REVIEW ARTICLE
DISCLOSING AGENTS IN PERIODONTICS: AN UPDATE Zoya Chowdhary1, Ranjana Mohan2, Vandana Sharma3, Rohit Rai4, Aruna Das5 1.Post graduate student, Department of Periodontology, Teerthankar Mahaveer Dental College & Research Center, Moradabad. 2.Professor and Head, Department of Periodontology, Teerthankar Mahaveer Dental College & Research Center, Moradabad. 3.Assistant Professor, Department of Periodontology, Vyas Dental College, Jodhpur. 4.Assistant Professor, Department of Periodontology,Dental College, Azamgarh. 5.Professor & Head,Department of Oral Medicine and Radiology,Dental College,Azamgarh
ABSTRACT Dental plaque, colonies of harmful bacteria which form on tooth surfaces and restorations, cannot be flushed away by simply rinsing with water. Active brushing of the teeth is required to remove the plaque which adheres to tooth surfaces. It is a well-accepted fact that dental plaque, when allowed to accumulate on tooth surfaces, can eventually lead to gingivitis, periodontal disease, caries and calculus. Thus, it is apparent that effective removal of deposits of dental plaque is absolutely essential for oral health. Accordingly, proper oral hygiene practices which may be carried out by an individual on his or her own teeth or by a dentist would be facilitated by readily available means of identification and location of plaque deposits in the oral cavity. Key words: Dental plaque; Disclosing agent; F.D. & C.; Plaque Control.
INTRODUCTION the presence and quantity of plaque.2 Certain agents (dyes) may be used to make Dental plaque removal is an important the supragingival plaques visible and such issue in health promotion. Plaque agents are called disclosing agents. deposition brings about the inflammatory Staining of bacterial plaque is an aid for changes on the periodontium that can lead patients in developing an efficient system to destruction of tissues and loss of of plaque removal and also in explaining 1 attachment. Since dental plaque is usually and teaching the significance of plaque in transparent and colorless and not easily dental disease.1 visible, an individual frequently is not aware of the quantity or the location of HISTORY: dental plaque present in their mouth. 3 Therefore, it is desirable to use plaque- In 1914 Skinner used the first disclosing disclosing compositions to identify areas solution i.e iodine to teach home care of of the mouth where plaque buildup is a the mouth and recommended the use of a problem. The use of disclosing disclosing solution to ensure that all compositions motivates a person in the "foreign substance" was removed, long 4 early removal of dental plaque by showing before Loe et al. (1965) and Axelsson & Lindhe (1974) 5 confirmed in their studies
Corresponding Author: Dr Zoya Chowdhary Email: [email protected] Zoya et al,2015; 1(1):103-110 that there is a strongly positive correlation matter is meant to include mucinous between the presence of dental plaque and plaque, calculus and material surfaces).8 both caries and gingivitis. In 1920 Berwick introduced a dye that was the combination Disclosing agents are solutions or wafers of brilliant green and crystal violet 6, capable of staining bacterial deposits on followed by Easlick (1935) who used the surfaces of teeth, tongue, and 16 bismark brown 7 and Raybin (1943) 8 used gingiva. gention violet and proved the advantages A disclosing agent is a material, usually of non iodine dye. Soon after Skinner’s some form of dye in liquid or tablet form iodine was superceded by organic dye that is applied to teeth to stains plaque on solutions because of the objectionable the surfaces of teeth. 17 features of iodine solutions. TYPES: Amim (1958,63) 9,10 had been most instrumental in popularising the use of Disclosing Solutions disclosing agents and introduced the use of F. D. & C Red #3 (Erythrosin) dye and Disclosing Tablets 11 like Raybin (1945) maintained that Disclosing Wafers disclosing agents were bound to revolutionise the home care regimen. In Disclosing Lozenges 1971 Heffemen and his colleagues 12 noted that plaque, calculus and stains were more Disclosing Mouth-rinses apparent under ultra-violet illumination, USE: Fig 1 and the following year, Lang et al. (1972) 13 examined the applicability of a A disclosing agent is used for the fluorescent disclosing agent used with the identification of bacterial plaque, which Plaklite®. In the same year Block et al 14 might otherwise be invisible to the naked developed a twotone dye test which eye, for instruction, evaluation, and stained more mature plaque blue (F. D. & research.15 C. Green #3 and newly formed plaque red PURPOSE: 1 (F. D. & C. Red #3) thus providing a "colour guide' as to the age of the plaque. A. Personalized patient instruction and motivation. DEFINITION: B. Self – evaluation by the patient. A disclosing agent is a selective dye in solution, tablet, or lozenge form used to C. To evaluate the effectiveness of visualize and identify dental biofilm on the oral hygiene maintenance. surfaces of the teeth.15 D. Conducting research studies to gain Raybin defined disclosing agent as a new information about the solution which when applied on the tooth, incidence and formation of makes visible by staining roughness and deposits on the teeth, the foreign matter on the tooth. (Foreign effectiveness of specific devices for dental biofilm control, and anti-
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biofilm agents and to evaluate 1. Iodine preparations clinical and instructional group health programs.15 2. Mercurochrome preparations 3. Bismark brown PROPERTIES: 2 4. Merbromin A. Taste:
Taste should be comfortable to the patient. 5. Erythrosine Agent should be flavoured so that it 6. Fast green encourages the patient co-operation. 7. Fluoroscein B. Intensity of colour: 8. Two tone solution ( stains older A contrast colour should be evident. It plaque blue and newer red) should be differentiated from the surrounding environment. 9. Basic fuchsin.
C. Duration of intensity: 10. Buckley’s solution
Stains should not get washed off 11. Berwick’s solution immediately. It should stay in oral 12. Talbot’s solution environment. 13. Iodo-glycerol solution D. Irritation to oral mucosa membrane: 14. Metaphen solution
Solution should not cause irritation to oral 15. Allura red mucosa and also it should not cause any 15 allergy to oral mucosa. FORMULAE:
E. Antiseptic properties: A wide variety of disclosing agents has been used. Skinner’s iodine solution was Application of an antiseptic before scaling formerly the most widely used. Aniline is frequently advised and if an antiseptic dye has been shown to have carcinogenic disclosing agent is used, one solution potential. Therefore the use of basic serves dual purpose. fuchsin and beta rose has been discoursed.1 The formulae of few of the disclosing F. Diffusibility: agents are: The solution should be thin enough so that A. Iodine preparations it can be readily applied to the exposed surfaces of the teeth, yet thick enough to 1. Skinner’s Iodine solution: impart an intense colour to the dental biofilm. Iodine crystals - 3.3 g
AGENTS USED FOR DISCLOSING Potassium iodide – 1.0 g PLAQUE: Zinc iodine – 1.0 g
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Water (distilled) – 16.0 ml F.D. & C Red No. 3 or No. 28 - 6.0 g
Glycerin - 16.0 ml Water (distilled) to make – 100.0 ml
2. Diluted Tincture of Iodine 2. For direct Topical application
Tincture of iodine – 21.0 ml Erythrosin - 0.8g
Water (distilled) – 15 ml Water (distilled) - 100.0 ml
B. Mercurochrome preparations Alcohol (95%) - 10.0 ml
1. Mercurochrome solution (5%) Oil of peppermint - 2 drops
Mercurochrome – 1.5 g 3. Tablet or wafers
Water (distilled) to make – 30.0 ml F.D. & C Red No 3 - 15.0 mg
2. Flavoured Mercurochrome Sodium chloride - 0.747% Disclosing solution Sodium sucaryl - 0.747% Mercurochrome - 13.5 gm Calcium sterate - 0.995% Water (distilled) - 3.0 l Soluble saccharin – 0.186% Oil of peppermint - 3 drops White oil - 0.124% Artificial noncariogenic sweetener Flavoring – 2.239% C. Bismark Brown (Easlick’s Disclosing solution) Sorbitol to make 7-grain tablet
Bismark Brown - 3.0 g F. Fast green:
Ethyl alcohol - 10.0 ml F.D. & C Green No. 3 - 5% or 2.5%
Glycerin - 120.0 ml G. Fluoroscein:
Anise (flavoring) - 1 drop F.D. & C Yellow No.8 (used with special ultraviolet light source to make agents D. Merbromin visible).
Merbromin, N.F. – 450.0 mg H. Two tone
Oil of peppermint - 1 drop F.D. & C Green No. 3
Water (distilled) to make - 100 ml F.D. & C Red No. 3
E. Erythrosin Thicker (older) plaque stains blue thinner (newer) plaque stains red. 1. Concentrate for application by Rinsing I. Basic Fuchsin 1
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Basic Fuchsin - 6 gm d. Use swab or small cotton pellet with cotton pliers to carry the Ethyl Alcohol (95%) - 100 ml solution to the teeth.
Add two drops of solution to H2Oin a e. Apply solutions to the crowns of dappen dish. the teeth only.
MECHANISM OF TWO-TONE f. Direct the patient to spread the
DISCLOSING AGENT: agent over all surfaces of teeth Gallagher et al carried out in-vivo and in- with the tongue. vitro tests to estimate the mechanism of g. Examine the distribution of the the differential staining phenomenon of the agent and request the patient too Two-tone disclosing agent (Dis-plaque). rinse if indicated. The results demonstrated that the differential staining was thickness- II. Rinsing dependent and not associated with bacterial or biochemical factors. Thus, it A few drops of concentrated preparation is was concluded that the metachromasia of placed in a paper cup and water is added dental plaque stained with Two-tone for the appropriate dilution. Instruct the disclosing agent (Dis-Plaque) was a result patient to swish and rinse with the solution of a diffusion phenomenon in which one so that it is applied on all tooth surfaces. component diffuses more readily than III. Tablets or wafer: another from plaque, rather than from any chemical changes that might occur in Patient should chew the wafer or tablet. vivo.18 Swish it around for 30 to 60 seconds and rinses. METHODS OF APPLICATION- 15 INTERPRETATION OF FINDINGS: 15 Gingival tissue evaluation should be done before application because disclosing a. Clean tooth surface do not absorb agent will mask tissue colors. the coloring agent. When pellicle and bacterial plaque are present, I. Solution for direct application they absorb the agent and are (painting): disclosed.
a. Ask the patient to rinse to remove b. Pellicle stains as a thin relatively food particles and heavy saliva. clear covering, whereas bacterial b. Apply water based lubricant plaque appears darker, thicker and generously to prevent staining of more opaque. the lips. c. Two-tone Fig 2
c. Dry the teeth with compressed 1. Red Biofilm: Newly formed, air, retracting cheek and tongue. thin, usually supragingival.
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2. Blue Biofilm: Thicker, older, 3) Purchase solutions in small more tenacious; usually it is quantities. Do not keep solutions seen at and just below gingival containing alcohol longer than 2 or margin, especially on proximal 3 months because the alcohol will surfaces and where brush or evaporate and render the solution floss is not easily applied; may too highly concentrated. be associated with calculus deposits. 4) Use small bottles with dropper caps for solutions. Transfer solution to a PATIENT INSTRUCTION: 15 dapen dish for use. Do not contaminate the solution by Because biofilm and pellicle are frequently dipping cotton pliers with pellet invisible to a patient, a disclosing agent directly into the container bottle. can provide a visual method for patient instruction. 5) Request local druggist to stock disclosing tablets for patients to a. Explain dental biofilm: purchase. Advice patients of the The patient needs to be informed about the stores where the agents may be composition and effect of biofilm in the purchased. production of gingival and periodontal RECENT ADVANCES: 19 infections, with particular reference to the individual mouth. Plaque Disclosing agents used in Photodynamic (PDT) b. Show location and distribution of biofilm: The PDT consist of mainly there components. These are light, oxygen, and With a mirror, the patient can observe the a photosensitizer. Once the photosensitizer teeth and the disclosed dental biofilm. A is irradiated with light of a specific small mouth mirror is needed to show the wavelength, it absorbs photons of the lingual surfaces and posterior facial areas. wavelength and transfers the excitation c. Demonstrate methods for daily energy to molecular oxygen which is in biofilm removal turn metamorphosed to its diamagnetic form, singlet oxygen with other reactive TECHNICAL HINTS FOR oxygen species (ROS) formed downstream DISCLOSING AGENTS: 15 such as superoxide anion, hydroxyl radicals, and hydrogen peroxide. Of the 1) Avoid using disclosing or ROS, singlet oxygen plays a central role antiseptic solutions on teeth that for cytotoxicity in PDT, indicating that the have tooth-color restorations larger amount of singlet oxygen the target because these materials may be is exposed to, the more effectively stained by coloring agents. undesired cells such as cancer cells and 2) Do not apply a disclosing agent bacteria are killed. before a sealant is to be placed. Plaque disclosing agents, which are used to detect plaques on the tooth surface,
108 Journal Of Dental College Azamgarh Zoya et al,2015; 1(1):103-110 usually contain photosensitizers such as It is very rare to find any patient without rose bengal, erythrosine, and phloxine, all even mild plaque present in his oral cavity, of which are also used for food coloring. yet since long disclosing agent have Thus, if these plaque disclosing agents are proved to be a good adjunct for the irradiated with light of a suitable patients’ maintenance care. There is no wavelength for the photosensitizers, conclusive evidence that disclosing of singlet oxygen is validly and locally plaque in dental office aids patient generated around the plaques disclosed by motivation by improving subsequent the agents. plaque control, nor there is evidence that home use of a disclosing agent improves CONCLUSION: the standard of plaque control.
REFERENCES
1. Shefali Sharma. Plaque Disclosing American Journai of Orthodontics. Agent – A Review. Journal of 1935(21):78-88. Advanced Dental Research; 8. Raybin, M. Disclosing agents: their 2010:(1)Oct. importance and uses. The Dental 2. J. Micheal Skaggs, Robert E. Dckson, Outlook. 1943(4): 159-162. James H. Bowers & Edward A. Tavss. 9. Amim, S, S. Thoughts concerning Plaque disclosing composition. pathogenesis, treatment and 4992256, Feb 12, 1991. prevention of periodontal disease. 3. Skinner, F. H. The prevention of Journal of Periodontotogy. pyorrhoea and dental caries by 1958(29):217-223. prophylaxis. Dental Cosmos. 10. Amim, S, S. The use of disclosing 1914(56):229-309. agents for measuring tooth 4. Loe, H., Thielade, E. & Jensen, S.B. cleanliness. Journal of Experimental gingivitis in man. Periodontology. 1963(34):227-245. Journal of Periodontology. 11. Raybin, M. Disclosing solutions. 1965(36):177-187. Dental Items of Interest. 5. Axelsson, P, & Lindhe, J. The effect 1945(67):235-243. of a preventive programme on dental 12. Heffemen, J. J., Cooley. R. O., Hale, plaque, gingivitis and caries in J. B., Olsen, N.H. & Lyon, H.W. Use schoolchildren. Results after one and of ultraviolet illumination in oral two years. Journal of Clinical diagnosis. Journal of the American Periodontology, 1974(1):126-138, Dental Association. 1971(82): 1353- 6. Berwick, C. C. The disinfection of the 1360. oral mucosa with crystal violet and 13. Lang, N. P., Ostergaard, E. & Loe, H. brilliant green. Journal of Dental A fluorescent plaque disclosing agent. Research. 1920(2):21-42. Journal of Periodontal Research. 7. Easlick, K. A. The dentist's 1972(7):59-67. management of young children, 14. Block, P, L, Lobene, R. R, & Derdivanis, J, P. A two-tone dye test
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for dental plaque. Journal of 18. Gallagher H.C. et al. Mechanism of Periodontology. 1972(43):423-426. action of two tone plaque disclosing 15. Esther. M. Wilkins. Clinical practice agent. J. Periodontol. 1977:395. of the dental hygienist. 10th ed. 388- 19. Kirika Ishiyama, Keisuke Nakamura, 391. Hiroyo Ikai, Taro Kanno, Masahiro 16. Newman. Takei. Klokkevold. Kohno, Keiichi Sasaki, Yoshimi Carranza; Carranza’s clinical Niwano. Photogenerated Singlet periodontology; 9th edition; Elsevier: Oxygen for Disinfection. 2006 2012(7):May. 17. Mosby’s Dental dictionary. 2nd 20. A.E.S. Tan & A. Bryan Wade. The edition, Elsevier:2008. role of visual feedback by a disclosing agent in plaque control. Journal of Clin Periodontol. 1980(2):140-148.
FIGURES
Fig 1: Use of Disclosing Agent (A) Appearance of the teeth before application of a disclosing agent. Dental biofilm and pellicle are usually invisible. (B) After use of a disclosing agent on the same teeth as those in A. Dental biofilm and pellicle takes on the colour of the dye used in the disclosing agent. As noted, soft deposits are extensive, and are especially thick on the proximal surface.
Fig 2: Plaque disclosed after application of Two-tone disclosing agent
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