutination factors in plaque.for acidic agglutination factors in plaque.

SPECTRUM OF ACTIVITY:SPECTRUM OF ACTIVITY: Chlorhexidine has broad spectrum of activity and is Chlorhexidine has broad spectrum of activity and is

effective against a wide variety of gram+ve and effective against a wide variety of gram+ve and gram-ve organisms, yeasts and fungi.gram-ve organisms, yeasts and fungi.

Gram+ve organisms are more sensitive than gram-Gram+ve organisms are more sensitive than gram-ve organisms and streptococci are more sensitive ve organisms and streptococci are more sensitive than staphylococci. than staphylococci.

Rinsing with 10ml of 0.2% chlorhexidine for 1 min. Rinsing with 10ml of 0.2% chlorhexidine for 1 min. has resulted in suppression of new plaque has resulted in suppression of new plaque deposits.salivary bacterial counts taken immediately deposits.salivary bacterial counts taken immediately after rinsing with 0.2% solution demonstrated a 80% after rinsing with 0.2% solution demonstrated a 80% to 90% reduction of organisms.to 90% reduction of organisms.

Subsequent to cessation of drug application salivary Subsequent to cessation of drug application salivary count of organisms return to baseline value within count of organisms return to baseline value within 48hrs. M 48hrs. M

SUBSTANTIVITY OF CHLORHEXIDINE:SUBSTANTIVITY OF CHLORHEXIDINE: The ability of the drug to absorb onto or bind to the The ability of the drug to absorb onto or bind to the

soft and hard tissues is known as substantivity.soft and hard tissues is known as substantivity. Substantivity of chlorhexidine was first described in Substantivity of chlorhexidine was first described in

1970’s.1970’s. What gives chlorhexidine its advantage over many What gives chlorhexidine its advantage over many

other agents is its ability to bind strongly to many other agents is its ability to bind strongly to many sites in the oral cavity.sites in the oral cavity.

It is this substantivity that enables it to function as It is this substantivity that enables it to function as a form of slow release device and maintain an a form of slow release device and maintain an ongoing rather than intermittent antibacterial ongoing rather than intermittent antibacterial action.action.

The proportion of chlorhexidine retained is directly The proportion of chlorhexidine retained is directly dependent upon concentration, volume and pH in dependent upon concentration, volume and pH in the mouth.the mouth.

CLINICAL USAGE:CLINICAL USAGE: It is accepted by FDA and ADA.It is accepted by FDA and ADA. Available as mouthwash- 0.2% chlorhexidine, Available as mouthwash- 0.2% chlorhexidine,

recommended as 10ml per rinse and 0.12% recommended as 10ml per rinse and 0.12% chlorhexidine recommended as 15ml per rinse.chlorhexidine recommended as 15ml per rinse.

Avialable as gel 1%Avialable as gel 1% It is more difficult to incorporate chlorhexidine It is more difficult to incorporate chlorhexidine

into toothpastes because of binding of into toothpastes because of binding of chlorhexidine to components in the toothpaste.chlorhexidine to components in the toothpaste.

SAFETY OF CHLORHEXIDINE:SAFETY OF CHLORHEXIDINE: Animal experiments have shown that primary route Animal experiments have shown that primary route

of ecretion is through faeces.of ecretion is through faeces. It is poorly absorbed by the GIT and therefore It is poorly absorbed by the GIT and therefore

displays very low toxicity.displays very low toxicity. No evidence of carcinogenic or teratogenic No evidence of carcinogenic or teratogenic

alterations has been found.alterations has been found.

SIDE EFFECTS:SIDE EFFECTS: Tooth stainingTooth staining High calculus scoresHigh calculus scores Burning sensationBurning sensation Impairment in taste sensationImpairment in taste sensation

Quaternary ammonium Quaternary ammonium compoundscompounds

Quaternary ammonium compounds such as Quaternary ammonium compounds such as cetylpyridinium chloride have moderate plaque cetylpyridinium chloride have moderate plaque inhibitory activity.inhibitory activity.

Although they have greater initial oral retention Although they have greater initial oral retention and equivalent antibacterial action to and equivalent antibacterial action to chlorhexidine but they are less effective than chlorhexidine but they are less effective than chlorhexidine in inhibiting plaque and gingivitis.chlorhexidine in inhibiting plaque and gingivitis.

One reason for this may be that they are readily One reason for this may be that they are readily desorbed from the oral mucosa.desorbed from the oral mucosa.

Phenols and essential oilsPhenols and essential oils Phenols, either alone or in combination, have been Phenols, either alone or in combination, have been

used as mouthrinses or lozenges.used as mouthrinses or lozenges. Most phenols exert a non-specific action which is Most phenols exert a non-specific action which is

dependent upon the ability of drug.dependent upon the ability of drug. In its non-ionized form, it penetrates through the In its non-ionized form, it penetrates through the

lipid component of the cell walls of gram-ve lipid component of the cell walls of gram-ve organisms and denatures the bacterial proteins.organisms and denatures the bacterial proteins.

Listerine is an essential oil/phenolic mouthwash Listerine is an essential oil/phenolic mouthwash which has been shown to have moderate plaque which has been shown to have moderate plaque inhibitory effects and some antigingivitis effects.inhibitory effects and some antigingivitis effects.

It has been accepted by ADA to be an aid to home It has been accepted by ADA to be an aid to home oral hygiene proceduresoral hygiene procedures..

Goodson et al (1985)Goodson et al (1985) demonstrated that after 9 demonstrated that after 9 month application of listerine, there was a month application of listerine, there was a reduction of nearly 80% in plaque toxic activity.reduction of nearly 80% in plaque toxic activity.

Phenolic compounds are also known as Phenolic compounds are also known as scavangers of oxygen free radicals and hence scavangers of oxygen free radicals and hence should have an effect on leucocyte activity.should have an effect on leucocyte activity.

Adverse effects are minimal and safety has been Adverse effects are minimal and safety has been established by quite long clinical use.established by quite long clinical use.

Some patients find an initial burning sensation Some patients find an initial burning sensation and bitter taste.and bitter taste.

Occasional staining of minimal amount has been Occasional staining of minimal amount has been found.found.

TriclosanTriclosan

Triclosan, a trichlora-2’-hydroxydiphenyl ether, is a Triclosan, a trichlora-2’-hydroxydiphenyl ether, is a non-ionic antiseptic which lacks the staining effects non-ionic antiseptic which lacks the staining effects of cationic agents.of cationic agents.

It has been used recently in a number of It has been used recently in a number of commercial mouthwashes and toothpastes.commercial mouthwashes and toothpastes.

It ha a broad antibacterial properties and moderate It ha a broad antibacterial properties and moderate antiplaque properties when used in combination antiplaque properties when used in combination wit zinc.wit zinc.

It has been found to retain in mouth and to have It has been found to retain in mouth and to have clinical efficacy without side effects.clinical efficacy without side effects.

The primary site of action is bacterial cellular The primary site of action is bacterial cellular membrane of bacteria. At bacteriostatic conc., membrane of bacteria. At bacteriostatic conc., triclosan prevents the uptake of essential amino triclosan prevents the uptake of essential amino acids. At bactericidal conc., it causes disorganization acids. At bactericidal conc., it causes disorganization of the cellular membrane and leakage of cellular of the cellular membrane and leakage of cellular contents.contents.

Triclosan itself has little or no substantivity, its Triclosan itself has little or no substantivity, its substantivity can be increased by its combination substantivity can be increased by its combination with copolymers of methoxyethylene and maleic acid with copolymers of methoxyethylene and maleic acid ( Gantrex, ISP corps ).( Gantrex, ISP corps ).

Despite its more rapid clearance, triclosan has been Despite its more rapid clearance, triclosan has been shown to be present in an elevated level in plaque shown to be present in an elevated level in plaque and saliva for 8 hrs. and in the oral mucosa for 3 hrs. and saliva for 8 hrs. and in the oral mucosa for 3 hrs. after tooth brushing.after tooth brushing.

There is evidence that triclosan may also act as an There is evidence that triclosan may also act as an antiinflammatory agent in mouthrinses and antiinflammatory agent in mouthrinses and toothpastes.toothpastes.

Antigingivitis effect of triclosan is due to its Antigingivitis effect of triclosan is due to its antiinflammatory property.antiinflammatory property.

Plant / Benzophenathridine Plant / Benzophenathridine alkaloidalkaloid

BPA was believed to be the active ingredient in tooth BPA was believed to be the active ingredient in tooth cleaning sticks used by the native cultures in africa.cleaning sticks used by the native cultures in africa.

The active ingredient is Sanguinarine.The active ingredient is Sanguinarine. Sanguinarine has been isolated from the alcoholic Sanguinarine has been isolated from the alcoholic

extract of powdered rhizomes of the blood root plant,extract of powdered rhizomes of the blood root plant, Sanguinaria candensisSanguinaria candensis..

Sanguinarine contains the reactive iminium ions, these Sanguinarine contains the reactive iminium ions, these ions are retained in the plaque for several hours after ions are retained in the plaque for several hours after use.use.

Sanguinarine has cationic nature and acts by inhibiting Sanguinarine has cationic nature and acts by inhibiting thiol dependent enzymes. Acts partly by interferring with thiol dependent enzymes. Acts partly by interferring with the membrane bound metallic constituents, reducing the membrane bound metallic constituents, reducing glycolysis and inhibiting the adherence of oral bacteria.glycolysis and inhibiting the adherence of oral bacteria.

Sanguinarine appears to an effective plaque Sanguinarine appears to an effective plaque inhibitory agent but is less effective than inhibitory agent but is less effective than chlorhexidine in this regard.chlorhexidine in this regard.

Also unlike chlorhexidine it is not able to prevent Also unlike chlorhexidine it is not able to prevent the development of gingivitis.the development of gingivitis.

Mouthwash is much more effective than Mouthwash is much more effective than toothpaste. This may be due to binding of other toothpaste. This may be due to binding of other components in the toothpaste to the chemically components in the toothpaste to the chemically reactive site of sanguinarine.reactive site of sanguinarine.

Commercial available mouthrinse contains Commercial available mouthrinse contains sanguinarine in Zn ions- Viadent (0.03% sanguinarine in Zn ions- Viadent (0.03% Sanguinarine Zn chloride).Sanguinarine Zn chloride).

Enzyme preparationsEnzyme preparations The rationale of using enzymes as active agents in The rationale of using enzymes as active agents in

antiplaque preparations was that they would be able to antiplaque preparations was that they would be able to break the matrix of already formed plaque and break the matrix of already formed plaque and calculus. Furthermore, it was accepted that certain calculus. Furthermore, it was accepted that certain proteolytic enzymes would be bactericidal to plaque proteolytic enzymes would be bactericidal to plaque microorganisms.microorganisms.

However, clinical trials on animals and humans have However, clinical trials on animals and humans have been disappointing.been disappointing.

The initial efforts during 1950-1970 were to employ The initial efforts during 1950-1970 were to employ enzymes directly to degrade the intercellular matrix enzymes directly to degrade the intercellular matrix and plaque integrity.and plaque integrity.

The following preparations were tested:The following preparations were tested:

Preparation of dehydrated pancreas (Viokase)Preparation of dehydrated pancreas (Viokase) MucinaseMucinase Protease-amylaseProtease-amylase Fungal enzymesFungal enzymes DextranaseDextranase MutanaseMutanase

All these preparations are of historic interest and All these preparations are of historic interest and they are not in use now.they are not in use now.

Oxygenating agentsOxygenating agents

H2O2, sodium peroxyborate, peroxycarbonate are H2O2, sodium peroxyborate, peroxycarbonate are useful in ANUG .useful in ANUG .

Futher investigations are required for these Futher investigations are required for these substances to act as antiplaque agent.substances to act as antiplaque agent.

AntibioticsAntibiotics

Penicillins, Vancomycin, Niddamycin and Penicillins, Vancomycin, Niddamycin and Kanamycin have been used for antiplaque activity.Kanamycin have been used for antiplaque activity.

All of these reduce significant amount of plaque All of these reduce significant amount of plaque formation.formation.

Potential problem with their use is of bacterial Potential problem with their use is of bacterial resistance.resistance.

Hypersensitivity reaction on topical application are Hypersensitivity reaction on topical application are common.common.

The potential benefit of using long term antibiotics The potential benefit of using long term antibiotics is less than harm.is less than harm.

Metallic saltsMetallic salts Mainly Zn, Sn, Cu salts are having antiplaque and Mainly Zn, Sn, Cu salts are having antiplaque and

anticalculus activities.anticalculus activities. At high concentration they can be bactericidal.At high concentration they can be bactericidal. At sublethal levels:At sublethal levels: a. can inhibit plaque growth by altering the surface a. can inhibit plaque growth by altering the surface

potential of plaque bacteria thus reducing the rate of potential of plaque bacteria thus reducing the rate of bacterial deposition onto the teeth.bacterial deposition onto the teeth.

b. can inhibit a number of enzyme systems relating b. can inhibit a number of enzyme systems relating to carbohydrate metabolism.to carbohydrate metabolism.

c. can cause proteolysis.c. can cause proteolysis. Zn citrate ( 0.5%, 1% ) has been utilized for years as Zn citrate ( 0.5%, 1% ) has been utilized for years as

antiplaque and anticalculus agent.antiplaque and anticalculus agent. In the laboratory, it can inhibit acid production by In the laboratory, it can inhibit acid production by

oral streptococci and trypsin like protease of oral streptococci and trypsin like protease of P.gingivalis.P.gingivalis.

Anticalculus agentsAnticalculus agents AcidsAcids AlkaliesAlkalies Chelating agentsChelating agents EnzymesEnzymes UreaUrea AntimicrobialsAntimicrobials MetalsMetals BisphosphonatesBisphosphonates Victamine C Victamine C PyrophosphatesPyrophosphates Polymers & copolymersPolymers & copolymers

AcidsAcids One of the earliest techniques to dissolve calculus was to use One of the earliest techniques to dissolve calculus was to use

wooden stick moistened with Aromatic sulphuric acid wooden stick moistened with Aromatic sulphuric acid (Barker (Barker 1872).1872).

This technique was modified by This technique was modified by Niles (1881)Niles (1881) who suggested the who suggested the use of Nitomuriatic acid.use of Nitomuriatic acid.

Other acids included are:Other acids included are: 20% trichloroacetic acid20% trichloroacetic acid Bifluoride of mercuryBifluoride of mercury 10% sulphuric acid10% sulphuric acid The problem with acids is that they are caustic to soft tissues The problem with acids is that they are caustic to soft tissues

and decalcify tooth structure.and decalcify tooth structure. Stones (1939)Stones (1939) reported that ability of an acid to dissolve tooth reported that ability of an acid to dissolve tooth

structure was greater than its ability to dissolve calculus.structure was greater than its ability to dissolve calculus.

AlkaliesAlkalies

Badanes (1929)Badanes (1929) noted the beneficial effect of noted the beneficial effect of Natural mineral waters on the removal of calculus Natural mineral waters on the removal of calculus because of its alkalie content.because of its alkalie content.

It dissolves the three principle constituents of It dissolves the three principle constituents of salivary calculus; globulin, mucin and calcium salivary calculus; globulin, mucin and calcium oxalate.oxalate.

But this idea did not find support.But this idea did not find support.

Chelating agentsChelating agents Chelating agents are used to dissolve crystallized calcium Chelating agents are used to dissolve crystallized calcium

salts and are capable of combining with calcium to form salts and are capable of combining with calcium to form stable compounds.stable compounds.

Sodium hexametaphosphate was found to remove Sodium hexametaphosphate was found to remove supragingival calculus from extracted teeth in 10-15 days supragingival calculus from extracted teeth in 10-15 days (Kerr & Field 1944).(Kerr & Field 1944).

Warren et al (1964)Warren et al (1964) found that with sodium found that with sodium hexametaphosphate decalcification of cementum was hexametaphosphate decalcification of cementum was greater than that of calculus. Because of this finding its use greater than that of calculus. Because of this finding its use was ceased.was ceased.

EDTA gel ( Sofscale) has been used as a prescale gel to EDTA gel ( Sofscale) has been used as a prescale gel to soften the caculus by soften the caculus by Jabro etal in 1992Jabro etal in 1992. but its efficacy has . but its efficacy has not been supported by other studies.not been supported by other studies.

EnzymesEnzymes

The mode of action of enzyme preparation is to break The mode of action of enzyme preparation is to break down plaque matrix or to affect the binding of calculus to down plaque matrix or to affect the binding of calculus to the tooth.the tooth.

The first enzyme to be tested was mucinase The first enzyme to be tested was mucinase (Stewart (Stewart 1952)1952) and it was found to reduce caculus formation and and it was found to reduce caculus formation and calculus which did form was softer and more easily calculus which did form was softer and more easily removed.removed.

Dehydrated pancreas ( Viokase ) was found to rduce Dehydrated pancreas ( Viokase ) was found to rduce calculus formation by 60% calculus formation by 60% (Jensen et al 1959).(Jensen et al 1959). Viokase Viokase was introduced into chewing gums.was introduced into chewing gums.

Enzymes of fungal origin have been found to be superior to Enzymes of fungal origin have been found to be superior to Viokase in reducing calculus formation (40.5% v 14.5%).Viokase in reducing calculus formation (40.5% v 14.5%).

UreaUrea

The idea of using urea as a anticalculus agent The idea of using urea as a anticalculus agent stems from its solvent action on protein.stems from its solvent action on protein.

Urea at a concentration of 30% causes maximum Urea at a concentration of 30% causes maximum reduction of calculus.reduction of calculus.

Acetohydroxamic acid ( AHA ) – irreversible Acetohydroxamic acid ( AHA ) – irreversible inhibitor of urease has been studied as an inhibitor of urease has been studied as an anticalculus agent but results are not significant anticalculus agent but results are not significant and further it leads to increase in caries.and further it leads to increase in caries.

AntimicrobialsAntimicrobials Penicillin, Cetylpyridinium chloride, Niddamycin, Triclosan and Penicillin, Cetylpyridinium chloride, Niddamycin, Triclosan and

chlorhexidine have been studied as an anticalculus agent.chlorhexidine have been studied as an anticalculus agent. Out of these penicillin and cetylpyridinium chloride have not Out of these penicillin and cetylpyridinium chloride have not

been found to decrease calculus levels.been found to decrease calculus levels. Although chlorhexidine is a potent antiplaque agent but it leads Although chlorhexidine is a potent antiplaque agent but it leads

to increase in calculus levels to increase in calculus levels ( Loe etal 1976, Lang et al 1982, ( Loe etal 1976, Lang et al 1982, Grossman et al 1986 ).Grossman et al 1986 ).

Niddamycin (Niddamycin (CC10232CC10232) has been found to decrease calculus ) has been found to decrease calculus formation but it is not used because of concern for bacterial formation but it is not used because of concern for bacterial resistance.resistance.

Triclosan has been found to asist in plaque control and inhibition Triclosan has been found to asist in plaque control and inhibition of calculus formation although to what extent, its not clear. It is of calculus formation although to what extent, its not clear. It is predominantly used in combination with other anti-calculus predominantly used in combination with other anti-calculus agents.agents.

MetalsMetals

Metal salts inhibit calculus formation by two Metal salts inhibit calculus formation by two mechanisms. Firstly they inhibit plaque formation mechanisms. Firstly they inhibit plaque formation by causing metabolic changes in bacterias. by causing metabolic changes in bacterias. Secondly they inhibit mineralization.Secondly they inhibit mineralization.

A dentrifrice containing zinc chloride and sodium A dentrifrice containing zinc chloride and sodium floride has been shown to retard calculus floride has been shown to retard calculus formation.formation.

BisphosphonatesBisphosphonates

Bisphosphonates are a group of synthetic pyrophosphate Bisphosphonates are a group of synthetic pyrophosphate analogue which prevent calculus deposition by inhibiting analogue which prevent calculus deposition by inhibiting crystal growth. The bisphosphonates studied for their crystal growth. The bisphosphonates studied for their anticalculus effect are as follows and all of them have anticalculus effect are as follows and all of them have been found to reduce caculus formation.been found to reduce caculus formation.

EHDP (Ethanehydroxydiphosphonate)EHDP (Ethanehydroxydiphosphonate) Sodium etidronateSodium etidronate DPD (Diphosphono-propane-dicarboxylic acid)DPD (Diphosphono-propane-dicarboxylic acid) AHP ( Azacycloheptane 2,2-diphosphonic acid )AHP ( Azacycloheptane 2,2-diphosphonic acid ) PBTA ( 2-phosphonobutane 1,2,4 tricarboxylate )PBTA ( 2-phosphonobutane 1,2,4 tricarboxylate )

Victamine CVictamine C

It is a surface active organophosphorous It is a surface active organophosphorous compound that has been found to be effective in compound that has been found to be effective in inhibiting the invitro crystallization of calcium inhibiting the invitro crystallization of calcium phosphate onto the smears of supragingival phosphate onto the smears of supragingival calculus.calculus.

Victamine C has a specific taste that leads to Victamine C has a specific taste that leads to increased salive flow that leads to reduction in increased salive flow that leads to reduction in calculus.calculus.

PyrophosphatesPyrophosphates

Prevent calcification by interrupting the Prevent calcification by interrupting the conversion of amorphous cacium phosphate to conversion of amorphous cacium phosphate to hydroxyapatite.hydroxyapatite.

The results from clinical studies are not found to The results from clinical studies are not found to be significant so they are not in use.be significant so they are not in use.

Polymers and copolymersPolymers and copolymers

The following agents have been tried:The following agents have been tried: Oligomer of sufoacrylic acidOligomer of sufoacrylic acid EDITEMPAEDITEMPA BTC/copolymer mixtureBTC/copolymer mixture Gantrez (0.05% solution of methoxyethylene and Gantrez (0.05% solution of methoxyethylene and

maleic acid)maleic acid)

All of them have been shown to have anticalculus All of them have been shown to have anticalculus effect either alone or in combination with other agents effect either alone or in combination with other agents such assuch as

combination of incorporation of copolymer in a combination of incorporation of copolymer in a periodontal pyrophosphate/NaF paste. periodontal pyrophosphate/NaF paste.