The Widely Used Antimicrobial Triclosan Induces High Levels of Antibiotic Tolerance In Vitro and Reduces Antibiotic Efficacy up to 100-Fold In Vivo.

The antimicrobial triclosan is used in a wide range of consumer products ranging from toothpaste, cleansers, socks, and baby toys. A bacteriostatic inhibitor of fatty acid synthesis, triclosan is extremely stable and accumulates in the environment. Approximately 75% of adults in the United States have detectable levels of the compound in their urine, with a sizeable fraction of individuals (>10%) having urine concentrations equal to or greater than the minimal inhibitory concentration for Escherichia coli and methicillin-resistant Staphylococcus aureus (MRSA). Previous work has identified connections between defects in fatty acid synthesis and accumulation of the alarmone guanosine tetraphosphate (ppGpp), which has been repeatedly associated with antibiotic tolerance and persistence. Based on these data, we hypothesized that triclosan exposure may inadvertently drive bacteria into a state in which they are able to tolerate normally lethal concentrations of antibiotics. Here we report that clinically relevant concentrations of triclosan increased E. coli and MRSA tolerance to bactericidal antibiotics as much as 10,000-fold in vitro and reduced antibiotic efficacy up to 100-fold in a mouse urinary tract infection model. Genetic analysis indicated that triclosan-mediated antibiotic tolerance requires ppGpp synthesis but is independent of growth. These data highlight an unexpected and certainly unintended consequence of adding high concentrations of antimicrobials in consumer products, supporting an urgent need to reevaluate the costs and benefits of the prophylactic use of triclosan and other bacteriostatic compounds.

Control of Plaque and Gingivitis by an Herbal Toothpaste - A Randomised Controlled Study.

PURPOSE: To compare the efficacy of an herbal toothpaste with two other chemically active toothpastes regarding plaque and gingivitis control. MATERIALS AND METHODS: Seventy-six (27 females and 49 males, mean age 47.8 years, range 40-58 years) of 84 initial participants with slight and moderate chronic periodontitis used standardised manual toothbrushes and their usual technique for daily manual mechanical plaque control for 24 weeks of supportive periodontal therapy. The volunteers were randomly assigned to one of 3 groups: group 1 used the herbal toothpaste, group 2 a triclosan/copolymer toothpaste, and group 3 an amine/stannous fluoride toothpaste. OHI, API, SBI, BOP, PD and AL were recorded at baseline and after 6, 12 and 24 weeks (PD and AL only at baseline). The Kruskal-Wallis, Mann-Whitney U-, Friedman, and Wilcoxon tests were used for statistical analysis. RESULTS: Moderate changes occurred in API and OHI in all groups. The herbal toothpaste resulted in significantly lower API and OHI in comparison to the fluoride toothpaste during the study period (p = 0.001 and 0.049, minimum and maximum of cases, respectively). SBI was significantly improved in all groups starting after 12 weeks (p = 0.001 and 0.033). BOP remained largely unchanged in all groups and was always significant lower in the herbal toothpaste group (p = 0.001 and 0.036). CONCLUSION: During the study period of 24 weeks, the herbal toothpaste was as good as the control toothpastes. No side effects were seen. In terms of improving periodontal conditions, the tested herbal toothpaste could be a suitable alternative to conventional toothpastes with artificial chemical ingredients.

Antiplaque, Antifungal Effectiveness of Aloevera Among Intellectually Disabled Adolescents: Pilot Study.

PURPOSE: Various candida species have been associated with poor oral hygiene and active carious lesions. The purpose of this study was to evaluate the effectiveness of aloe vera compared to triclosan toothpaste against total candida, C. albicans, C. tropicalis, Candida krusei, and plaque/gingivitis among intellectually disabled adolescents over 30 days. METHODS: A double-blind prospective randomized trial was conducted among 40 intellectually disabled adolescents randomly allocated into aloe vera/triclosan groups. The gingival (Löe and Silness index), plaque (Silness and Löe index), and candidal carriage counts were assessed at baseline and follow-up. Caregivers brushed the participant's teeth twice a day using a modified bass method and refrained from any other oral hygiene practices for at least two hours prior to assessment. RESULTS: Aloe vera-contaiing toothpaste caused significant reductions in gingival inflammation and plaque index scores compared to the triclosan group at the end of 30 days. Also, total candidal counts and C. albicans counts were significantly lower in the aloe vera group compared to triclosan at the end of the 30-day follow-up (P<0.05). CONCLUSION: Aloe vera-containing toothpaste was effective in reducing plaque, gingivitis, and overall candidal counts compared to triclosan. Moreover, individuals treated with aloe vera experienced improved oral health status without any negative side effects.

Effect of adjunctive use of green tea dentifrice in periodontitis patients - A Randomized Controlled Pilot Study.

OBJECTIVES: Green tea is known to possess anti-inflammatory, antibacterial and antioxidant activities. This study evaluated the effect of a locally prepared green tea dentifrice on specific parameters assessing gingival inflammation and severity of periodontal disease, when used as an adjunct to scaling and root planing (SRP) in the management of chronic periodontitis by comparing with a fluoride-triclosan-containing control dentifrice. MATERIALS AND METHODS: Thirty patients, with mild to moderate chronic periodontitis, were randomly allocated into two treatment groups, 'test' and 'control' after initial SRP. The test group was given green tea dentifrice with instructions on method of brushing, while the control group received a commercially available fluoride and triclosan containing dentifrice. Clinical parameters of Gingival Index (GI), Plaque Index (PI), percentage of sites with bleeding on probing (BOP), probing depth (PD) and clinical attachment level (CAL) along with biochemical parameters of total antioxidant capacity (TAOC) and glutathione-S-transferase (GST) activity in gingival crevicular fluid (GCF) were recorded at baseline line and 4 weeks post-SRP. RESULTS: Intragroup analysis at 4 weeks showed statistically significant improvements of GI, PI, BOP, PD, CAL and TAOC in both groups. GST activity however, was increased only in the test group. At the end of the study period, the test group showed statistically significant improvements in GI, BOP, CAL, TAOC and GST levels compared to the control group. CONCLUSION: On comparison with fluoride-triclosan dentifrice, green tea showed greater reduction of gingival inflammation and improved periodontal parameters. Green tea dentifrice may serve as a beneficial adjunct to non-surgical periodontal therapy.

Comparing three toothpastes in controlling plaque and gingivitis: A 6-month clinical study.

PURPOSE: To investigate the clinical efficacy of three toothpastes in controlling established gingivitis and plaque over 6 months. METHODS: 135 subjects were enrolled in a single-center, double-blind, parallel group, randomized clinical study. Subjects were randomly assigned to one of three treatments: triclosan/copolymer/fluoride dentifrice containing 0.3% triclosan, 2.0% copolymer and 1,450 ppm F as sodium fluoride in a silica base; herbal/bicarbonate dentifrice containing herbal extract and 1,400 ppm F as sodium fluoride in a sodium bicarbonate base; or fluoride dentifrice containing 450 ppm F as sodium fluoride, and 1,000 ppm F as sodium monofluorophosphate. Subjects were instructed to brush their teeth twice daily for 1 minute for 6 months. RESULTS: After 6 months, subjects assigned to the triclosan/copolymer/fluoride group exhibited statistically significant reductions in gingival index scores and plaque index scores as compared to subjects assigned to the herbal/bicarbonate group by 35.4% and 48.9%, respectively. There were no statistically significant differences in gingival index and plaque index between subjects in the herbal/ bicarbonate group and those in the fluoride group. The triclosan/copolymer/fluoride dentifrice was statistically significantly more effective in reducing gingivitis and dental plaque than the herbal/bicarbonate dentifrice, and this difference in efficacy was clinically meaningful.

Effect of a toothpaste containing triclosan, cetylpyridinium chloride, and essential oils on gingival status in schoolchildren: a randomized clinical pilot study.

OBJECTIVE: This randomized double-blind in vivo pilot study has evaluated the effects of a toothpaste containing fluoride (control) versus toothpaste containing fluoride, triclosan, cetylpyridinium chloride and essential oils (experimental) in controlling supragingival dental plaque and bleeding on probing in a sample of healthy schoolchildren. METHOD AND MATERIALS: In total, 48 children (8 to 10 years) were selected and randomly divided into two groups (experimental and control), using the two different toothpastes twice a day for 2 minutes each for a 4-week period. The investigation included an evaluation of plaque quantity, using the Turesky modified Quigley-Hein method, and bleeding on probing that was recorded dichotomously. The unit of analysis was set at the gingival site level. Plaque Index and bleeding on probing were analyzed using distribution tables and chi-square test. A generalized estimating equation was used to estimate the parameters of a generalized linear model with a possible unknown correlation between outcomes. RESULTS: In total, 40 schoolchildren completed the trial. Considering each group separately, a statistically significant difference in plaque scores was recorded for both treatments (z-test = 9.23, P < .01 for the experimental toothpaste; and z-test = 7.47, P < .01 for the control toothpaste). Nevertheless, the effect over time was higher for the experimental toothpaste than for the control one (3.38 vs 1.96). No statistically significant results were observed regarding bleeding on probing. CONCLUSION: The 4-week use of the experimental toothpaste seems to produce higher plaque reduction compared to fluoridated toothpaste without other antibacterial ingredients. This finding has to be confirmed in a larger study.

Community-level assessment of dental plaque bacteria susceptibility to triclosan over 19 years.

BACKGROUND: Triclosan is a broad-spectrum antimicrobial agent used in toothpaste to reduce dental plaque, gingivitis and oral malodor. This community-level assessment evaluated the susceptibility of dental plaque bacteria to triclosan in samples collected over 19 years. METHODS: A total of 155 dental plaque samples were collected at eleven different times over 19 years from 58 adults using 0.3% triclosan, 2% copolymer, 0.243% sodium fluoride toothpaste and from 97 adults using toothpaste without triclosan. These included samples from 21 subjects who used triclosan toothpaste for at least five years and samples from 20 control subjects. The samples were cultured on media containing 0, 7.5 or 25 µg/ml triclosan. Descriptive statistics and p values were computed and a linear regression model and the runs test were used to examine susceptibility over time. RESULTS: Growth inhibition averaged 99.451% (91.209 - 99.830%) on media containing 7.5 µg/ml triclosan and 99.989% (99.670 - 100%) on media containing 25 µg/ml triclosan. There was no change in microbial susceptibility to triclosan over time discernible by regression analysis or the runs test in plaque samples taken over 19 years including samples from subjects using a triclosan-containing dentifrice for at least five years. CONCLUSIONS: This community-level assessment of microbial susceptibility to triclosan among supragingival plaque bacteria is consistent with the long-term safety of a 0.3% triclosan, 2% copolymer, 0.243% sodium fluoride dentifrice.

No evidence of triclosan-resistant bacteria following long-term use of triclosan-containing toothpaste.

BACKGROUND AND OBJECTIVE: There is a paucity of data in relation to the possible emergence of triclosan (TCS)-resistant bacteria following long-term exposure to TCS toothpaste. Therefore, this study investigated whether long-term continuous exposure to TCS in toothpaste selects for TCS-resistant bacteria within the oral biofilm. MATERIAL AND METHODS: Dental plaque samples were collected from 40 individuals during year 5 of a randomised controlled trial. Participants had been randomly assigned to use TCS (3000 µg/mL TCS) (n = 18) or placebo toothpaste (n = 22). Diluted plaque samples were plated on to Wilkins-Chalgren agar plates containing 5% (v/v) laked sheep red blood cells and TCS (concentrations ranging from 25 to 150 µg/mL) and incubated at 37 °C under microaerophilic and anaerobic conditions for 2-10 d. Selected bacterial isolates were identified by partial 16S rDNA sequencing and TCS minimum inhibitory concentration (MIC) determined for each isolate. RESULTS: At 3000 µg/mL TCS no growth was observed under microaerophilic or anaerobic conditions in either group. The MICs of TCS for all isolates ranged from 125 to 1000 µg/mL in both groups. Species common to both groups had similar MICs. Veillonella parvula and Campylobacter gracilis were the most frequent isolates from both groups, with similar MICs in both groups. CONCLUSION: The use of TCS-containing toothpaste did not appear to lead to an increase in MIC of TCS of oral bacterial isolates.

An in vitro comparison of dentifrice formulations in three distinct oral microbiotas.

OBJECTIVES: In vitro biofilm models, representative of some aspects of nascent, supra-gingival plaques (Hydroxyapatite Disc Biofilm Models), developed supra-gingival plaques (Modified Drip-flow Biofilm Reactors) and sub-gingival plaques (Multiple Sorbarod Devices) were used to compare the antimicrobial effects of a triclosan-containing dentifrice with a stannous fluoride and zinc lactate combination. DESIGN: Triplicate salivary biofilm microcosms were maintained for 2d (hydroxyapatite discs), 5d (Sorbarods) or up to 6d (drip flow reactors). Dentifrice slurries (10%, w/v) were added once to the discs and repeatedly to the Drip Flow Reactors and Sorbarods. Plaques were analysed by differential culture and gravimetrically. RESULTS: Whilst both dentifrices were comparably effective at reducing viability and plaque accumulation in mature supragingival plaques, the triclosan dentifrice produced comparatively larger reductions in total streptococci and anaerobes in nascent plaques (p<0.05) and greater reductions in Gram-negative anaerobes and streptococci in subgingival plaques. CONCLUSIONS: We have used a multi-model approach to determine the effectiveness and specificity of dentifrices against compositionally distinct plaques. Whilst both formations reduced bacterial viability and plaque accumulation, their effects could be differentiated in nascent and deep plaques where the triclosan dentifrice caused larger viability reductions.

Clinical and microbiologic effects of commercially available dentifrice containing aloe vera: a randomized controlled clinical trial.

BACKGROUND: Certain plants used in folk medicine serve as a source of therapeutic agents that have antimicrobial and other multipotential effects. This prospective, randomized, placebo, and positively controlled clinical trial was designed to evaluate the clinical and microbiologic effects of a commercially available dentifrice containing aloe vera on the reduction of plaque and gingival inflammation in patients with gingivitis. METHODS: Ninety patients diagnosed with chronic generalized gingivitis were selected and randomly divided into three groups: group 1, placebo toothpaste; group 2, toothpaste containing aloe vera; and group 3, toothpaste with polymer and fluoride containing triclosan. Clinical evaluation was undertaken using a gingival index, plaque was assessed using a modification of the Quigley-Hein index, and microbiologic counts were assessed at baseline, 6 weeks, 12 weeks, and 24 weeks. A subjective evaluation was also undertaken by questionnaire. RESULTS: Toothpaste containing aloe vera showed significant improvement in gingival and plaque index scores as well as microbiologic counts compared with placebo dentifrice. These improvements were comparable to those achieved with toothpaste containing triclosan. CONCLUSION: Toothpaste containing aloe vera may be a useful herbal formulation for chemical plaque control agents and improvement in plaque and gingival status.

Clinical and antimicrobial evaluation of a mouthwash and toothpaste for xerostomia: a randomized, double-blind, crossover study.

OBJECTIVES: Specific toothpaste and mouthwash for xerostomia based on triclosan, fluoride, and mineral salts were studied in order to evaluate their efficacy in improving the quality of life as well as their in vitro antimicrobial action. MATERIALS AND METHODS: 30 patients with dry mouth and hyposalivation confirmed by sialometry were included in a randomized, double-blind, crossover study, during two weeks for each experimental phase. Dryness and oral comfort, difficulty in speaking, chewing, swallowing and using dental prostheses, as well as taste and sleep disorders were evaluated. Values of minimal biocidal and minimal inhibitory concentrations of both products against microorganisms that often cause oral disorders in these patients were determined and compared. RESULTS: The use of the mouthwash and toothpaste studied improved the dry mouth symptoms, whilst no significant differences when compared with the salivary enzyme substitutes were observed. The test products showed, in general, a higher biocidal and inhibitory action than the control products, with particularly noteworthy action against cariogenic bacteria. CONCLUSIONS: The use of a toothpaste and mouthwash based on triclosan, fluoride, gingival revitalizers and mineral salts, improves the quality of life of patients suffering xerostomia.

Comparative effects of various commercially available mouthrinse formulations on oral malodor.

OBJECTIVES: The primary aim of this study was to compare a new mouthwash (SB12®) containing 0.025% chlorhexidine and 0.3% zinc for oral malodor reduction against four commercially available mouthwashes and negative control. A secondary aim was to compare the two methods for measuring volatile sulphur compounds (VSC) by halimetry and OralChroma. METHODS: Organoleptic scale, halimeter and the OralChroma were used to assess oral malodour and VSC. The effects of five test formulations and water (negative control) were assessed after 30, 60, 90 and 180 min, with 1 week between the treatments to avoid any cross-over effect. RESULTS: Reduction in H(2) S by halimetry and malodour levels by organoleptic assessment ranged from, slight (LacerFresh®) (P > 0.05), moderate (BreathRx®, SmartMouth® (P < 0.01) to marked effects (SB12®, Listerine®) (P < 0.001) at all time points compared with water. The largest differences were observed at 30 min and decreased with time. SB12® showed separation from Listerine® at 180 min, using ANOVA plus Bonferroni's Multiple Comparison post-test (P < 0.05). Relationships between organoleptic, halimeter and OralChroma were between R² = 0.795 and 0.926. CONCLUSION: SB12 shows a consistent and reproducible inhibitory effect on oral malodor parameters, which in turn correlate well with each other.

[Mouthwash solutions with microencapsuled natural extracts: Efficiency for dental plaque and gingivitis]. / Bains de bouche aux extraits naturels microencapsulés : effets sur la plaquedentaire et la gingivite.

Mouthwash solutions are mainly used for their antiseptic properties. They currently include synthetic agents (chlorhexidine, triclosan, etc.) or essential oils (especially Listerine). Many natural extracts may also be used. These associate both antiseptic effects and direct action on host response, due to their antioxidant, immunoregulatory, analgesic, buffering, or healing properties. The best known are avocado oil, manuka oil, propolis oil, grapefruit seed extract, pycnogenol, aloe vera, Q10 coenzyme, green tea, and megamin. The development of new technologies, such as microencapsulation (GingiNat concept), may allow an in situ slow release of active ingredients during several hours, and open new perspectives for mouthwash solutions.

Antimicrobial agents used in the control of periodontal biofilms: effective adjuncts to mechanical plaque control?

The control of biofilm accumulation on teeth has been the cornerstone of periodontal disease prevention for decades. However, the widespread prevalence of gingivitis suggests the inefficiency of self-performed mechanical plaque control in preventing gingival inflammation. This is particularly relevant in light of recent evidence suggesting that long standing gingivitis increases the risk of loss of attachment and that prevention of gingival inflammation might reduce the prevalence of mild to moderate periodontitis. Several antimicrobials have been tested as adjuncts to mechanical plaque control in order to improve the results obtained with oral home care. Recent studies, including meta-analyses, have indicated that home care products containing chemical antimicrobials can provide gingivitis reduction beyond what can be accomplished with brushing and flossing. Particularly, formulations containing chlorhexidine, mouthrinses containing essential oils and triclosan/copolymer dentifrices have well documented clinical antiplaque and antigingivitis effects. In vivo microbiological tests have demonstrated the ability of these antimicrobial agents to penetrate the biofilm mass and to kill bacteria growing within biofilms. In addition, chemical antimicrobials can reach difficult-to-clean areas such as interproximal surfaces and can also impact the growth of biofilms on soft tissue. These agents have a positive track record of safety and their use does not seem to increase the levels of resistant species. Further, no study has been able to establish a correlation between mouthrinses containing alcohol and oral cancer. In summary, the adjunct use of chemical plaque control should be recommended to subjects with well documented difficulties in achieving proper biofilm control using only mechanical means.

Antimicrobial efficacy of various disinfecting solutions in reducing the contamination of the toothbrush -- a comparative study.

BACKGROUND: Contaminated toothbrushes may play a role in the transmission of local or systemic diseases. As modern dentistry emphasises prevention and infection control, toothbrushes should be correctly stored, disinfected and changed at regular intervals. PURPOSE: The aim of this study was to test the efficacy of 3% neem, 2% triclosan, 0.2% chlorhexidine gluconate and 1% sodium hypochlorite as toothbrush disinfectants against Streptococcus mutans. MATERIALS AND METHODS: This was a double-blind, linear crossover, within-group comparative experimental trial conducted among 40 children aged 12 to 15 years. The study was divided into five phases: (1) distilled water (control); (2) 3% neem; (3) 2% triclosan; (4) 0.2% chlorhexidine gluconate; and (5) 1% sodium hypochlorite. The toothbrushes were collected after 5 days of brushing and were soaked for 12 h in antimicrobial solutions of separate phases, after which the toothbrushes were submitted for microbial analysis to check for the presence of S. mutans. RESULTS: The mean colony-forming units (CFUs) of S. mutans at phase 1 when compared with baseline was not significant (P = 0.17). The other phases had a significant drop in mean CFUs of S. mutans from baseline (P < 0.001). The percentage reduction of mean CFUs of S. mutans from baseline was the highest in phase 2 (86%). CONCLUSION: It can be concluded that all the solutions are effective in toothbrush decontamination, but 3% neem has greater efficacy than other solutions.

Antibacterial activity of triclosan chitosan coated graft on hernia graft infection model.

The use of mesh in hernia repair has become common, because of lower recurrence rate and simple application. Data from the meta-analysis and the multi-central studies support the use of meshes in hernia repair. One of the complications due to the hernia repair with mesh is the infection. The incidence range is between 1 and 10%. Triclosan embedded commercial absorbable suture materials are used to reduce surgical site infection rate. This study was planned on mesh infection model, because of the low incidence rate. The agent isolated from mesh infections was mostly Staphylococcus aureus and thus it was used as the infecting agent in this research. To achieve a better therapeutic efficacy, triclosan was formulated in chitosan gels. Chitosan is an attractive biopolymer because of its biocompatible, biodegradable, bioadhesive properties. Gel formulations using chitosans (low, medium and high molecular weight) were prepared in 1% (v/v) acetic acid solution and in vitro release profiles were evaluated. Gel formulations showed release profile extended up to 7 days and high molecular weight chitosan gel formulation was released higher quantity drug than other formulations. Meshes coated with triclosan loaded chitosan gel were used to reduce bacterial count and to prevent mesh infection in the study. 24h and simultaneous bacteria inoculation was used to model mesh infection. The rats were observed for 8 days by means of surgical site infection. On the eighth day, the animals were sacrificed and the grafts were removed. Tissue squeezers were used to liberate bacterias from removed grafts. The isolated suspensions were cultured on blood agar plates and colony-forming units were counted overnight. Grafts coated with triclosan loaded chitosan gel presented satisfactory preventive effect against graft infection.

Anticalculus effect of a triclosan mouthwash containing phytate: a double-blind, randomized, three-period crossover trial.

BACKGROUND AND OBJECTIVE: Dental calculus occurs as a consequence of supersaturation of saliva with respect to calcium phosphates. This mineralization of dental plaque can be delayed by the presence of crystallization inhibitors, such as pyrophosphate or bisphosphonates. Phytate inhibits brushite and hydroxyapatite crystallization and has the potential to prevent dental calculi formation. The aim of the present study was to examine the effects of phytate and zinc, administered in a mouthwash solution, to prevent the formation of dental calculus. MATERIAL AND METHODS: Healthy dental plaque-forming volunteers (n = 25) took part in a randomized, double-blind, three-period crossover clinical study to assess the efficacy of a phytate-containing mouthwash in relation to control and placebo effects. Subjects rinsed their mouths for 1 min, twice each day, with 20 mL of the test solution, without ingestion. Mouthwash efficacy was assessed through quantification of the amounts of calcium, phosphorus and magnesium present in the residues obtained by dental cleaning, performed by a single trained examiner. RESULTS: A good correlation was found among total calcium, magnesium and phosphorus in calcified dental plaque residues, indicating that any of these variables is adequate for evaluating the reduction of plaque crystallization as calcium phosphate. A statistically significant decrease in total calcium, magnesium and phosphorus was found in the phytate-treatment period compared with control and placebo periods, demonstrating the efficacy of the proposed treatment in reducing dental calculus formation. CONCLUSION: The high efficacy of phytate in reducing dental calculus formation suggests that this substance may be an effective treatment for preventing the development of calculus deposits.

Antimicrobial agents used in the control of periodontal biofilms: effective adjuncts to mechanical plaque control?

The control of biofilm accumulation on teeth has been the cornerstone of periodontal disease prevention for decades. However, the widespread prevalence of gingivitis suggests the inefficiency of self-performed mechanical plaque control in preventing gingival inflammation. This is particularly relevant in light of recent evidence suggesting that long standing gingivitis increases the risk of loss of attachment and that prevention of gingival inflammation might reduce the prevalence of mild to moderate periodontitis. Several antimicrobials have been tested as adjuncts to mechanical plaque control in order to improve the results obtained with oral home care. Recent studies, including meta-analyses, have indicated that home care products containing chemical antimicrobials can provide gingivitis reduction beyond what can be accomplished with brushing and flossing. Particularly, formulations containing chlorhexidine, mouthrinses containing essential oils and triclosan/copolymer dentifrices have well documented clinical antiplaque and antigingivitis effects. In vivo microbiological tests have demonstrated the ability of these antimicrobial agents to penetrate the biofilm mass and to kill bacteria growing within biofilms. In addition, chemical antimicrobials can reach difficult-to-clean areas such as interproximal surfaces and can also impact the growth of biofilms on soft tissue. These agents have a positive track record of safety and their use does not seem to increase the levels of resistant species. Further, no study has been able to establish a correlation between mouthrinses containing alcohol and oral cancer. In summary, the adjunct use of chemical plaque control should be recommended to subjects with well documented difficulties in achieving proper biofilm control using only mechanical means.

In vivo antiplaque efficacy of combined antimicrobial dentifrice and rinse hygiene regimens.

PURPOSE: To evaluate using digital plaque image analysis the antiplaque efficacy of oral care regimens including use of antimicrobial toothpaste in combination with antimicrobial mouthrinse. METHODS: 16 subjects completed the study protocol including: (1) initial treatment phase, all subjects used a standard sodium fluoride dentifrice with 2x/day brushing, (2) second treatment phase, subjects were randomized to two treatment groups: stannous fluoride/sodium hexametaphosphate dentifrice or sodium fluoride triclosan/copolymer dentifrice; (3) third treatment phase, the group using stannous fluoride dentifrice rinsed with alcohol-free cetylpyridinium chloride mouthrinse and the group using triclosan dentifrice rinsed with essential oil mouthrinse. During each phase, plaque levels were assessed in the morning before toothbrushing (AM), post-brushing in the morning (PB) and in the afternoon (PM). RESULTS: Stannous fluoride dentifrice was superior to triclosan dentifrice in plaque growth inhibition between toothbrushing. Both mouthrinses provided additional plaque prevention benefits when used with antimicrobial dentifrices. The cetylpyridinium chloride mouthrinse and stannous fluoride dentifrice regimen was particularly effective, building accretive efficacy over time. Average plaque reductions exceeded 50% vs. sodium fluoride dentifrice alone. Chemotherapeutic dentifrices and rinses increase plaque control used alone and particularly in combination. The stannous fluoride-cetylpyridinium chloride regimen showed the greatest benefits.