Efecto Del Barniz de Clorhexidina Al 1% y Solucion de Xilitol Al 40& en SM (2)

7/22/2019 Efecto Del Barniz de Clorhexidina Al 1% y Solucion de Xilitol Al 40& en SM (2)

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PEDIATRIC DENTIS TRY V 33 I NO 7 NOV I DEC 11

Scientic ArticleThe Effect of 1 % Chlorhexidine Varnish and 40% Xy litol So lution on Streptococcus Mutansand Plaque Acc um ulation in ChildrenRenata Simes Morae s, DDS, MS' A driana Mo dest o, DDS, MS, PhD, DMD^ Ktia Regina Netto dos Santos, BS, PiiD^ David Drake, BS, MS, PinD

Abstract: Purpose: The purpose of this study was to determine the effect of the association of 1 % chiorhexidine varnish (CHX) and 40% xyiitoi soiution(XYL) on Streptococcu s mutans (SM) counts and piaque indices in 2- to 5-year-oids. Methods: Sixty-eight ch ildren were seiected with medium ieveis (1 x 1 0 ^ )to very high ieveis (> 1 x 1 0 ^ ) of SM in the saiiva. Subjects w ere divided into 4 groups of 17 chiidren e ach: (1) X; (2) CHX+XYL ; (3) XYL: and(4) 0.05%sodium fluoride (F). An asse ssment of SM ieveis and piague indices was done on all chiidren at b aseline, 1 5 days, and at 1 , 3, and 6 mon ths. SM levis weredetermined by the spatuia method. Results: Although the reduction in SM counts in all groups w as statistically significant, differences amon g groupswere not o bserved, and the CH X and F groups seemed to show the greatest effect Plaque reduction was observed in ai i groups, whereas statisticai iysignificant decreases among groups w ere not observed. Conclusions: One percent chiorhexidine va rnish associated with 40 % xyiitoi soiution tested in thpresent study doe s not provide significant suppression of Streptococcu s mutan s counts and reduction of piaque accu muiation at any foiiow-up timepoints. (Pediatr Dent 2011:33:484-90) Received March 2,2010 I Last Revision August 5 , 2010 I Accepted August 6,2010K E Y W O R D S : C A R I O L O G Y , S T R E P T O C O C C U S M U T A N S , P R E V E N T I V E D E N T I S T R Y , C H L O R H E X i D IN E , X Y L I T O L

While studies have shown that the incidence of dental cariesin young children has decreased overall in the past 20 years insome countries, there is growing evidence of oral health dispa-rities in countries having a lower socioeconomic level. There aremany countries and minority populations where the incidenceis still high.' Moreover, according to the (WHO),' caries inci-dence in children is still at an alarming level around the world.Therefore, there is great need for the development of preven-tive, practical, and cost-effective strategies for dental caries to beglobally controlled.A number of studies have provided evidence that, althoughdental caries is dependent on different factors, the main causa-tive agent is Streptococcus mutans {SM) colonization and conse-quent plaque accumulation on dental surfaces. The higher theSM level, the higher the plaque accumulation and the greaterthe risk of developing carious lesions.^"' Therefore, control ofSM levels is an important target of caries prevention and con-trol.' Among the possible strategies in SM control, chemothe-rapeutic treatment regimens have received much attention andhave presented satisfactory results in promoting SM suppression,plaque reduction, and, consequently, caries prevention or in-cidence decrease.'' Of the chemical agents used in dentistry,chiorhexidine (CHX) and xylitol (XYL) seem to offer strong

'Dr. Moraes is a pdiatrie dentist in private practice, Rio de Janeiro, Brazil; " D r . Modestois an associate professor. Department of Pdiatrie Dentistry, School of Dental Medicine,University of ttsburgh, ttsburgh. Pa; Wr. dos Santos is an associate professor. De-partment of Medical Microbiology, Federal University of R io de Janeiro, Rio de Janeiro,Brazil; and * D r . Drake is a professor. Department of Endodontics, Dows Institute forDental Research, College of Dentistry, University of Iowa, Iowa City, Iowa.Correspond with D r. Modesto at amszoS

antimicrobial activity. It is of interest that these agents havecompletely different modes of ac tion.CHX is an antimicrobial substance having the best effectagainst S M . '' In high concentrations (40%, 33 % , 25%, 20%, or1 0 % CHX in varnish), it has an immediate bactericidal action,as it penetrates the cellular wall and causes cytoplasm preci-pitation. In smaller concentrations (3% and 1% CH X in varnishand gd and 0.2% and 0.12% CHX in rinse), it has hydrophilic-hydrophobic properties and a bacteriostatic effect that inter-feres with membrane transport, allowing its light-weightmolecules to infiltrate into the offending micro-organism.**XYL is a sugar substitute usually used in foods, candiesand chewing gum. It cannot be metabolized by SM , so it pro-motes changes in SM metabolism by means of a strain-selectiveprocess: XYL-resistant strains proliferate with limited capacityto adhere to hard surfaces compared with XYL-sensitive strains,which decrease in number.'" These changes in the 571^ population lead to caries con trol.Studies have been conducted combining CHX and XYLand combining these agents with others with the aim of ob-taining better results when compared with their individuause.'^''' According to their characteristics, this pairing wouldbe expected to suppress bacterial levels via CHX use, while lesspathogenic strains would be suppressed via XYL use. Nevertheless, very few investigators have studied the association be-tween these 2 substances; none of the studies was conductedin children, b ut only with adu lts,"" " the elderly,'^ or in vitro.'*CHX and XYL, separately or combined, seem to performwell against SM in these studies; however, these substancewere never used in young children. Therefore, the purpose ofthis study was to determine the effect ofthe association of 1%CHX varnish and 40% XYL solution on SM counts and plaquindices in 2- to 5-year-olds.


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PEDIATRIC DENTISTRY V 33 I NO 7 NOV / DEC

MethodsThis study was approved by the Institutional Review Boardsof Federal University of Rio de Janeiro, Rio de Janeiro, Braziland University of Pittsburgh, Pittsburgh, Pa. Informed writtenconsent was obtained from the children's legal guardians. Theexperimental design of the study is summarized in Figure 1.

.Subject wi cttlon (n=S)

- 'CHX(N=I7)

.

Trailmcnl Rruu

CHX+XYL(N=M)

ISd i tsro l lnwup l ImMkrobbI IcniPlaque mscssme

ps ~ ^

XYL

c pont.

~ ~ .

_ F(N=15)

1 miinlh roilow up litnr pointMicrohiai let)Piuque Bs

CHX ond CII\+.\Y Rvln

Figure 1. Study design.

Subject recruitment. This blinded investigation of 6-months duration recruited 2- to 5-year-old children from apublic preschool and from a public pdiatrie dental clinic.A trained dentist examined all the children in adental chairwith standard light source and air jet, using a mouth mirrorand dental explorer, after cleaning the children's teeth witha toothbrush to verify the condition of the dentition. Childrenwith cavitated carious lesions were excluded, while those withactive white spot lesions and restorations were allowed to con-tinue in the study.The mothers were interviewed by the same trained dentistabout oral hygiene, dietary habits, fluoride usage, antimicro-bial exposure of the child, and their knowledge about the chemi-cal agents tobe used in the study. During the interview, theyreceived dietary and hygiene instructions for the child. Chil-dren who were taking systemic antimicrobial medication, sys-temic medication that could affect the oral microflora, or whohad received oral application of any antimicrobial agent with-in 3months prior to the study were excluded from the study.A total of 144 children were recruited toparticipate based onthese criteria.Pretest. Final selection from the intital 144 children wasbased on the subjects' salivary SM levels assessed by the tongueblade method." In this technique, a3-cm, sterile wooden spa-tula is used tocollect saliva and inoculate the contact platewith the saliva. However, because of the small size of a 2- to3-year-old's mouth, a 3-cm spatula would make this methodnot feasible inyoung children. Inview of this, we developeda pretest to investigate the effect of the contact area of thetongue blades on SM counts inRodac contact plates to verifythe possibility of using a shorter spatula for young ch ildren.SM 10449 (serotype c) was used for these experiments withbatch cultures started from 90C stocks. Primary cultures of

SM (0.1 mL) were grown in 50-mL Trypticase soy broth sup-plemented with yeast extract in 5% carbon dioxide (CO^) at37C overnight. Before sterilization, the media were treatedwith invertase toremove trace amounts of contaminating su-crose. Cultures were harvested by centrifugation and resus-pended inan equal volume of fresh medium. Three differendilutions of 5M were prepared:1. ahigh concentration (1 x 10'), representing a quan-tity of colony-forming units (CFU) higher than 101(>101 CFU) in the plates;2. a medium concentration (1 x 10'), between 11 an100 CFU (11-100 CFU); and3. a low concentration (1 x 10'), between 1 and 10 CFU(1-10 CFU).For SM inoculation, 72 sterile wooden tongue blades,1.8 cm wide, (1 for each Rodac plate) were used. The spatulaswere rotated 10 times in the 5A/suspension; then, each sideof the spatula was pressed against the Mitis salivarius, sorbitokanamycin, and bacitracin (MSKB) agar medium^" onto Rodacplates of a predetermined length, inoculating the SM . Thirty-six 2.5-cm-long blades were used for group 1, and 36 3-cm-long blades were used for group 2. It is important to empha-

size that each length represented different inoculation areas. Allthe plates were incubated in 5% CO^ at 37C for 48 hours.The resulting colonies were counted with the aid of a dissect-ing microscope on the spatula impression area by a previotislytrained observer.SM counts were analyzed by 2-way analysis of variance(ANOVA) with Tukey-Kramer post-tests, with a significancelevel of 5% .There were no statistically significant differences incolonycounts across the plates {P


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PEDIATRIC DENTISTRY V 33 I NO 7 NOV / DEC 11

level (11-100 CFU=1 x 10'); 3=high level (101-250 CFU=1 x10'); 4=very high level (>250 CFU >1 x 10^)." Only childrenwith moderate, high, and very high SM levels were selected forthe study (N = 68) . The Vf levels assessed for the subjects' selec-tion was considered the baseline of 5A levels.At the same appointment, the plaque assessment was ini-tiated. Plaque assessment of the labial surface of the primarymaxillary incisors was performed without using disclosingsolution. Each incisor received a score according to the presenceand quantity of plaque: O=absence of visible plaque; l=visibleplaque on less than half the surface; 2=visible plaque on morethan a half the surface (modified from Weber's criteria forplaque scores).^' This plaque assessment was considered thebaseline plaque indices for the selected children.Treatment. The 68 selected children were divided into 4groups of 17 each, according to treatment: (1) 1% CHX var-nish (Cervitec, Ivoclar Vivadent, Mississauga, Ontario, Canada);(2) 40% XYL solution; (3) CHX+XYL; and (4) 0.05% sodiumfluoride (F) solution. A single trained dental hygienist per-formed all treatment procedures and provided all the informa-tion and instructions for the children and their parents in adental ofiSce. The dentist was blind for the group allocation.In the CHX group, the CHX varnish was applied by quad-rant to all dental surfaces with a microbrush over a 3-monthinterval (every 3 months). Before application, the teeth wereprofessionally cleaned, isolated with cotton rolls, then air-dried for 30 seconds. Parents received written and verbal in-structions to not: give any food or drink for 1 hour aftertreatment; brush the child's teeth for 24 hours; floss for 1 week;and provide sweet or hard foods for the next 24 hours. In theXYL group, the mothers were instructed to apply the xylitolsolution at home with gauze every night after the last oralhygiene throughout the entire study period (6 months). Eachapplication was to expend 24 drops6 drops for each he-miarch. Each child received a bottle of 100 mL XYL to takehome. The XYL bottle was replaced every 3 months or when

necessary. In the CHX+XYL group, mothers were instructedthe same way as in the previous groups. In addition, XYL so-lution use was started 24 hours after CHX application. In theF group, mothers received the same instructions given in theXYL group. Toothbrushes were to be replaced by new ones ateach retreatment appointment. The microbial test and plaque

assessment were repeated after 15 days, 1 month, 3 months,and 6 months from the first treatment appointment (Figure 1).Treatment acceptance. The Faces Scale^^ was used to mea-sure the children's acceptance of treatment. This scale consistsof 3 face pictures (Figure 2), which were shown to childrenolder than 3-years-old to check their reaction. After the firsttreatment, the child was asked to point to the face that wassimilar to his or her impression of the treatment. Childrenyounger than 3 years old were excluded from this evaluationbecause they could not tinderstand the difference between sa-tisfaction and dissatisfaction on the Faces Scale.Statistical analysis. A nalyses of the microbiological andclinical data were done using SPSS ll.O software (SPSS inc,Chicago, 111). Nonparametric statistical analyses were performedusing Kruskal-Wallis A NOVA . Values of /'


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PEDIATRIC DENTISTRY V 33 I NO 7 NOV / DEC 11

At the 6-month follow-up time point, reduction in SM countswas observed again in all groups, with the F group being themost effective (Table 1; Figure 3). Mean variations of S'A/scores,according to the follow-up periods, were higher between baselineand 15 days for all treatment groups. The CHX and F groupsshowed the highest variation (close to a 1-point score). It wasnot, however, statistically significant (Table 1). A decrease inSM levels at the follow-up time points can be seen in Table 2,but statistically significant differences were not found.The plaque means were very similar among the groups atbasel ine, dem onstr at ing a uniform abi l i ty for p laque forma-tion within 24 hours among the groups (Table 3). All groupsexperienced reduct ion of p laque, al though in small amountsand without statistically significant differences and regardlessof the treatment, within 1 month. At 3 months, the XYL groupreturned to baseline scores and did not change at 6 months. TheCHX group returned to baseline scores as well (Table 3; Figure 4).After evaluating treatment acceptance, it was observed that,of the 10 CHX group children who answered the face scale.

15ays 1 monih SmonihsFollow up time point

Figure 3. Means of Streptococcus mutans counts after the trearment(chlorehexidine [CHX ]; CHX+xylitol [XYL]; XYL; and fluoride [F]),and during the foliow-up time points (15 days, 1 month, 3 months, and6 months).

ds

mo

N O . AN D % DISTRIBUTIONS O F CHILDREN ACCORDMUTANS LEVELS.

Treatment

C H XCHX+XYLXYLFC H XCHX+XYLXYLFC H XCHX+XYLXYLFC H XCHX+XYLXYLFC H XCHX+XYLXYLF

TREAlNG TO 5r/?fPrOCOCCL/S

rMENTS, AND FOLLOW-UP TIME POINTSStreptococcus mutans levels

N_

--1

211-21-112--1

0%_

. --7--

1868-157-11918--

17

N

---52126222--1

-12

1%

---

381781838-13

1514--9

-1333

N

65764462157352233331

2%35364440293350186

4247233633222727503817

N

5234-222521331415121

3%29141927.

17171831177232117449

46172517

N

6765444334533325122I

4%355038332933252719333323215022459

332517

Total

17141615141212111612151314691111686

N=no. of children; %=perccntage of children with the scote in the gtoup; CH X =1% chlot-h gtoup ; CHX+XY L=1% chlothexidine vatnish + 40% xylitol solution gto up;

9 were satisfied a nd 1 was dissatisfied. O f the 9 CHX +X YLgroup ch ildren , 6 were happy and 3 were indifferent. O f the10 XYL grou p child ren, 9 were happy and 1 was indifferent;of the 9 F group children, 6 were happy and 3 were indifferent.The only child who did not like the treatment also exhibitedpoor beha vior after the clinical exam ination. O verall, the resultsshowed excellent children's acceptance of the tested agents.The interviews verified that all the children had a cario-genic diet owing to high carbohydrate consumption, as well ashigh frequency. They all had prior contact with fiuoride, al-though none had regular exposure to i t . Evaluat ion of theparents ' knowledge about the chemical agents used in th isstudy showed that, of the 68 parents interviewed, only 3 wereunaware about fluoride's role in tooth protection. Seven mothershad already heard about CHX. They did not know, however,that it could be applied on teeth. O nly 2 mothe rs had alreadyheard about XYL in chewing gum .O nly 1 XYL group child reported diarrhea on the first dayof using XYL. N o stains or irritated gingival tissue were observedon the teeth at any of the fo l low-ups in ei ther the CHXgroup or CHX+XYL group.D r o p o u t s . O f the 68 selected chi ldre n, 62 returned to

treatment for the first follow-up (15 days), 55 returned for thesecond (1 month), 40 reported for the th ird (3 months), and31 returned for the fourth (6 mo nths) . Th e highest dro pou trate was observed for the CHX+XYL group (Table 2).DiscussionPretest discussion. According to Szklo and N ie to ," pretes tshave been developed to verify the feasibility and efficiency ofthe study procedures and, if necessary, correct the proceduresbefore f ieldwork begins . The se authors also mentio ned thatthis type of study is developed with a convenience sample underlaboratory condit ions . O ur pretes t was conducted exact lyaccording to their guidelines. The development of a pilotstudy was rejected because it was not considered a necessary

p rocedure once the p re tes t answered a l l the ques t ionsthat emerged on the occasion of a study plan.To train for the study, the clinical steps used in thestudy were reproduced in the pretest. For the same purpose,MSKB media (selective media for SM ) was used in the pre-test, although a standard SM strain was used to practice itsmanipulation and to observe the growth of these bacteriain a very selective growth me dium .The results showed no significant differences in colonycounts across the plates under laboratory conditions. Thissuggests that, while the contact area of the tongue blade forinoculation could vary between 2.5 and 3.0 cm according tothe child's age and mo uth size, it should not affect the results.Discussion. Strategies based on oral hygiene and non-cariogenic diet are often insufficient to prevent the establish-me nt of dental caries. The refore , chemica l caries contro lstrategies are usually the main target of researchers.Subjects between 2 and 5-years-old were the target ofthis research because:

1. The combinat ion of CHX and XYL for chi ldren hasnot been previously studied.2. Preventive measures have been considered to be themost economical and enduring alternatives to reducedental caries.^''

Although CHX is the most potent antimicrobial agentso far documented against SM , the observed suppressionof these micro-organisms in the CHX group was not sta-tistically significa nt in accord ance of system atic review


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15 days 1 month 3 monthsFollow up lime point

Figure 4. Means of plaque accumulation after the treatment (chlore-hexidine [CHX]; CHX+xylitol [XYL]; XYL; and fluoride [F]) and duringthe follow-up time points (15 days, 1 month, 3 months, and 6 months).

information." This result also cottoborates ptevious studies inwhich 1% CHX vatnish applicat ion was not very f requentnot was it done within a short time interval.^'' '^^ By contrast,f tequent applicat ion of CHX within a relat ively shor t t imef tame^'"*" in high concenttat ions '"" and the combination off tequen t app l ica t ion and in tens ive p to fess ional mechan ica ltooth cleaning^^ resulted in statistically significant supptession.Thetefote, it is likely that we would have seen significant re-duction in SM if mote CHX applications had been petformedin the short time petiod of the study. It is impottant to em-phasize that a predetermined protocol for CHX use does notex is t . Recommended modes o f admin is t ta t ion o f th i s agen tin the literature have not been consistent.

SM tecolonizat ion has been repor ted af ter inter ruptionof treatment with CHX, based on the f requency of therapy,vehicle used, and concentrat ion of the agent .^ ' ' ' " Total SMtecolonization was not observed at the follow-up time pointseven after low SM supptession and low frequency and concen-trat ion of CHX. The best reduction in plaque accumulat ion,although not statistically significant, seemed to occut in theCHX gtoup. This finding agrees with anothet study, in whichan initial decrease in plaque accumulation was obsetved fol-lowed by teduction that became less pronounced.'**In the XYL gtoup, ini t ial SM supptession was observedaf tet 15 days when compared with basel ine, and this sup-ptession was sustained duting all follow-ups (Table 1). Thesetesults, although not statistically significant, agree with othet

studies, in which SM teduction did not persist fot a long timeafter XYL therapy,''*'""' probably because of the increase in se-lected XYL-resistant sttain s.'"The plaque index reduction previously repotted^' ' was notevident in the ptesent s tudy. This f inding could be a conse-quence of low-frequency XYL use, even if used in high con-centration. XYL has a dose-dependent effect. '** Most of thestudies evaluated this agent as applied with a high frequency(between 3 and 5 t imes a day) with chewing gum as thevehicle, which stays in the mouth longer when compared withothet means of applicat ion. Anothet impottant point is thatXYL's effectiveness, as well as that of sodium fiuotide, was to-tally dependent on the mothers' compliance with the applicationregimes and could not be controlled by the dentist or hygienist.

Studies lacking combination therapy with CHX and XYLhave been inftequently tepotted. The few available studies, how-evet, tepotted bettet performance of these combined agents forVf sup pres sion ,"'" plaque index reduc tion ,' ' and reduction ofmothet-child transmission of 5 M " ' In this study, we did not ob -serve the previously tepotted enhanced outcomes from this com-bination therapy. These weak results ate ptobably a consequenceof the same ptoblems pointed out fot the othet treatment gtoupswith these agents alone.CHX vatnish was chosen fot the present s tudy becausethe young children evaluated in this s tudy did not have thecapacity to spi t out the mouthwash. Cel was also ruled outbecause of its bittet taste and the difficulty of maintaining thesubstance in contact with the teeth. A highet concenttat ionof CHX varnish was also ruled out because of its bitter taste.This unpleased taste could represent a behavior problem forthe young childten used in the s tudy. The authots t r ied toremove all possible factors which could interfere in the workwith young childten. Addit ionally , 1% CHX vatnish ptesentsgood clinical outcomes in previous studies."*" Foremost, thevatn ish r equ i tes f ewet app l ica t ions compared wi th mouth-wash and gel. The XYL solution has not been used in clinicalstudies, and it was chosen because it would be very difficultto control gum chewing in young childten. New vehicles areneeded to effectively deliver xylitol at thetapeutically effectivelevels ovet time*'.

Th e SM suppression obsetved in the F gtoup illustrates theantimicrobial ptopetties of fluotide, which had already beenobse tved by Yoshihara et al.,"*^ alt ho ug h th e fluoride was tes tedM E AN S O F PLAQU E ASSESSM EN T AT FO LLOW - U P T I M E POI N T S AN D M E AN V AR IAT I ON OF P L A Q U E A S S E S S M E N T B E T W E E N

Treatment

C HXCHX-hXYLXYLFTotal

hUL

N

1714161562

_ U W - U P I l lV lt

BaselineMean(SD)

1.800.291.600.371.600.301.600.37-

KUIIM

N

1412121149

1 i AINU bAit15 ds

Mean(SD)1.480.331.310.221.540.021.520.06

-0.39

.LIINt ALL

Meanvariation0.260.220.020.06

-

ur\u\

N

1612151355

M lU 1 r\CAIIVILIN 1Plaque assessment

1 m oMean(SD)

1.640.341.540.231.480.431.400.32-

0.87

Meanvariation0.120.040.130.17

-

N

146911

40

3 mosMean Mean(SD) variation

1.620.451.160.491.610.411.520.45

-0.70

0.100.330.000.09-

N

1168631

6 mosMean(SD)

1.810.251.250.381.650.371.350.22-

0.

Meanvariation-0.060.25-0.090.10

-17

/^ .0 5 derived from tionparametric test: Kruskall-Wallis; N=no. of children; mean=mean of plaque scores; mean variation=mean of variation compared to baseline; CHX= 1 % chlorhexidinevarnish group; CHX-hX=l% chlorhexidine varnish + 40% xylitol solution group; XYL=40% xylitol solution group; F=0.05% sodium fluoride group.


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PEDIATRIC DENTIS TRY V 33 I NO 7 NOV ( DEC 1

in higher concentrations. The observed SM suppression be-tween 3 and 6 months, even though not statistically significant,corroborates the idea that the agent's performance is highlydependent on its use. At the 3-month follow-up, the bottle con-taining the treatment solution was replaced by a new one.This fact could have worked as a motivating factor for theparents to continue applying fluoride solution throughout theentire study period.Plaque assessment was based only on the surface areacovered with plaque. The quality of plaque in these areas wasnot evaluated. Moreover, it is known that SM levels and plaqueaccumulation have an important relationship with carbohy-drate consumption.'' In this study, it was observed that allchildren had a cariogenic diet, which could interfere with theagent's performance. Even though dietary instructions were givenat the beginning of the study, changing one's habits is a dif-ficu lt task, especially with only one motivation session.A nonpa ram etric statistical analysis was performed formicrobiological and clinical data without use of means ofscores. The means of scores were used only in tables and gra-phics to illustrate the results.Initially, the sample size of this study was determined to be

100 children, 25 in each group. After subject selection, how-ever, only 68 children (-47%) out of 144 were included inthe study based on their high SM levels. It is difficult to com-pare our SM colonization prevalence with other studies main-ly because of the different methodologies applied, especiallythe different selective SM media used.The spatula method was chosen because it was consideredone of the simplest of laboratory tests, requiring fewer stepsthan other lab tests. In this method, the saliva sample doesnot need to be diluted before inoculating the media. Thischaracteristic makes the test most appropriate for epidemio-logical studies or dental practice. Another important advan-tage is that a spatula or tongue blade is used to collect thesaliva sample, which makes it practical for small children,compared with other classical methods in which the saliva hasto be collected after stimulation.The MSKB agar medium, more selective for recovery ofSM than the mitis salivarius bacitracin (MSB) agar medium,was used in this study. MSB is not exclusively selective for SM ,and the colonial morphology is not a foolproof method ofdistinguishing SM from the other streptococcal species. Theauthors showed that recovery of SM on MSKB was 13% lessthan on MSB. This fact could have determined that ch il-dren with medium levels of SM would have been classified aslow-level, and thus could have been excluded from the study.MSKB medium, however, was chosen for its long shelf life,high capacity to select SM colonies, and low number of non-mutans colonies that could be visually confused with SM important characteristics for more precise colony counting.^"The Faces Scale was used to evaluate pain through a self-report. This scale was chosen because it is an attractive ap-proach, simple, and quick to conduct.^^ The excellent accept-ance of CHX by children, regardless of its bitter taste, isprobably due to the varnish vehicle, which allows low concen-tration and safe application without contact with the tongue.'^This result would probably not have been achieved had the gelvehicle been used. The other groups' acceptance was probablydue to either the sweet taste of the XYL or the absence of thetaste of sodium fluoride, in addition to the fact that the childrenfelt more comfortable with their mothers' applying the agents.The good acceptance of chiorhexidine varnish by children hadalready been reported.''''

Future studies should be performed to test the effects ofmore frequent applications of CHX and XYL.ConclusionsBased on this study's results, the following conclusions can bemade:1. Overall reduction in Streptococcus mutans counts wobserved in all treatment groups with the 1% chior

hexidine varnish group presenting the most reduction.2. All treatment groups presented reduction of plaqueaccumulation with the 0.05% sodium fluoride groupshowing the most plaque reduction.3. Effective antimicrobials and delivery vehicle systems areneeded to reduce plaque and cariogenic bacteria inyoung children.AcknowledgmentsThe authors wish to thank Dr. Cindy L. Marek, associate pro-fessor. College of Dentistry, University of Iowa, Iowa City,Iowa for technical assistance with the xylitol solution prepara-tion. Bonny Olson for technical support, Ktia Pereira forclinical support. Dr. Ronir Raggio, associate professor. FederalUniversity of Rio de Janeiro, Rio de Janeiro, Brazil and MonicaMagnanini for statistical support, and Ivoclar Vivadent for theCervitec do nation.References1. World Health Organization. Oral health information sys-tems. Available at: "http://www.who. int/oral_health/action/information/surveillance/". Accessed November 3, 2009.2. Alaluusua S, Malmivirta R. Early plaque accumulation: Asign for caries risk in young children. Community DentOral Epidemiol 1994;22:273-6.3. Maciel SM, Marcenes W, Sheiham A. The relationship be-tween preference, levels of salivary mutans streptococci, and

caries experience in Brazilian pre-school children. PaediatrDent 2001;l 1:123-30.4. Koga-Ito CY, de Martins CA, Balducci I, Jorge AO. Cor-relation among mutans streptococci counts, dental caries,and IgA to Streptococcus mutans in saliva. Pesqui OdonBras2004;18:350-5.5. Okada M, Soda Y, Hayashy F, et al. Longitudinal studyof dental caries incidence associated with Streptococcumutans and Streptococcus sobrinus in preschool childreJ Med Microbiol 2005;54:66l-5.6. Thystrup A, Fejerskov O. Textbook of Clinical Cariol-ogy. 2nd ed. Copenhagen, Denmark: Munksgaard; 1994:333-53.7. Emilson CC. Susceptibility of various micro-organisms tochiorhexidine. Scand J Dent Res 1977;85:255-65.8. Matthijs S, Adriaens PA. Chiorhexidine varnishes: A review.J Clin Periodontol 2002;29:l-8.9. Trahan L, Mouton C. Selection for Streptococcus mutawith an altered xylitol transport capacity in chronic xylitolconsumers. J Den t Res 1987;66:982-8.10. Trahan L, Sderling E, Dran MF, et al. Effect of xylitolconsumption on the plaque-saliva distribution of mutansstreptococci and the occurrence and long-term survivalof xylitol-resistant strains. J Dent Res 1992;71:1785-91.11. Benchabane, H, Lortie LA, Buckley ND, Trahan L, FrenetteM. Inactivation of the Streptococcus mutans fxpC genconfers resistence to xylitol, a caries-preventive natural car-bohydrate sweetener. J Dent Res 2002;81:380-6.


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12. Pienihkkinen K, Sderling E, Ostela I, et al. Compari-son of the efficacy of 40% chlorhexidine varnish and 1%chlorhexidine fluoride gel in decreasing the level of sali-vary mutans streptococci. Caries Res 1995;29:62-7.13. Mkinen KK, Hujoel PP, Bennett CA, et al. Polyol chew-ing gums and caries rates in primary dentition: A 24-month cohort study. Caries Res 1996;30:408-17.14. Jannesson L, Renvert S, Kjellsdotter P, et al. Effect of triclosan-containing toothpaste supplemented with 10% xylitol onmutans streptococci in saliva and dental plaque. Caries Res2002;36:36-9.15. Simons D, Beighton D, Kidd EA, et al. The effect ofchlorhexidine/xylitol chewing gum on plaque accumula-tion and gingival inflammation. J Clin Periodontol 1999;26:388-91.16. Thorild 1, Lindau B, Twetman S. Effect of maternal use ofchewing gums containing xylitol, chlorhexidine, or fluo-ride on mutans streptococci colonization in the mothers'infant children. Oral Health Prev Dent 2003; 1:53-7.17. Simons D, Kidd EA, Beighton D, et al. The effect ofchlorhexidine/xylitol chewing-gum on cariogenic salivarymicroflora: A clinical trial in elderly patients. Caries Res1997;31:91-6.18. Modesto A, Drake D. Multiple exposures to chlorhexidineand xylitol: Adhesion and biofilm formation by Streptococ-cus mutans. Curr Microbiol 2006;52:418-23.19. Khler B, Bratthall D. Practical method to facilitate esti-mation to Streptococcus mutans levels in saliva. J ClinMicrobiol 1979;9:584-8.20 . Kimmel L, Tinanoff N. A modified mitis salivarius me-dium for caries diagnostic test. Oral Microbiol Immunol1991;6:275-9.21 . Weber K. A Comparison of the Effectiveness of 3 Educa-tional Interventions in the Prevention of Early ChildhoodCaries [PhD thesis]. Iowa City, Iowa: University of Iowa;2003.22 . Pierro VS, Barcelos R, de Souza IP, Raymundo RJ. Pdiatriebitewing film holder: Preschoolers' acceptance and radio-graphs' diagnostic quality. Pediatr Dent 2008;4:342-7.23 . Szklo M, Nieto FJ. Quality assurance and control. In: Epi-demiology: Beyond the Basics. Gaithersburg, Md: AspenPublishers, 20 00:343 -404.24 . Ercan E, Dlgergil T, Yildirim I, Dalli M. Prevention ofmaternal bacterial transmission on children's dental-caries-development: 4-year results of a pilot study in a rural-child population. Arch Oral Biol 2007;52:748-52.25. Ribeiro LG, Hashizume LN, Maltz M. The effect of dif-ferent formulations of chlorhexidine in reducing levels ofmutans streptococci in the oral cavity: A systematic reviewof the literature. J De nt 2 007;5:359-70.26 . Emilson CG, Cisselsson H, Birkhed GH. Recolonizationpattern of mutans streptococci after suppression by threedifferent modes of chlorhexidine gel application. Eur JOral Sei 1999;107:170-5.27 . Madlna M, Vitalyos G, Mrton S, et al. Effect of chlor-hexidine varnishes on bacterial levels in plaque and salivaduring orthodontic treatment. J Clin Dent 2000; 11:42-6.

28 . Lunsen DM, Soet JJ, Weerheijm KL, et al. Effects of dentaltreatment and single application of a 40% chlorhexidinevarnish on mutans streptococci in young children underintravenous anesthesia. Caries Res 2000;34:268-74.29 . ^ a n AK, Seow WK, Purdie DM , et al. The effects of chlorhexi-dine gel on Streptococcus mutans infection in 10-month-oinfants: A longitudinal, placebo-controlled, double-blindtrial. Pediatr Dent 2 003;25 :215-22.30. Attin R, Tuna A, Attin T, et al. Efficacy of differently con-centrated chlorhexidine varnishes in decreasing mutansstreptococci and lactobacilli counts. Arch Oral Biol 2003;7:503-9.31. Derks A, Frencken J, Bronkhorst E, Kuijpers-JagtmanAM, Katsaros C. Effect of chlorhexidine varnish applica-tion on mutans streptococci counts in orthodo ntic patients.Am J Orthod Dentofacial Orthop 2008;133:435-9.32 . Nom ura Y, Takeuchi H , Kaneko N , et al. Feasibility oferadica tion of mutan s streptococ ci from oral cavities. JOral Sei 2004;46:179-83 .33. Schaeken MJM, Schuten MJ, Van Der Kieboom CWA,et al. Influence of contact time and concentration of chlor-hexidine varnish on mutans streptococci in interproximaldental plaque. Caries Res 1991;25:292-5.34. Frentzen M, Ploenes K, Braun A. Clinical and microbio-logical effects of local chlorhexidine application. Int DentJ 2002;52:325-9.35. Sderling E, Isokangas PJ, Tenovuo P, et al. Long-termxylitol consumption and mutans streptococci in plaqueand saliva. Caries Res 1991;25:153-7.36. Autio JT. Effect of xylitol chewing gum on salivary Strep-tococcus mutans in preschool children. J Dent Child 20069:81-6.37. Kandelman D, Gagnon G. Clinical study of the incidenceand progression of dental caries in relation to consumptionof chewing-gum containing xylitol in school preventiveprograms. J Dent Res 1990;69:1771-5.

38. Wennerholm K, Arends J, Birkhed D, et al. Effect of xylitoland sorbitol in chewing-gums on mutans streptococci, plaquepH, and mineral loss of enamel. Caries Res 1994;28:48-54.39. Hildebrandt GH, Brandon, Sparks BS. Maintaining mu-tans streptococci suppression with xylitol chewing gum.J Am Dent Assoc 2000; 131:909-16.40 . Araujo AM, Naspitz GM, Chelotti A, Cai S. Effect ofCervitec on mutans streptococci in plaque and on cariesformation on occlusal fissures of erupting permanentmolars. Caries Res 2002 ;36:373 -6.41 . Featherstone JDB. Delivery challenges for fluoride, chlor-hexidine, and xylitol. BMC Oral Health 2006;6(suppl 1):1-5.42 . Yoshihara A, Sakuma S, Kobayashi S, et al. Antimicro-bial effect of fluoride mouthrinse on mutans streptococciand lactobacilli in saliva. Pediatr Dent 2001;23:l 13-7.43 . Helderman WH, Matee MIN, Hoeven V, et al. Cariogeni-city depends more on diet than the prevailing mutansstreptococcal species. J Dent Res 1996;75:535-45.AA. Splieth C, Steffen H, Rosin M, et al. Caries preventionwith chlorhexidine-thymol varnish in high risk schoolchil-dren. Community Dent Oral Epidemiol 2000;28:419-23.


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