Chemicals were advocated for oral health care

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1 Quality Resource Guide MetLife designates this activity for 1.0 continuing education credit for the review of this Quality Resource Guide and successful completion of the post test. Dentifrices and Mouthrinses to Reduce Plaque and Gingivitis Educational Objectives Following this unit of instruction, the practitioner should be able to: 1. Know the American Dental Association guidelines for granting their Seal of Acceptance to antiplaque/antigingivitis products. 2. Assess the efficacy of antimicrobial mouthrinses and dentifrices based on evidence from clinical trials of 6 months or longer. 3. Identify the properties of the commonly available antimicrobial mouthrinses and dentifrices. 4. Compare available dentifrices and mouthrinses for safety and efficacy. Introduction Chemicals were advocated for oral health care as early as 2700 B.C. when European writings suggested that the mouth should be rinsed with urine from a child. 1 The upper classes in India of about 1500 years ago were very concerned with cleanliness of the mouth, with evidence showing they brushed their teeth, and used mouthrinses composed of betel leaves, camphor, cardamom or other herbs. 2 Today, a number of products developed through advanced chemical engineering are marketed for plaque and gingivitis reduction. These oral hygiene agents contain antimicrobial agents categorized as antiseptics. These antiseptics are applied topically or subgingivally in dentistry to destroy microorganisms, inhibit their reproduction, or inhibit their metabolism, disrupting biofilm formation. Effectiveness of oral antiseptics depends on formulation, concentration, and quantity; it varies widely among agents. With the exception of chlorhexidine, antiseptics are usually available without prescription because they have an excellent safety profile. In addition antiseptics do not act like antibiotics and do not cause development of significant bacterial resistance. Efficacy is agent-related and varies among products. A number of antiseptics (Cetylpyridinium Chloride, Chlorhexidine, Essential Oils, Stannous Fluoride, Triclosan) have been evaluated over the years and several have been frequently studied in clinical trials that were six months or longer. The most widely investigated antiseptic agents in dentifrices are triclosan and stannous fluoride. Mouthrinses studied most often contain essential oils, chlorhexidine and cetylpyridinium chloride. These agents have been investigated for safety and efficacy using the methodological approaches described below. Some of these products carry the American Dental Association (ADA) Seal of Acceptance. Detailed information about all ADA Accepted products can be found at ada.org/en/science-research/ada-seal-of-acceptance for professionals, and at ada-seal-products/ for consumers/patients. Methodological Considerations in Clinical Trials Evaluating Oral Antiseptics The most valuable clinical studies are those that produce good-quality, patient-oriented data that validate clinical decisions. Studies with limited-quality data, or those with inconsistent findings, are considered to be of lesser value. Lower levels of evidence to support clinical use of oral antiseptics come from consensus guidelines, extrapolations from bench SECOND EDITION Author Acknowledgements Sebastian G. Ciancio, DDS Director, Center for Dental Studies Clinical Professor of Pharmacology Distinguished Service Professor and Chair Department of Periodontics and Endodontics School of Dental Medicine State University of New York at Buffalo Dr. Ciancio has no relevant financial relationships to disclose. The following commentary highlights fundamental and commonly accepted practices on the subject matter. The information is intended as a general overview and is for educational purposes only. This information does not constitute legal advice, which can only be provided by an attorney. Metropolitan Life Insurance Company, New York, NY. All materials subject to this copyright may be photocopied for the noncommercial purpose of scientific or educational advancement. Originally published August Reviewed and updated August Expiration date: August The content of this Guide is subject to change as new scientific information becomes available. MetLife is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at Accepted Program Provider FAGD/MAGD Credit 11/01/12-12/31/16. Address comments to: dentalquality@metlife.com MetLife Dental Quality Initiatives Program 501 US Highway 22 Bridgewater, NJ

2 research, clinical research, or case studies. Dental practitioners should evaluate data presented to support the clinical use of an oral antiseptic in terms of quality of evidence, quantity of evidence and consistency of evidence. 3 The ADA has established guidelines for awarding their Seal of Acceptance to products marketed to reduce accumulation of plaque and development of gingivitis. 4,5 These guidelines may also be used by practitioners to evaluate the efficacy and safety of oral antimicrobial agents, and are as follows: 1. At least two (2) studies, each of at least 6 months duration, done at separate institutions with measurements taken at baseline, midpoint, and end of study 2. If a shift in the bacterial species occurs, it is not to gram-negative, anaerobic and motile forms 3. Bacterial resistance does not develop 4. A statistically significant reduction in gingivitis occurs (greater than 15% in any single study and averaging at least 20% for data from more than one study) 5. No negative effects on teeth and restorations, or on oral soft tissues Data obtained from clinical study endpoints are typically interpreted using statistical analysis. Most results are reported as a level of statistical significance (p<0.05, p<0.01, p<0.001) with p values <0.05 often considered to be statistically significant. Statistical significance identifies the relative chance that differences in the experimental group s outcome compared to the control group s outcome may be due to random error. Statistical significance does not imply that the findings make a clinical difference. The practitioner must determine the clinical relevance of the findings and their application to individual patients. Once manufacturers submit data that meet the criteria listed above to the ADA, the ADA Seal of Acceptance is awarded. Mouthrinses and dentifrices that carry the ADA Seal may be recommended to patients as being both safe and efficacious. ADA product reviews may be accessed at org/en/science-research/ada-seal-of-acceptance/ ada-seal-products/product-category/?attributes=pla que%2fgingivitis+control+mouthrinse (mouthrinses) and egory/?attributes=plaque%2fgigivitis+control (toothpastes). Systematic Reviews of Dentifrices and Mouthrinses Systematic Reviews are considered to provide the strongest evidence for an overall evaluation of clinical studies. The first current systematic review (meta-analysis) of six-month clinical trials of mouthrinses and dentifrice ingredients to control plaque and gingivitis was published in the Journal of the American Dental Association in The goal of this systematic review was to evaluate the efficacy of antiplaque, antigingivitis agents in studies involving six-month randomized clinical trials. The focused question for this systematic review was: Are mouthrinses or dentifrices effective (and which ones) as antiplaque and/or antigingivitis agents in six-month randomized clinical trials of adults 18 years and older? Since plaque reduction is usually associated with gingivitis reduction, measures of both entities have been traditionally included in most clinical trials. Recent data suggests that gingivitis may be significantly reduced even though plaque scores are not (due to an agent altering the metabolic activity of bacteria in plaque biofilm. In this review, the author found a total of 50 articles and/or reports that met inclusion criteria similar to those outlined for the ADA Seal of Acceptance outlined above. Because some of these studies compared multiple products with placebo groups, there were a total of 70 study cohorts in these studies. Dentifrices The systematic review6 reported that seventeen studies support the antiplaque and antigingivitis effects of dentifrices containing 0.30 percent triclosan/2.0 percent Gantrez copolymer. Dentifrices with stannous fluoride had statistically significant, but marginally clinically significant, evidence of an antiplaque effect; however, they demonstrated both a statistically and clinically significant antigingivitis effect. The review focused on triclosan and stannous fluoride since these are the two antiseptics that are most often sold in dentifrices in the United States for the reduction of plaque and gingivitis. Triclosan Triclosan is a broad-spectrum antimicrobial agent that is marketed for use in oral products. In the early 1990s, a new dentifrice containing 0.3% triclosan, 2.0% polyvinylmethyl ether maleic acid (PVM/MA) copolymer, and 0.243% sodium fluoride in a silica base was introduced. The addition of the copolymer to the dentifrice formulation allowed a greater uptake and retention of triclosan to the enamel and buccal epithelial cells than when triclosan was formulated alone. This retention provided a long-lasting effect that has been well documented. 7 The product carries the ADA seal and is approved by the FDA for the reduction of plaque and gingivitis. Triclosan is only available as an additive in one brand of dentifrice in the United States. Outside the United States, it is found in mouth rinses and in dentifrices both with and without the copolymer. Triclosan/copolymer dentifrice, when compared to the placebo dentifrice, demonstrated plaque reduction of up to 58.9% and gingivitis reduction of up to 41.9%. No significant adverse effects (including absence of development of bacterial resistance) were noted in studies of up to 5 years duration. 8 Triclosan/copolymer dentifrice also shows the ability to significantly reduce supragingival calculus formation (23-57%), with an average reduction of 37%). 9 Laboratory studies suggest that, in addition to its antibacterial activity, this product may also have an anti-inflammatory effect. 10 Long-term studies suggest that use of a triclosan/copolymer dentifrice may be of benefit in stabilizing patients following periodontal therapy. 8,11,12,13 Studies in humans do not support data from studies in animals suggesting adverse effects of triclosan on thyroid and reproductive functions. It should be noted that doses used in the animal studies were 10,000-1,000,000 times higher than those levels found in humans. Further, no clinical signs of toxicity or changes of various clinical and biochemical parameters were found in a study in Page 2

3 which subjects brushed twice daily with a triclosan containing dentifrice. Also, recently, FDA reaffirmed the inclusion of triclosan in a toothpaste. 14 Further, the American Dental Association on August 15, 2014 continued its approval of Colgate Total with its Acceptance Seal. 15 Stannous Fluoride Stannous fluoride was first introduced into the U.S. market in the 1950s as an additive to dentifrices aimed at reducing carious lesions. Later, due to staining and taste issues, it was removed from dentifrices and replaced by sodium fluoride or sodium monofluorophosphate as an anticaries agent. Stannous fluoride was reformulated in 1997 into a dentifrice additive to reduce plaque and gingivitis as well as caries activity. However, the formulation was not successful in the U.S. marketplace possibly because of problems with tooth staining. 16 The newest formulation reported in the literature is a dentifrice containing 0.45% stannous fluoride and sodium hexametaphosphate. Sodium hexametaphosphate has been incorporated into the formulation to aid in the control of calculus and extrinsic tooth staining via inhibition of pellicle formation and mineralization. 17 The product carries the ADA Seal. Studies of this dentifrice have demonstrated reductions in plaque accumulation ranging up to 8.5% and reductions in gingivitis ranging up to 26%. Tooth staining was not reported in the most recent studies of this formulation. Two studies showed that a stannous fluoride dentifrice inhibited calculus formation 56% better than a Triclosan/co-polymer/fluoride dentifrice and also reduced dentinal hypersensitivity. 18,19 Evaluation of use of this dentifrice by patients following periodontal therapy suggests that gingivitis is reduced better than by a sodium fluoride dentifrice. Aside from tooth staining (when stannous fluoride is used without sodium hexametaphosphate) reported in some studies, no serious adverse events have been reported following the use of a stannous fluoride dentifrice. One study compared a stabilized stannous fluoride dentifrice to a triclosan/copolymer dentifrice and found the reduction in Gingival Index to be better with the stannous fluoride product. 20 Another study compared the two dentifrices for effects on periodontitis in patients with xerostomia and found similar beneficial effects. 21 Table 1 provides information on studies that have been conducted with triclosan, and with stannous fluoride. Mouthrinses Three systematic reviews and one metaanalysis were found that evaluated the efficacy of anti-plaque, anti-gingivitis mouthrinses. The systematic reviews concluded that there is strong evidence supporting the efficacy of chlorhexidine and essential oils as antiplaque, anti-gingivitis mouthrinses. The evidence for cetylpyridinium chloride (CPC) was weaker due to few clinical trials testing the same formulations of CPC. There was one meta-analysis of studies from a manufacture of Delmopinol, but it was not a systematic review of the literature. The report based on the meta-analysis concluded that Delmopinol was an effective anti-plaque, anti- gingivitis agent. 6,22 Evaluation of clinical relevance by estimating percent reduction due to the active agents and changes over time in the placebo groups, demonstrated that the clinical effect of both chlorhexidine and essential oil containing mouthrinses met or exceeded reductions over time for placebo groups. Again the results for CPC were less consistent, but were similar to reductions over time in the placebo groups. The author concluded that these results suggest that the clinical benefits of anti-plaque, anti- gingivitis mouthrinses are similar to the benefits of oral prophylaxis and oral hygiene instructions at six month recall appointments. A more extensive review was conducted in 2015 by Serrano, et al. 23 Their analysis differed from previous ones in that they did not specify which agents were better than others evaluated. They stated No specific recommendations can be made based on the results of the present review, as no direct comparisons among products were performed. They further stated that the clinician should take into account when prescribing or recommending these products, the results of the described meta-analysis, in terms of magnitude of the effect, number of available studies, consistency of the results and heterogeneity. In addition, adverse effects, economical costs and the clinical indication should also be taken into account. The first systematic analysis by Gunsolley of mouthrinses 6 concluded that the largest body of studies supported the efficacy of mouthrinses containing essential oils. A smaller body of studies supported a strong antiplaque, antigingivitis effect from mouthrinses containing 0.12 percent chlorhexidine. Results for mouthrinses containing cetylpyridinium chloride varied and depended on the product s formula. Few of the studies evaluated the relative efficacy of the different agents. The studies compared mouthrinses containing active agents with control mouthrinses, as well as, in some cases, with mouthrinses containing other active agents. Four studies compared mouthrinses containing essential oils with chlorhexidine mouthrinses. In all cases, 0.12% chlorhexidine exhibited a greater antiplaque effect than did mouthrinses containing essential Table 1 - Comparison of Dentifrices for Plaque and Gingivitis Reduction Product # Studies # Patients % Plaque % Gingivitis Tooth Staining ADA Seal of Acceptance Triclosan/Copolymer/Fluoride No Yes Stannous Fluoride No Yes Randomized, placebo controlled clinical studies of at least 6-month duration, following ADA Seal of Acceptance Guidelines Although tooth staining has occurred with stannous fluoride products, clinical studies of this product reported no staining Page 3

4 oils (the effect for essential oils was about 60% of that for the chlorhexidine mouthrinse). However, the data suggested efficacy of controlling gingivitis to be similar for chlorhexidine and essential oil containing mouthrinses. Three subsequent systematic reviews verified the findings from the first review. The systematic reviews concluded that there is strong evidence supporting the efficacy of chlorhexidine and essential oils as anti-plaque, anti-gingivitis mouthrinses. The evidence for cetylpyridinium chloride (CPC) was weaker due to few clinical trials testing the same formulations of CPC. 24,25,26 Delmopinol Delmopinol is a surfactant which coats the tooth surface and reduces the ability for bacteria to attach to these surfaces as well as to each other. It is available as a 0.2% solution containing 1.5% alcohol. Side effects include staining which can be removed by a dental prophylaxis. Plaque reductions range from % and gingivitis averages 18% 27 It does not carry the ADA seal of Acceptance. There was one meta-analysis of studies from a manufacturer of Delmopinol, but it was not a systematic review of the literature. The report based on the metaanalysis concluded that Delmopinol was of value as an effective anti-plaque, anti-gingivitis agent. 22 The ability of various mouthrinse ingredients (as well as some dentifrices) to adhere to the organic pellicle of teeth, oral mucosa, salivary proteins and bacteria, is referred to as substantivity. Following a 30 second rinse with chlorhexidine, a drug with high substantivity, 30% of the drug is retained and is slowly released over time, enhancing the product s efficacy. Dosing Consideratios and Adjustments The usual adult dosage (and often the geriatric dosage) for mouthrinses is ml (about the amount an average person can comfortably hold in their mouth). Some mouthrinses are packaged with a cap that holds ml. Patients can be instructed to count to 20 or 30 (by one thousands to provide the appropriate rinsing time. Mouthrinses are generally not recommended for children <6 years since they have difficulty expectorating. Also, mouthrinses containing alcohol are not generally recommended for children <12 years and for adults taking medications for which concomitant use of alcohol is contraindicated. Use caution in prescribing mouthrinses containing alcohol to patients in recovery from alcoholism since alcohol in the mouthrinse may trigger their desire for alcohol. Although alcohol can denature bacterial cell walls, it serves as a non-therapeutic vehicle in most mouthrinses. There has been some concern about the association between mouthrinses containing alcohol and oral cancers, but current findings do not establish a causal relationship. Chlorhexidine is sold in the United States, by prescription, as a 0.12% concentration in mouthrinses, all of which contain 11.6% alcohol and are approved for control of plaque and gingivitis by the Food and Drug Administration and accepted by the ADA (until December 31, 2007). Chlorhexidine mouthrinses no longer carry the ADA Seal of Acceptance since the ADA decided not to utilize the Seal of Acceptance program after January 1, 2008 for prescription products. Chlorhexidine s therapeutic activity is decreased by a number of anions including detergents, phosphate, sulfate, and carboxyl groups as well as calcium, all of which are found in dentifrices. 28 For maximum effect, chlorhexidine-containing rinses should not be used in conjunction with brushing with a dentifrice. It should be used independently or minutes after brushing and rinsing. It is also important that it be used undiluted twice daily as directed by the Table 2 - Six-Month Studies of Mouthrinses Product # Studies Efficacy ADA Accepted % Plaque % Gingivitis Chlorhexidine 0.12% Statistically significant for all Yes* Essential Oils 25 (4 had 2 active arms)** Statistically significant for 16; Non-significant for 9 Yes Cetylpyridinium Chloride: % 5 Statistically significant reduction only in plaque in 4 studies, non-significant in 1 study No % 4 Statistically significant reduction in gingivitis in 3 studies, minimal reduction in plaque in 1 study No Stannous Fluoride 5 One study shows statistically significant reduction in plaque and gingivitis at 4 mos., but not after 4 mos. Other studies show little or no statistically significant benefits. * Effective Jan 1st, 2008, ADA no longer placed its Seal of Acceptance on prescription (professional?) products. No ** Total equals 25 because 4 of the studies listed had 2 active arms Page 4

5 manufacturer (15 ml for 20 sec) for maximum efficacy. Reductions in plaque accumulation up to 61% and gingivitis up to 39% have been reported in clinical studies of chlorhexidine use. Adverse effects have been reported with its use, including staining of teeth, reversible desquamation in young children, alteration of taste, and an increase in calcified deposits. Long-term microbiologic studies do not demonstrate the development of resistant strains of bacteria. Generic formulations, as well as a 0.12% product that does not contain alcohol, are available, but have not been clinically tested in 6 month trials. The equivalence of a non-alcoholic to 0.12% mouthrinses containing alcohol was demonstrated in a two week study 29 and found to be therapeutically equivalent to the alcohol containing product. Chlorhexidine is not recommended to be used in children under age 18 because of its side effects. A mouthrinse containing a mixture of three phenolic-derived essential oils (thymol, menthol, eucalyptol), combined with methyl salicylate, has been extensively studied and is readily available in the United States. Clinical studies show it reduces plaque accumulation up to 56% and gingivitis up to 36%. A recent meta-analysis of an essential oil mouthrinse included a data base of 29 studies in 5000 patients. This analysis showed that patients who use an essential oil mouthrinse for 6 months were 5 times as likely to have a healthy mouth, 7.5 times to have more plaque free sites, and 2.2 times to have less bleeding sites. 30 Adverse effects reported have been a burning sensation during use. It is available in a % alcohol vehicle. A non-alcohol essential oil containing mouthrinse is also available and initial data suggests efficacy almost as good as the product containing alcohol. However, more studies are needed to establish efficacy. This product should be used undiluted as directed by the manufacturer (20 ml for 30 sec) as a rinse twice daily. This mouthrinse, and some generic copies of it are ADA accepted and FDA approved for the reduction of plaque and gingivitis. Due to their alcohol content, these rinses are not recommended for use in children under age 12. Cetylpyridinium Chloride Cetylpyridinium chloride (CPC) is classified as a quaternary ammonium compound. Mouthrinses with concentrations of 0.05%, 0.07%, and 0.045% are available in the U.S. marketplace. Like chlorhexidine, the activity of CPC is altered by charged particles sometimes found in dentifrices. The 0.07% product has no alcohol. The others are available in a 14% to 18% alcoholic vehicle. Studies of the 0.07% CPC mouthrinse have shown reductions in gingivitis up to 38% and reductions in plaque accumulation up to 36%. 31 One study compared the 0.07% CPC mouthrinse to an essential oil mouthrinse and found similar reductions in gingivitis. 32 However, two more recent 6 month studies found an essential oil mouthrinse to be more effective than one containing 0.07% CPC. 33,34 Side effects from CPC rinses have been reported, including staining of teeth and soft tissue irritation. These products are not accepted by the ADA for the reduction of plaque and gingivitis. Stannous Fluoride Some studies have suggested that a stannous fluoride mouthrinse may be of value in the reduction of plaque accumulation and gingivitis development, while other studies have found little or no benefit. In view of the conflicting reports, considerable reservation has been voiced on the efficacy of a stannous fluoride mouthrinse as an antiplaque/ antigingivitis agent. Side effects associated with this agent include taste alteration and staining of teeth. It is marketed mainly as a non-alcoholic solution. It is not ADA accepted or FDA recognized in a mouthrinse formulation for reduction of plaque or gingivitis. A more recent report of three systemic reviews of mouthrinses 28 stated: The systematic reviews concluded that there is strong evidence supporting the efficacy of chlorhexidine and essential oils as antiplaque, anti-gingivitis mouthrinses. The evidence for cetylpyridinium chloride (CPC) was weaker due to few clinical trials testing the same formulations of CPC. The report also stated: Evaluation of clinical relevance by estimating percent reduction due to the active agents and change over time in the placebo groups, demonstrated that the clinical effect of both chlorhexidine and essential oil containing mouthrinses met or exceeded reductions over time for placebo groups. Again the results for CPC were less consistent, but were similar to reductions over time in the placebo groups. Summary/Conclusions The current market of mouthrinses and dentifrices produces a myriad of options for the consumer and the dental care provider. Several strategies may be used to make good decisions. This QRG provides a brief review of research on mouthrinses and dentifrices to help dental professionals recommend the correct mouthrinse and dentifrice for a patient s specific issues. The most effective nonprescription products usually carry the ADA seal. The effectiveness of any mouthrinse is tied to the use of the agent as prescribed. This means the directions for proper dose, duration of time in the mouth, and frequency of use, must be carefully followed by the patient. If a patient misses a dose, he or she should use the agent as soon as possible; doubling the dose will offer no benefit. To receive the greatest antiplaque or anticaries benefit, the patient should brush and rinse before retiring to bed. After using a mouthrinse, the patient should not rinse with water or drink anything for at least 30 minutes. Immediately drinking or rinsing with water will increase the drug s clearance from the mouth and reduce its effectiveness. Changes in taste sensation may also occur if the mouth is rinsed with water immediately after mouthrinse use. Alcohol containing mouthrinses should be kept out of the reach of young children, as their ingestion of 4 or more ounces of rinses containing alcohol could cause alcohol intoxication. Page 5

6 REFERENCES 1. Weinberger B. Introduction to the history of dentistry. St. Louis: Mosby, Ring M. In Dentistry, An Illustrated History, New York, Abrams, Newman MG, Weyart R, Hujoel P. JEBDP improves grading system and adopts strength of recommendation taxonomy grading (SORT) for guidelines and systematic reviews. J Evid Base Dent Pract 2007;7: Council on Dental Therapeutics. Guidelines for acceptance of chemotherapeutic products for the control of supragingival dental plaque and gingivitis. JADA 1986;112(43): American Dental Association. Chemotherapeutic products for the control of gingivitis. Chicago: American Dental Association Council on Dental Therapeutics; Gunsolley JC. A meta-analysis of six-month studies of antiplaque and antigingivitis agents. JADA 2006;137(12): Gaffar A, Nabi N, Kashaba B, Williams M, Herles S, Olsen S, Afflito J. Antiplaque effects of dentifrices containing triclosan/copolymer/naf system versus triclosan dentifrices without the copolymer. Am J Dent 1990, 3:S7-S Cullinan MP, Westerman B, Hamlet SM, Palmer JE, Faddy MJ, Seymour GJ. The effect of a triclosan-containing dentifrice on the progression of periodontal disease in an adult population. J Clin Perio 2003; 30: Banoczy J, Sari K, Schiff T, Petrone M, Davies R. Volpe AR. Anticalculus efficacy of three dentifrices. Am J Dent Aug;8(4): Mustafa M, Wondimu B, Yucel Lindberg T, Kats A-Hallstrom T, Jonsson AS, Modeer T. Triclosan reduces microsomal prostaglandin E sythase-1 expression in human gingival fibroblasts. J Clin Periodontol 2005; 32: Rosling B, Wannfors B, Volpe AR, et al. The use of triclosan/copolymer dentifrice may retard the progression of periodontitis. J Clin Perio 1997;24: Ellwood RP, Worthington HC, Blinkhorn ASB, et al. Effect of a triclosan/copolymer dentifrice on the incidence of periodontal attachment loss in adolescents. J Clin Perio 1998;25: Furuichi Y, Rosling B, Volpe AR, Lindhe J. The effect of a triclosan/copolymer dentifrice on healing after non-surgical treatment of recurrent periodontitis. J Clin Periodontol 1999;26(2): FDA. Triclosan:What Consumers Should Know American Dental Association. ( 16. Comosci DA and Tinaoff N. Anti-bacterial determinants of stannous fluoride. J Dent Res 1984;63: White DJ. A new and improved dual action whitening dentifrice technology sodium hexametaphosphate. J Clin Dent 2002;13: Schiff T, Saletta L, Baker RA, He T, Winston JL. Anticalculus efficacy and safety of a stabilized stannous fluoride/sodium hexametaphosphate dentifrice. Compendium. 2005;26(9) (Suppl 1): Schiff T, Saletta L, Baker RA, Winston JL, He T. Desensitizing effect of a stabilized stannous fluoride/sodium hexametaphosphate dentifrice. Compendium. September 2005; 26(9) (Suppl 1): Archila L, Bartizek RD, Winston JL, Biesbrock AR, McClanahan SF, He T. The comparative efficacy of stabilized stannous fluoride/sodium hexametaphosphate dentifrice and sodium fluoride/triclosan/copolymer dentifrice for the control of gingivitis: a 6-month randomized clinical study. J Perio 2004;75: Papas A, He T, Martuscelli G, et al. Comparative efficacy of stabilized stannous fluoride/sodium hexametaphosphate dentifrice and sodium fluoride/ triclosan/copolymer dentifrice for the prevention of periodontitis in xerostomic patients: a 2-year randomized clinical trial. J Periodontol 2007 Aug;78(8): Addy M, Mora J, Newcombe RG. Meta-analyses of studies of 0.2% delmopinol mouth rinse as an adjunct to gingival health and plaque control measures. J Clin Periodontology 2007;34(1); Serrano J, Escribano M, Roldan S, Martin C, Herrera D. Efficacy of adjunctive anti-plaque chemical agents in managing gingivitis: a systematic review and meta-analysis. J Clin Periodontol 2015;42(sup. 16):S106-S Haps S, Slot DE, Berchier CE, van de Weijden GA. The effect of cetylpyridinium chloride-containing mouth rinses as adjunct to toothbrushing on plaque and parameters of gingival inflammation: a systematic review. Int J Dent Hyg 2008;6(4): Stoeken JE, Parasevas S, van der Weijden GA. The long-term effect of a mouthrinse containing essential oils on dental plaque and gingivitis:a systematic review. J Periodontol 2007;78(8): Gunsolley, JC. Clinical efficacy of antimicrobial mouthrinses. J Dent S1:86-S Nagelberg RH. Understanding advances in oral rinse technologies. Compendium 2011(Spec iss): Barkvoll P, Rolla G, Svendsen AK. Interaction between chlorhexidine digluconate and sodium lauryl sulfate in vivo. J Clin Periodontol 1989;16: Borrajo JLL, Varela LG, Castro GL, Rodriguez-Nunez I, Figueros MG, Torreira MG. Efficacy of chlorhexidine mouthrinses with and without alcohol: A clinical study. J Periodontol 2002;73: Araujo MWB, Charles CA, Weinstein RB, McGuire JA, Parikh-Das AM, Du Q, Zhang J, Berlin JA, et al. Meta-analysis of the effect of an essential oil-containing mouthrinse on gingivitis and plaque. JADA; 2015:146980: Ayad F, Prado R, Mateo LR, Stewart B, Szewczyk G, Arvanitidou E, Panagakos FS. A comparative investigation to evaluate the clinical efficacy of an alcohol-free CPC-containing mouthwash as compared to a control mouthwash in controlling dental plaque and gingivitis: a six-month clinical study on adults in San Jose, Costa Rica. J Clin Dent 2011;22(Spec Iss): Albert-Kiszely A, et al. Comparison of the effects of cetylpyridinium chloride with an essential oil mouth rinse on dental plaque and gingivitis - a six-month randomized controlled clinical trial. J Clin Periodontol 2007;34(8): Cortelli SC, Cortelli JR, Shang H, Costa R, Charles CA. Gingival health benefits of essential-oil cetylpyridinium chloride mouthrinses: a 6-month randomized clinical study. Am J Dent 2014;27: Santos SL, McGuire JA Wu MM, Goyal CR, Sharma NC. Superior plaque ad gingivitis efficacy of an essential oil-containing mouthrinse compared to a 0.07% cetylpyridinium chloride mouthrinse. J Dent Hyg 2012;86: Page 6

7 POST-TEST Internet Users: This page is intended to assist you in fast and accurate testing when completing the Online Exam. We suggest reviewing the questions and then circling your answers on this page prior to completing the online exam. (1.0 CE Credit Contact Hour) Please circle the correct answer. 70% equals passing grade. 1. The American Dental Association established guidelines for awarding their Seal of Acceptance to products for the reduction of plaque and gingivitis. All of the following reflect these guidelines EXCEPT: a. At least two studies must be conducted b. Studies should be at least 6 months in duration c. Bacterial resistance should be demonstrated d. Safety to teeth, restorations and oral soft tissues should be demonstrated 2. Results of clinical trials for antimicrobial dentifrice should be: a. Statistically significant b. Clinically significant c. Both A and B d. None of the above 3. An active ingredient in dentifrices that demonstrates both antibacterial and anti-inflammatory properties is: a. Triclosan/copolymer b. Stannous fluoride c. Sodium fluoride d. Zinc citrate 4. Stain is controlled when stannous fluoride is combined with which product? a. Triclosan/copolymer b. Sodium hexametaphosphate c. Sodium fluoride d. Zinc citrate 5. Which of the following are considered to provide the strongest evidence for an overall evaluation of clinical studies? a. case studies b. systematic reviews c. Consensus Guidelines d. Disease-oriented research 6. Which of the following is the most effective agent for reduction of plaque and gingivitis in a mouthrinse formulation? a. Essential oils b. Chlorhexidine c. Cetylpyridinium Chloride d. Stannous Fluoride 7. All of the following may produce an extrinsic staining of teeth EXCEPT: a. Essential Oils b. Chlorhexidine c. Cetylpyridinium Chloride d. Stannous Fluoride 8. The addition of a copolymer to the product s formulation allowed a greater uptake and retention to the enamel and buccal epithelial cells of which of the following agents: a. Stannous Fluoride b. Triclosan c. Essential Oils d. Cetylpyridinium Chloride 9. All of the following agents are found in products awarded the American Dental Association Seal of Acceptance for the reduction of plaque and gingivitis EXCEPT: a. Essential oils b. Triclosan c. Stannous Fluoride d. Cetylpyridinium Chloride 10. Which of the following agents has been shown to be beneficial in the reduction of dentinal hypersensitivity? a. Triclosan b. Chlorhexidine c. Essential Oils d. Stannous Fluoride Page 7

8 REGISTRATION/CERTIFICATION INFORMATION (Necessary for proper certification) Name (Last, First, Middle Initial): PLEASE PRINT CLEARLY Street Address: Suite/Apt. Number City: State: Zip: Telephone: Fax: Date of Birth: State(s) of Licensure: License Number(s): Preferred Dentist Program ID Number: Check Box If Not A PDP Member AGD Mastership: Yes No FOR OFFICE USE ONLY AGD Fellowship: Yes No Date: Please Check One: General Practitioner Specialist Dental Hygienist Other Quality Resource Guide - Dentifrices and Mouthrinses to Reduce Plaque and Gingivities 2nd Ed. Providing dentists with the opportunity for continuing dental education is an essential part of MetLife s commitment to helping dentists improve the oral health of their patients through education. You can help in this effort by providing feedback regarding the continuing education offering you have just completed. Please respond to the statements below by checking the appropriate box, 1 = POOR 5 = Excellent using the scale on the right How well did this course meet its stated educational objectives? 2. How would you rate the quality of the content? 3. Please rate the effectiveness of the author. 4. Please rate the written materials and visual aids used. 5. The use of evidence-based dentistry on the topic when applicable. N/A 6. How relevant was the course material to your practice? 7. The extent to which the course enhanced your current knowledge or skill? 8. The level to which your personal objectives were satisfied. 9. Please rate the administrative arrangements for this course. 10. How likely are you to recommend MetLife s CE program to a friend or colleague? (please circle one number below:) extremely likely neutral not likely at all What is the primary reason for your 0-10 recommendation rating above? 11. Please identify future topics that you would like to see: Thank you for your time and feedback. To Complete Program Traditionally, Please Mail Your Post Test and Evaluation Forms To: MetLife Dental Quality Initiatives Program 501 US Highway 22 Bridgewater, NJ Page 8