Changes in Oral Microflora with Oral Gargling and Interdental Brushing

Home , Spiral bacteria

Original Article Int J Clin Prev Dent 2015;11(3):143-152ㆍhttp://dx.doi.org/10.15236/ijcpd.2015.11.3.143 ISSN (Print) 1738-8546ㆍISSN (Online) 2287-6197

Su-Hyang Kim1, Chung-Jae Lee2, Kyu-Hwan Lee3, Su-Kyung Jwa4

1Department of Oral Health, Graduate School, Dankook University, Cheonan, 2Department of Dental Laboratory Technology, Shin Han University, Uijeongbu, 3Department of Health Promotion Center, Seoul National University Bundang Hospital, Seongnam, 4Department of Dental Hygiene, Daegu Health College, Daegu, Korea

Objective: The study used phase contrast microscopy to examine the influence on the proximal oral bacterial microflora after interdental brushing using cethyl pyridium chloride (CPC) solution in 50 adult volunteers. Methods: The study was done from August to September 2014 at the dental public health center in Deagu-si with Dankook University Hospital Institutional Review Board approval. Results: Numerous cocci present at the interproximal site prior to use of CPC were markedly reduced at the interdental brush tip following CPC use (p＜0.01). Coccai motility as an indication of motility was no different prior to and after CPC application(p＞0.05). The total number of Bacillus and number of motile Bacillus were significantly after CPC brushing (both p＜0.01). Total number and number of motile filamentous and spiral microorganisms were decreased after CPC application(all p＜0.05). The results indicate the effcacy of mouth rinsing with CPC. While there may be a relationship between the total and motile numbers of oral microorganisms, no relationship was routinely evident between age and microbe number. Conclusions: Use of CPC to sterilize the tip of the interdental brush after use the proximal area is recommended to achieve the best antiseptic effect.

Keywords: cethyl pyridium chloride, interdental brush

Introduction ing in Korea, with a 7.3% increase recorded from 2006 to 2011 [1]. Dental plaque is produced on the outer surface of the pelicle. The prevalence of periodontal disease, which is mainly due Primary plaque colonizers in the early stage of plaque formation to microorganisms resident in dental plaque, has been increas- include aerobic. Gram positive bacteria. As dental plaue thick- ens and oxygen becomes more limited in the interior of the plaque, anaerobic bacteria including Gram negative bacteria in- Corresponding author Su-Kyung Jwa habit the plaque [2]. The latter include Prophyromonas gingivalis, Department of Dental Hygiene, Daegu Health College, 15 Prevolella intermidia, Aggregatibacter actinomycetemcomitans, Youngsong-ro, Buk-gu, Daegu 41453, Korea. Tel: +82-53- Tannerella forsythia, and Fusobacterium nucleatum [3]. 320-4516, Fax: +82-53-320-1345, E-mail: [email protected]. ac.kr Microorganisms that develop at the interproximal area and in the gingival pocket proximally are hard to remove. Received March 24, 2015, Revised June 16, 2015, Specialized oral hygiene devices like silk dental floss and inter- Accepted June 17, 2015 dental brush are needed. Indications for use of the interdental

Copyright ⓒ 2015. Korean Academy of Preventive Dentistry. All rights reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

143 International Journal of Clinical Preventive Dentistry brush include patients with a wide interdental area. Periodontal Materials and Methods surgery, use of fixed prosthodontic appliance, implant and or- thodontic appliances [2]. 1. Subjects Interdental brushes and toothburshes should be anti- septically cleansed for optimal benefit and to avoid transfer of Fifty adult volunteers recruited at a public health center from microorganisms to tooth surfaces during brushing. Toothbrushes August to September 2014 participated in this study. The study can harbor millions to billions of bacteria, which can be deliv- was approved by Dankook University Hospital Institutional ered to the oral cavity [4]. Monthly replacement of a toothbrush Review Board. The age and the gender distribution of the sub- is recommended [5]. Differences in the numbers of micro- jects were shown in Table 1. organisms in the toothbrush bristle according to the cleaning 2. Materials method and cleansing time have been reported [6]. The tip of an interdental brush should be cleaned using an an- An interdental brush (Dr. Han’s Brush; Wooribiogen, Seoul, tiseptic, typically cethyl pyridium chloride (CPC). CPC is a Korea) and 0.05% CPC solution were provided to all subjects quatermary ammonium compound that exerts its bacteriostatic for cleaning of the proximal site and tip of interdental brush or bactericidal antiseptic action by disrupting the cell wall of (Figure 1). Gram postive bacterial and cell envelope of Gram negative bacteria [7-10]. Xantolisol is an especially potent ingredient [11,12]. It’s merits include lack of staining of teeth and a palat- able taste compared to chlorhexidine [13]. Phase contrast microscopy has proven useful to measure the total number of oral microorganisms on the surface of interest. As well, the approach can detemine the number of motile mi- crobes as an indication of viability [14]. However, the method cannot speciate microorganisms and can be subject to examiner bias [15]. Oral microorganisms commonly identified using phase contrast microscopy are cocci, bacillus, filamentous and spiral shaped types. A caries-related environment tends to be enriched in motile cocci and bacilli with motile, with periodontal disease associated with filamentous and spiral microorganisms [14-17]. Patient motivation for proper oral health could be boosted by Figure 1. Photograph of an interdental brush and cethyl pyridium the use of phase contrast microscopy, with images of the mi- chloride solution. crobes present in a patients’ mouth stimulating resolve fo proper dental hygiene [18,19]. The present study explored the use of phase contrast microscopy to chart the effect CPC sterilization of and interdental brush after use of the brush at the proximal region of the mouth.

Table 1. Age and gender of the subjects

Age (yr) Gender 30s 40s 50s 60s Total Male (n) 8 2 8 0 18 Female (n) 10 15 6 1 32 Figure 2. The interdental brush was moved back-and-forth times Total (n) 18 17 14 1 50 across the proximal area.

144 Vol. 11, No. 3, September 2015 Su-Hyang Kim, et al：Changes in Oral Microflora with Oral Gargling and Interdental Brushing

Figure 3. Sterilzation with cethyl pyridium chloride.

Figure 4. Applying of cethyl pyridium chloride at proximal area.

3. Method The interdental brush was used five times at the proximal area. Residue on the brush was smeared on a glass slide and covered with cover glass. Motile bacteria were recorded for 10 seconds during phase contrast microscopy examination (Figure 2). The brush was shaken in CPC solution for 1 minute and the residue examined as just described (Figure 3). CPC was applied 5 times to at the proximal area of the interdental brush tip (Figure 4). Figure 5, 6 display representative images of oral microorganisms recovered from the proximal area before and after 1-minute gargling with CPC solution, respectively. Dental plaque recovered using a micro-brush was smeared on a slide glass, a drop of saline was added and the suspension was covered with

Figure 5. Recovery of microorganisms from the proximal area before a cover glass (Figure 7). gargling with cethyl pyridium chloride.

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Figure 6. Microorganism recovery form the proximal area after cethyl pyridium chloride gargling.

Figure 7. Preparation of a smear for phase contrast microscopy examination.

and numbers of motile microorganisms were ranked on a scale of 0 to 3 (Table 2) [20]. 5. Statistical analysis SPSS ver. 12.0 software (SPSS Inc., Chicago, IL, USA) was used for Pearsons’ correlation coefficient statistical analysis after calculating the mean and standard deviation.

Results

Total number and motile number of cocci (Table 3-5), bacilli (Table 6-8) and filamentous (Table 9-11) microorganisms are Figure 8. Various types of oral microorganism shown in a representative summarized. Correlatons between the total number and motile phase contrast microscopy image. numbers of microorganisms before and after CPC sterilization are presented in shown in Table 12-16. CPC sterilization for a minute in CPC solution marked re- 4. Microscopic findings duced the number of cocci, with the reduction in cell number Oral microorganisms were observed using a model DCS being more modest when CPC was applied at the proximal area 6002 phase contrast microscope (Dr. Prevent, Seoul, Korea) at for a minute (Table 3). The reduction in the number of motile a magnification of ×400 on the image monitor after recording cocci in the proximal region was not as evident (p>0.05). But the image for 10 seconds. The morphological types of the micro- sterilization the tip of the interdental brush by a 1-minute shakin organisms was classified as cocci, bacillus, filamentous and in CPC solution was effective (p<0.05) (Table 4). The number comma/spiral type (Figure 8). The number of micoorganisms of cocci prior to tip sterilization and following gargling with

146 Vol. 11, No. 3, September 2015 Su-Hyang Kim, et al：Changes in Oral Microflora with Oral Gargling and Interdental Brushing

Table 2. Standardization of total number and motile number of oral microorganisms classified on the basis of morphology [20]

Cocci type Bacilli type Filament type Comma/spiral type Score Amount Motile Amount Motile Amount Motile Amount Motile 0 None None None None None None None None 1 1-7 Trembling 1-7 Trembling 1-7 Trembling 1-3 Trembling 2 8-70 Slight movement 8-30 Slight movement 8-30 Slight movement 4-8 Slight movement 3 ＞70 Active movement ＞30 Active movement ＞30 Active movement ＞8 Active movement

Table 3. Amout and motile changes of cocci (n=50) Table 5. Change of cocci before/after CPC gargling

Variable Amount Motile Variable Amount Motile After using at the proximal area 2.04±0.57 1.04±0.49 Before CPC gargling 1.88±0.59 0.90±0.58 After using CPC at proximal area 1.82±0.48 1.14±0.57 After CPC gargling 1.52±0.58 0.94±0.31 After sterilization with CPC 1.22±0.46 0.90±0.36 p-valuea 0.001 0.622 Values are presented as mean±standard deviation. CPC: cethyl pyridium Values are presented as mean±standard deviation. CPC: cethyl pyri- chloride. dium chloride. ap-value by paired t-test.

Table 4. Changes of cocci (paired t-test)

Amount Motile

Variable After using at the After using CPC at After sterilization After using at the After using CPC at After sterilization proximal area proximal area with CPC proximal area proximal area with CPC After using at the proxi------mal area After using CPC at the 0.006** - - 0.200 - - proximal area After sterilization with 0.001** 0.001** - 0.033* 0.002** - CPC CPC: cethyl pyridium chloride. *p＜0.05, **p＜0.01.

Table 6. Amount and motile changes of bacillus (n=50) Table 8. Changes of bacillus before/after CPC gargling

Variable Amount Motile Variable Amount Motile

After using at the proximal area 2.30±0.54 2.68±0.71 Before CPC gargling 2.16±0.50 2.36±0.56 After using CPC at proximal area 1.88±0.47 2.10±0.74 After CPC gargling 1.82±0.39 1.78±0.62 After sterilization with CPC solution 1.42±0.46 1.26±0.36 p-valuea 0.000 0.000 Values are presented as mean±standard deviation. CPC: cethyl pyri- Values are presented as mean±standard deviation. CPC: cethyl pyridium chloride. dium chloride. ap-value by paired t-test.

Table 7. Changes bacillus (paired t-test)

Amount Motile Variable After using at the After using CPC at After sterilization After using at the After using CPC at After sterilization proximal area proximal area with CPC proximal area proximal area with CPC After using at the proxi------mal area After using CPC at the 0.001** - - 0.117 - - proximal area after sterilization with 0.001** 0.001** - 0.000** 0.001** - CPC CPC: cethyl pyridium chloride. **p＜0.01.

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Table 9. Amount and motile changes of filament (n=50) Table 11. Changes of filament before/after CPC gargling

Variable Amount Motile Variable Amount Motile After using at the proximal area 2.06±0.71 2.60±0.76 Before CPC gargling 2.02±0.68 2.66±0.75 After using CPC at proximal area 1.52±0.84 2.10±1.13 After CPC gargling 1.62±0.83 2.08±1.14 After sterilization with CPC 1.04±0.83 1.10±1.00 p-valuea 0.000 0.000 Values are presented as mean±standard deviation. CPC: cethyl pyri- Values are presented as mean±standard deviation. CPC: cethyl pyridium chloride. dium chloride. ap-value by paired t-test.

Table 10. Changes of filament (paired t-test)

Amount Motile Variable After using at the After using CPC at After sterilization After using at the After using CPC at After sterilization proximal area proximal area with CPC proximal area proximal area with CPC After using at the proxi------mal area After using CPC at the 0.001** - - 0.001** - - proximal area After sterilization with 0.001** 0.001** - 0.001** 0.001** - CPC CPC: cethyl pyridium chloride. **p＜0.01.

Table 12. After using at the proximal area

Cocci Bacilli Filament Comma/spiral Type Value Age Amount Motile Amount Motile Amount Motile Amount Motile

Cocci amount r −0.072------p0.622------Motile r −0.176 0.285* ------p0.2210.045------Bacilli amount r 0.095 0.685** 0.183 ------p0.5120.0000.204------Motile r −0.0190.0620.2440.042----- p0.8960.6700.0870.773----- Filament amount r 0.126 0.648** 0.226 0.638** 0.054 ---- p0.3830.0000.1150.0000.708---- Motile r 0.007 0.417** 0.317* 0.248 0.023 0.577** - - - p 0.960 0.003 0.025 0.082 0.876 0.000 - - - r −0.051 0.499** 0.256 0.457** 0.101 0.616** 0.448** - - Comma/spiral amount p 0.724 0.000 0.072 0.001 0.487 0.000 0.001 - - Motile r −0.126 0.406** 0.248 0.248 0.097 0.232 0.453** 0.395** - p 0.383 0.003 0.082 0.083 0.501 0.104 0.001 0.005 - *p＜0.05, **p＜0.01.

CPC were significantly different (p<0.05) (Table 5), while gar- 12-16 showed the relationship between such factors for subjects gling did not appreciably change the number of motile cocci and the amounts or the motile of the microorganism, observed (p>0.05). Total and motile number of bacillus microorganisms with the phase contrast microscope. It revealed much relation- were reduced after CPC solution application (p<0.01) (Table 6), ships between each typed microorganism at any case such as with a more pronounced decreased evident following a 1-mi- after using the interdental brush for 5 time at the proximal area, nute tip sterilization (p<0.01). Similar results were found for fil- after applying CPC 1 to 2 drops into the proximal area or after amentous and spiral microorganisms (Table 9-11, 17-19). Table using CPC by inserting interdental brush tip into CPC solution

148 Vol. 11, No. 3, September 2015 Su-Hyang Kim, et al：Changes in Oral Microflora with Oral Gargling and Interdental Brushing

Table 13. After sterilization of tip with cethyl pyridium chloride solution

Cocci Bacilli Filament Comma/spiral Type Value Age Amount Motile Amount Motile Amount Motile Amount Motile Cocci amount r −0.316* ------p0.025------Motile r −0.209 0.464** ------p 0.145 0.001 ------Bacilli amount r −0.215 0.346* 0.360* ------p 0.133 0.014 0.010 ------Motile r −0.122 0.397** 0.257 0.613** - - - - - p 0.399 0.004 0.071 0.000 - - - - - Filament amount r −0.170 0.347* 0.410** 0.633** 0.525** - - - - p 0.237 0.013 0.003 0.000 0.000 - - - - Motile r −0.171 0.409** 0.389** 0.512** 0.553** 0.808** - - - p 0.235 0.003 0.005 0.000 0.000 0.000 - - - r −0.013 0.124 0.293* 0.331* 0.537** 0.518** 0.497** - - Comma/spiral amount p 0.930 0.390 0.039 0.019 0.000 0.000 0.000 - - Motile r −0.220 0.144 0.383** 0.430** 0.520** 0.620** 0.622** 0.655** - p 0.124 0.319 0.006 0.002 0.000 0.000 0.000 0.000 - *p＜0.05, **p＜0.01.

Table 14. After using cethyl pyridium chloride at proximal area

Cocci Bacilli Filament Comma/spiral Type Value Age Amount Motile Amount Motile Amount Motile Amount Motile Cocci amount r −0.205------p0.154------Motile r −0.1940.253------p0.1770.076------Bacilli amount r −0.034 0.368** 0.358* ------p0.8150.0090.011------Motile r 0.163 0.287* 0.292* 0.630** ----- p0.2570.0430.0390.000----- Filament amount r −0.078 0.452** 0.283* 0.732** 0.561** ---- p0.5880.0010.0470.0000.000---- Motile r 0.090 0.367** 0.241 0.629** 0.718** 0.833** - - - p 0.535 0.009 0.091 0.000 0.000 0.000 - - - r −0.045 0.516** 0.336* 0.628** 0.544** 0.674** 0.735** - - Comma/spiral amount p 0.757 0.000 0.017 0.000 0.000 0.000 0.000 - - Motile r −0.070 0.491** 0.382** 0.596** 0.504** 0.629** 0.730** 0.879** - p 0.628 0.000 0.006 0.000 0.000 0.000 0.000 0.000 - *p＜0.05, **p＜0.01. and shake it for a minute. This means that if one typed micro- cocci. Although not so much changes in cocci typed microorganism was increased in number it guessed the other typed organism, it revealed much changes for decreasing the amounts microorganisms increased the number or activity naturally. or motile of all typed microorganism, in case of sterilization This phenom was proved similar pattern in any cases of experi- with CPC solution by inserting the tip of interdental brush into ment for sterilization with CPC solution, shown in Table 12-16, CPC solution and shaking it for a minute, so it was recom- even in case for before or after mouthrinsing with CPC solution. mended to use the interdental brush tip with inserting into CPC In general, the motile of cocci type microorganism was not solution and shaking it for a minute, in clinical. remarkable changes became not so much activity in motile for

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Table 15. Before cethyl pyridium chloride gargling

Cocci Bacilli Filament Comma/spiral Type Value Age Amount Motile Amount Motile Amount Motile Amount Motile Cocci amount r −0.201------p0.161------Motile r −0.014 0.438** ------p 0.923 0.001 ------Bacilli amount r −0.197 0.672** 0.262 ------p 0.169 0.000 0.066 ------Motile r 0.043 0.620** 0.237 0.578** - - - - - p 0.764 0.000 0.097 0.000 - - - - - Filament amount r −0.036 0.709** 0.211 0.693** 0.458** - - - - p 0.805 0.000 0.142 0.000 0.001 - - - - Motile r 0.263 0.505** 0.203 0.415** 0.346* 0.733** - - - p 0.065 0.000 0.158 0.003 0.014 0.000 - - - r 0.024 0.654** 0.204 0.593** 0.633** 0.618** 0.451** - - Comma/spiral amount p 0.870 0.000 0.155 0.000 0.000 0.000 0.001 - - Motile r 0.106 0.366** 0.055 0.414** 0.318* 0.382** 0.454** 0.441** - p 0.462 0.009 0.704 0.003 0.024 0.006 0.001 0.001 - *p＜0.05, **p＜0.01.

Table 16. After cethyl pyridium chloride gargling

Cocci Bacilli Filament Comma/spiral Type Value Age Amount Motile Amount Motile Amount Motile Amount Motile Cocci amount r −0.037------p0.796------Motiler0.0000.175------p1.0000.224------Bacilli amount r −0.042 0.515** 0.245 ------p0.7720.0000.087------Motile r −0.049 0.270 0.036 0.258 - - - - - p 0.738 0.058 0.804 0.071 - - - - - Filament amount r 0.081 0.547** 0.088 0.627** 0.199 - - - - p 0.575 0.000 0.543 0.000 0.165 - - - - Motile r 0.321 0.507** −0.051 0.366** 0.305* 0.716** - - - p 0.023 0.000 0.724 0.009 0.031 0.000 - - - r 0.062 0.478** −0.017 0.466** 0.354* 0.541** 0.586** - - Comma/spiral amount p 0.667 0.000 0.905 0.001 0.012 0.000 0.000 - - Motile r 0.124 0.461** −0.050 0.523** 0.505** 0.584** 0.756** 0.722** - p 0.392 0.001 0.730 0.000 0.000 0.000 0.000 0.000 - *p＜0.05, **p＜0.01.

Table 17. Amount and motile changes of comma and spiral (n=50) Discussion Variable Amount Motile The main oral disease as dental caries and periodontal After using at the proximal area 2.20±0.90 2.82±0.56 disease. These are caused by dental plaque, which is comprised After using CPC at proximal area 1.28±0.86 2.10±1.15 After sterilization with CPC 0.82±0.85 1.18±1.08 of Gram positive aerobic bacteria at the exterior and Gram negative anaerobic bacteria in the interior [13]. Periodontal disease Values are presented as mean±standard deviation. CPC: cethyl pyri- is alleviated removing dental plaque through the proper use of dium chloride. oral hygiene devices.

150 Vol. 11, No. 3, September 2015 Su-Hyang Kim, et al：Changes in Oral Microflora with Oral Gargling and Interdental Brushing

Table 18. Changes of comma and spiral (paired t-test)

Amount Motile Variable After using at the After using CPC at After sterilization After using at the After using CPC at After sterilization proximal area proximal area with CPC proximal area proximal area with CPC After using at the proxi------mal area After using CPC at the 0.001** - - 0.001** - - proximal area After sterilization with 0.003** 0.001** - 0.001** 0.001** - CPC CPC: cethyl pyridium chloride. **p＜0.01.

Table 19. Changes of comma and spiral before/after CPC gargling solution to sterilize the interdental brush tip. Sterilization with achieved by a 1-minute agitation of the tip in CPC solution was Variable Amount Motile the most effective for decreasing bacterial numbers contamina- Before CPC gargling 2.06±0.91 2.80±0.63 tions. The pattern of effectiveness extended to cocci, bacilli, fil- After CPC gargling 1.26±0.83 2.04±1.14 p-valuea 0.000 0.000 amentous bacterial and spiral bacteria although the reductions observed for cocci were not as made. Values are presented as mean±standard deviation. CPC: cethyl pyridium chloride. ap-value by paired t-test. Conclusion

Overshelmingly the most cmmon oral hygiene device is the In conclusion sterilization of interdental brush tips with CPC toothbrush. A toothbrush needs to be used diligently and regu- after application of CPC the proximal site is recommended. larly (twice daily) to be effective. Even then periodontal disease Especially for patients with periodontal disease implant or can occus. A study from England, in which 67% of adults used orthodentic. a toothbrush more than twice daily, documented gingival bleed- ing in 79% of adults [13]. References In Korea, auxiliary oral hygiene is accomplished most fre- quently using mouth gargling followed in order by interdental 1. Marsh PD. Microbiological aspects of the chemical control of brush and silk dental floss. Dental floss and interdental brush plaque and gingivitis. J Dent Res 1992;71:1431-8. use can be effective for proximal cleansing of the dental plaque; 2. Paik DI, Kim HD, Shin SC, Cho JW, Park YD, Kim DK, et al. in one study 89% to 96% of dental plaque located in the proximal Clinical preventive dentistry. 5th ed. Seoul: KMS; 2011:65-79. area could be eliminated by use of the interdental brush after 3. Kim KK. Oral microbiology at a glance. Seoul: PanMun Educa- toothbrushing [21] Use of a toothbrush and interdental brush tion; 2013:47. 4. Jeong YK, Seong YR, Cho KS, Seong HK, Kim JB. Bacteriolog- together is better than a tooth brush alone to clean proximal den- ical contamination of home toothbrusher and hygiene improve- tal plaque [22]. ment. J Korean Acad Dent Health 1992;16:147-55. In the present study, a five-step clean strategy using CPC sol- 5. Glass RT, Lare MM. Toothbrush contamination: a potential ution was explored to find the most effective way of CPC steri- health risk? Quintessence Int 1986;17:39-42. lization of the interdental brush tip. A CPC concentration of 6. Kozai K, Iwai T, Miura K. Residual contamination of tooth- 0.025% to 0.1% is used most often for gargling, with an effect brushes by microorganisms. ASDC J Dent Child 1989;56:201-4. that is similar as the use of chlorohexidine but without the side 7. Holbeche JD, Ruljancich MK, Reade PC. A clinical trial of the effect of discoloration of tooth enamel [13]. In seeking to enu- efficacy of a cetylpyridinium chloride-based mouthwash 1. Effect on plaque accumulation and gingival condition. Aust merate bacterial in the oral cavity, we used the technique of Dent J 1975;20:397-404. phase contrast microscopy. The method allows observation of 8. Barnes GP, Roberts DW, Katz RV, Woolridge ED Jr. Effects of living bacteria without the need for staining [23]. The approach two cetylpyridinium chloride-containing mouthwashes on bac- can also be useful in inspiring patients to adopt and maintain terial plaque. J Periodontol 1976;47:419-22. proper oral hygiene [2]. 9. Lobene RR, Kashket S, Soparkar PM, Shloss J, Sabine ZM. The The results support the use of CPC as a detergent antiseptic effect of cetylpridinium chloride on human plaque bacteria and

www.ijcpd.org 151 International Journal of Clinical Preventive Dentistry

gingivitis. Pharmacol Ther Dent 1979;4:33-47. 16. The Korean Society for Microbiology. Medical microbiology. 10. Llewelyn J. A double-blind crossover trial on the effect of ce- Seoul: Ryo Moon Gak Publishing; 1991:608-20. tylpyridinium chloride 0.05 per cent (Merocet) on plaque 17. Gribbon JR. Van houte testbook of oral biology. Philadelphia: accumulation. Br Dent J 1980;148:103-4. Saunders; 1978:228-9. 11. Kim JB, Paik DI, Moon HS, Jin BH, Park DY. A study on the effect 18. Keyes PH, Wright WE, Howard SA. The use of phase-contrast of Cetylpyridinium chloried and bamboo salt containing mouth microscopy and chemotherapy in the diagnosis and treatment of rinse on the number of Streptococcus mutans and plaque index. periodontal lesions: an initial report (I). Quintessence Int Dent J Korean Acad Dent Health 1993;17:176-87. Dig 1978;9:51-6. 12. Shin SC, Lee H. Clinical study of mouth rinse containing sodium 19. Listgarten MA, Helldén L. Relative distribution of bacteria at fluoride, cetylpyridinium chloride and urusodesoxycholinic clinically healthy and periodontally diseased sites in humans. J acid on dental plaque and gingivitis. J Korean Acad Dent Health Clin Periodontol 1978;5:115-32. 1998;22:121-33. 20. Chang YS, Jung MA, Shin SC. Evaluation of motility and dis- 13. Kang MS, Kim HG, Kwon HK, Kim CY. A Study on the effects tribution of Oral Micro-flora in Korean using the phase Contrast of cetylpyridinium chloride - and bamboo salt - containing Microscope. Int J Clin Prev Dent 2008;4:28-39. mouthrinses on the inhibition of gingivitis. J Korean Acad Dent 21. Schmid MO, Balmelli OP, Saxer UP. Plaque-removing effect of Health 1995;19:219-28. a toothbrush, dental floss, and a toothpick. J Clin Periodontol 14. Cho EH, Shin SC. Clinical comparative study on the diagnosis 1976;3:157-65. power between some oral environmental tests and status of 22. Kiger RD, Nylund K, Feller RP. A comparison of proximal pla- individual. J Dankook Dent Res Inst 1990;2:61-75. que removal using floss and interdental brushes. J Clin 15. Kim EJ, Nam IS, CHo GS, Ahn SH, Kim JS, Kim HJ, et al. A Periodontol 1991;18:681-4. study on the reduction effects of oral microor ganisms through 23. Kim YK, Han MD. Oral microbiology. 3rd ed. Seoul: Komoonas; the different methods of controlling dental plaque. Int J Clin Prev 2001:3-325. Dent 2007;3:136-51.

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