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ORIGINAL ARTICLE
Year : 2017  |  Volume : 35  |  Issue : 2  |  Page : 174-180
 

Comparison of efficacy of three chemotherapeutic agents on Streptococcus mutans count in plaque and saliva: A randomized controlled triple blind study


1 Department of Pedodontics, Al Azhar Dental College Thodupuzha, Idukki, Kerala, India
2 Department of Pedodontics, K.V.G Dental College and Hospital, Sullia, Karnataka, India
3 Department of Pedodontics, PMS College of Dental Science and Research, Trivandrum, Kerala, India
4 Department of Public Health Dentistry, Coorg Institute of Dental Sciences, Virajpet, Karnataka, India
5 Department of Pedodontics, Dr. D. Y. Patil Dental College and Hospital, Pune, Maharashtra, India
6 Department of Pedodontics, Pacific Dental College and Hospital, Udaipur, Rajasthan, India

Date of Web Publication10-May-2017

Correspondence Address:
Ajay Narayan
Department of Pedodontics, Al-Azhar Dental College Thodupuzha, Idukki, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISPPD.JISPPD_319_16

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   Abstract 

Background: There is a need for exploration of the role of chemotherapeutic agents and its role in the prevention of early childhood caries (ECC) and its recurrence. Aim: The aim of this study was two-fold: (1) To compare the antimicrobial efficacy of three commonly used chemotherapeutic agents in the prevention of ECC in comparison with a control and (2) To ascertain the role of chemotherapeutic agents in the prevention of ECC. Materials and Methods: Sixty children with ECC in the age group 3–6 years were randomly allocated into four groups. To each group of children after full oral rehabilitation either 10% povidone-iodine (PI), or chlorhexidine (CHX) varnish (Cervitec Plus), or fluoride varnish (Fluor Protector) were applied twice at an interval of 1 week, Group 4 served as control. Streptococcus mutans count in saliva and plaque were collected at baseline, 30, 60, and 90 days and the presence of S. mutans was evaluated using the Dentocult SM strip mutans kit. The efficacy of 10% PI, CHX varnish (Cervitec Plus), and fluoride varnish (Fluor Protector) was compared with the control group at 30, 60, and 90 days. An intergroup comparison was also done during the same time intervals. Results: The reduction of S. mutans count in the plaque and saliva was greatest in the fluoride varnish treated groups at all time intervals (30, 60, and 90 days). Fluoride varnish, CHX varnish, and 10% PI showed significant improved efficacy when compared to the control group (P < 0.001). Fluoride varnish showed significantly lower counts of S. mutans compared to CHX varnish at all time intervals (30, 60, and 90 days) and also significantly lower counts compared to 10% PI at 60 and 90 days interval (P < 0.001).


Keywords: Cervitec, Dentocult SM strips, Fluor Protector, povidone iodine,Streptococcus mutans


How to cite this article:
Narayan A, Satyaprasad S, Anandraj S, Ananda S R, Kamath P A, Nandan S. Comparison of efficacy of three chemotherapeutic agents on Streptococcus mutans count in plaque and saliva: A randomized controlled triple blind study. J Indian Soc Pedod Prev Dent 2017;35:174-80

How to cite this URL:
Narayan A, Satyaprasad S, Anandraj S, Ananda S R, Kamath P A, Nandan S. Comparison of efficacy of three chemotherapeutic agents on Streptococcus mutans count in plaque and saliva: A randomized controlled triple blind study. J Indian Soc Pedod Prev Dent [serial online] 2017 [cited 2019 Dec 13];35:174-80. Available from: http://www.jisppd.com/text.asp?2017/35/2/174/206039



   Introduction Top


Dental caries is an infectious oral disease affecting a large population of inhabitants worldwide. Early childhood caries (ECC) is a virulent form of caries that begins soon after tooth eruption and can cause a devastating effect on the dentition of infants and preschool children. Children developing caries as infants and toddlers have higher risk of developing caries in the primary and permanent dentition even after full oral rehabilitation.[1],[2]

Children with ECC have elevated levels of Streptococcus mutans, the cariogenic microorganism colonizing the oral cavity at younger ages. Treatment of ECC is often expensive often requiring extensive restorative, extraction, and pulp therapies at a very young age. In addition to these expenses, general anesthesia or deep sedation may be required because the young children lack the ability to cope with the procedure.[3]

Maintenance of primary dentition in a healthy condition is important for the well-being of the child as far as proper masticatory, esthetics, phonetics, space maintenance, and prevention of aberrant habits are concerned.[4]

The focus of prevention should be based on patient and parent education regarding decay promoting feeding behaviors and reducing the levels of S. mutans infection so as to prevent recurrence.[3] Chemotherapeutic agents have been effective in reducing S. mutans infection and reduce plaque formation. However, there is no study comparing the efficacy of these agents.

This study was planned with the following aims and objectives:

  • To compare the antimicrobial efficacy of three commonly used chemotherapeutic agents (10% povidone iodine [PI], chlorhexidine [CHX] varnish and fluoride varnish) on S. mutans in saliva and plaque in comparison with a control and
  • To ascertain the role of chemotherapeutic agents in the prevention of ECC.



   Materials and Methods Top


Sixty children aged 3–6 years with ECC reporting to the Department of Pedodontics, KVG Dental College and Hospital, Sullia for treatment were selected. The inclusion/exclusion criteria were as follows.

Inclusion criteria

  • No significant medical history
  • Presence of full complement of primary teeth
  • Diet chart which reveals exposure to sugar more than four times daily
  • The presence of one or more decayed, missing or filled tooth (DMFT) surfaces in any primary tooth in a child 3–6 years of age.


Exclusion criteria

  • Patients whose parents do not give consent for examination
  • Children who do not cooperate for examination
  • Children with systemic diseases
  • Children who were on antibiotic or medications that might affect oral flora or salivary flow taken within the previous 3 months
  • History of fluoride treatment in the past 3–4 weeks.


Written informed consent was taken before the study from their mothers/caretakers. Child's medical and dental history was taken. The clinical examination was done for sixty children with mouth mirror and explorer, and each child was allocated a number. The study group was divided into four groups (three experimental and one control) by examiner A using a random number table. The groups were:

  1. Group 1: 15 children with ECC following full mouth rehabilitation and Chlorhexidine varnish, Cervitec Plus applied to their dentition twice at an interval of 1 week
  2. Group 2: 15 children with ECC following full mouth rehabilitation and 0.2 ml of 10% PI applied to their dentition for a span of 10 s twice in an interval of 1 week
  3. Group 3: 15 children with ECC following full mouth rehabilitation and fluoride varnish (F varnish), Fluor Protector (Ivoclar Vivadent, Schaan, Liechtenstein) applied to their dentition twice at an interval of 1 week
  4. Group 4: 15 children with ECC following full mouth rehabilitation and placebo varnish applied to their dentition (control group).


Salivary and plaque samples were collected from each participant for bacterial assessment at baseline (pre-) and post-treatment at 30, 60, and 90 days following second application of either 10% PI, F varnish (Fluor Protector), CHX varnish (Cervitec Plus), or placebo by examiner B. S. mutans count in each plaque and saliva sample was determined using Dentocult SM strip mutans test (Orion Diagnostica, Espoo, Finland) described by Jensen and Bratthall.[5]

The plaque was collected with a sterile toothpick 1–2 h after eating or brushing. The site for collection of plaque was the buccal surface of maxillary second molars and the lingual surface of mandibular molars [Figure 1]. This was then spread thoroughly but gently on the four sites of the rough surface of the plaque strip. For salivary assessment of S. mutans count, the rough surface of the Dentocult SM saliva strip was pressed against the saliva on the tongue, and the strip was removed gently through closed lips so as to remove excess saliva [Figure 2] and [Figure 3].
Figure 1: Collection of plaque

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Figure 2: Collection of saliva

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Figure 3: Removing excess saliva

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Using a needle or forceps, a bacitracin disc was placed in the selective culture broth about 15 min before sampling for making the media selective for S. mutans. The selective culture vial was then gently shaken for even distribution of bacitracin.

The plaque and salivary samples were placed in the selective culture broth, with the smooth surfaces clipped and attached to the cap. The samples were labeled, and a number was assigned to each sample. The vials were incubated at 37°C for 48 h in an upright position with the cap opened one-quarter turn to allow growth of microorganisms as per manufacturer's instructions. After incubation, the presence of S. mutans was evidenced by the detection of light blue to dark blue raised colonies on the inoculated surface of the strip [Figure 4]. Colonies suspended in the culture broth were excluded from the evaluation. Inspection of the growth was done by two independent examiners with the strip held sideways and with a magnifying glass, and the results were evaluated according to the manufacturer's chart [Figure 5].
Figure 4: Streptococcus mutans growth on strips

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Figure 5: Manufacturers model chart

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  • Class 0: <10,000 CFU/ml (CFU - colony forming unit)
  • Class 1: <100,000 CFU/ml
  • Class 2: 100,000–1000,000 CFU/ml
  • Class 3: >1000,000 CFU/ml.


The data thus obtained were tabulated for different time intervals (pretreatment, 30, 60, and 90 days) and was statistically evaluated using Mann–Whitney U-test. The statistician was blinded to the division of groups.


   Results Top


On comparison between different groups from baseline to 90 days in plaque and saliva, as shown in [Table 1] and [Table 2], it can be observed that there was no significant difference between the four groups at baseline (P = 0.992, P = 0.948). Interestingly, there was a highly significant difference between the groups at 30 days (P < 0.001), 60 days (P < 0.001), and 90 days (P < 0.001) intervals. Counts of S. mutans for F varnish group were the least when compared to the remaining groups after each of the time intervals.
Table 1: Comparison from baseline to 30, 60, and 90 days in plaque Streptococcus mutans count between different groups

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Table 2: Comparison from baseline to 30, 60 and 90 days in salivary Streptococcus mutans count between different groups

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F varnish, CHX varnish, and 10% PI showed a significantly improved efficacy when compared to the control during the 30, 60, and 90 days saliva sample estimation as shown in [Table 3]. CHX varnish and 10% PI showed no significant difference at all the time intervals. F varnish showed significantly lower counts when compared to CHX varnish after 60 and 90 days. In addition, F varnish showed significantly lower counts compared to 10% PI at all the time intervals.
Table 3: Multiple comparisons using Mann-Whitney U-test (saliva)

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In the intergroup comparison as shown in [Table 4], F varnish, CHX varnish, and 10% PI showed a significantly improved efficacy when compared to the control during the 30, 60, and 90 days plaque sample estimation. F varnish showed significantly lower counts when compared to CHX varnish at all the time intervals. In addition, F varnish showed significantly lower counts compared to 10% PI after 60 and 90 days. CHX varnish and 10% PI showed no significant difference at all the time intervals.
Table 4: Multiple comparisons using Mann-Whitney U-test (plaque)

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   Discussion Top


Dentistry has undergone transformation from the dental profession being once centered on restorative work, and extractions are now driven by way of prevention. Our goal today should be to preserve and promote dental health as dental caries continues to be one of the chronic debilitating diseases in children.

The remedy of ECC is especially targeted on preventing progress of lesions with the aid of restorations, diet counseling, educating parents regarding decay promoting feeding behaviors, maintain good oral hygiene, and the use of preventive agents such as topical fluorides.[6]

Enhanced outcomes can be achieved by way of recognizing the infectious nature of this disease and incorporating antimicrobial therapy as part of caries prevention and treatment. Topical antimicrobial agents that have been examined to suppress oral populations of S. mutans include antibiotics such as vancomycin, kanamycin, stannous fluoride, the bisbiguanides (CHX and alexidine), PI, and a combination of these agents.[7]

Tanzer et al. and Caufield and Wannemuehler observed that iodine has super penetrability into dental plaque and those characteristics make it an remarkable chemoprophylactic agent for oral use.[8],[9]

Topical application of iodine has shown to suppress oral populations of S. mutans for prolonged durations. This can be justified by the fact that demineralized enamel is more permeable to iodine which accounts for extended retention and antibacterial activity.

The oral milieu of children with ECC even after full mouth rehabilitation continues to be more favorable for the growth of pathogenic microorganism such as S. mutans and recurrence of lesions. In our study, we evaluated the topical impact of 10% PI on salivary count of cariogenic S. mutans for 30, 60, and 90 days on children with ECC after full mouth rehabilitation and observed that the use of 10% PI notably reduced the S. mutans in saliva for a duration of 30, 60, and 90 days. This is accordance with the results of Berkowitz et al. and Zhan et al.[6],[10]

CHX has been used effectively for the prevention of dental caries as it suppresses the growth of cariogenic S. mutans. It has the disadvantage such as staining of teeth and unpleasant taste which is overcome as it obtainable as in the varnish form. Cervitec, a varnish containing 1% CHX, and 1% thymol have the advantages that it is far retained on the tooth for an extended time; further, it can be applied on the interproximal and cervical areas and in fissures of teeth.[11]

A statistically significant reduction in salivary S. mutans counts following the application of CHX varnish, Cervitec Plus was observed after 30, 60, and 90 days from baseline. The findings of this study are in agreement with Petersson et al. and Attin et al., who found a reduction in salivary S. mutans for 3 months.[12],[13] In our study, CHX varnish, Cervitec Plus was applied twice in an interval of 1 week after full oral rehabilitation. This can be explained by the fact that prolonged suppression of S. mutans cannot be achieved by a one-time application of varnish and more frequent applications may be necessary to achieve the inhibitory effect.[14]

On comparison between different groups from baseline to 90 days in plaque and saliva, as shown in [Table 1] and [Table 2], it can be observed that there was no significant difference between the four groups at baseline (P = 0.992, P = 0.948). Interestingly, there was a highly significant difference between the groups at 30 days (P < 0.001), 60 days (P < 0.001), and 90 days (P < 0.001) intervals. Counts of S. mutans for F varnish were the least when compared to the remaining groups after each of the time intervals. This can be attributed to the fluoride deposited on the teeth by the F varnish which later leached out and resulted in an inhibitory effect on the plaque bacteria. Brown et al. in his study on the effect of fluoride on plaque streptococci showed that streptococci were eliminated in 10/30 patients whose plaque had 115 ppm fluoride.[15]

In our study, F varnish, CHX varnish, and 10% PI showed a significantly improved efficacy when compared to the control during the 30, 60, and 90 days saliva sample estimation as shown in [Table 3] (Mann–Whitney U-test, P < 0.001). CHX varnish and 10% PI showed no significant difference at all the time intervals. F varnish showed significantly lower counts when compared to CHX varnish after 60 and 90 days and also showed significantly lower counts compared to 10% PI at all the time intervals, thereby demonstrating that F varnish had more inhibitory effect on salivary S. mutans count.

F varnish, CHX varnish, and 10% PI showed a significantly improved efficacy when compared to the control during the 30, 60, and 90 days plaque sample estimation as shown in [Table 4] (Mann–Whitney U-test, P < 0.001). F varnish showed significantly lower counts when compared to CHX varnish at all the time intervals and also significantly lower counts compared to 10% PI after 60 and 90 days. The F varnish showed a significant reduction in plaque S. mutans compared to CHX varnish and 10% PI.

One limitation of this study was the short follow-up period of the study and also the S. mutans count was taken as the outcome measure instead of the decayed, missing, and filled surface/DMFT count. Although the S. mutans count is a reliable risk indicator for future caries activity, an increase or decrease of S. mutans count may or may not develop into an actual caries lesion.[16],[17]


   Summary and Conclusion Top


The following conclusions were derived from this study:

  • F varnish showed a statistically significant reduction of S. mutans count in plaque and saliva compared to the CHX varnish, 10% PI, and control group at 30, 60, and 90 days
  • F varnish, CHX varnish, and 10% PI showed a significantly improved efficacy compared to the control at 30, 60, and 90 days plaque S. mutans estimation
  • F varnish, CHX varnish, and 10% PI showed a significantly improved efficacy compared to the control at 30, 60, and 90 days salivary S. mutans estimation
  • F varnish showed significantly lower counts compared to CHX varnish after 60 and 90 days and significantly lower counts compared to 10% PI at all time intervals
  • There was no significant difference in the reduction of salivary and plaque S. mutans count in 10% PI and CHX varnish-treated groups
  • The use of chemotherapeutic agents have a significant role in reducing the salivary and plaque S. mutans count after full oral rehabilitation
  • The use of adjunctive chemotherapeutic agents for the preventing ECC and also relapse in children who have undergone full oral rehabilitation should be advocated. More extensive studies with a larger sample size, using newer agents, and over varying time periods should be carried out to find an effective agent to prevent a devastating disease like ECC and its recurrence.


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgments

We would like to thank Dr. Subbannaya K, Professor, Department of Microbiology; K.V.G. Medical College and Hospital for guiding and supporting us carry out this study. Our sincere thanks to Mr. Sripathi, Assistant Professor in Department of Pharmacy, Srinivas College, Mangalore, and Mr. Neeraj Pandey, Manager; KAN Health Care for helping us procure the materials for this study. We also thank the children and parents for their willingness to participate in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

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Foster T, Perinpanayagam H, Pfaffenbach A, Certo M. Recurrence of early childhood caries after comprehensive treatment with general anesthesia and follow-up. J Dent Child (Chic) 2006;73:25-30.  Back to cited text no. 1
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Peretz B, Ram D, Azo E, Efrat Y. Preschool caries as an indicator of future caries: A longitudinal study. Pediatr Dent 2003;25:114-8.  Back to cited text no. 2
    
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Tinanoff N, O'Sullivan DM. Early childhood caries: Overview and recent findings. Pediatr Dent 1997;19:12-6.  Back to cited text no. 3
    
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Jain M, Singla S, Bhushan B, Kumar S, Bhushan A. Esthetic rehabilitation of anterior primary teeth using polyethylene fiber with two different approaches. J Indian Soc Pedod Prev Dent 2011;29:327-32.  Back to cited text no. 4
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Jensen B, Bratthall D. A new method for the estimation of mutans streptococci in human saliva. J Dent Res 1989;68:468-71.  Back to cited text no. 5
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Berkowitz RJ, Koo H, McDermott MP, Whelehan MT, Ragusa P, Kopycka-Kedzierawski DT, et al. Adjunctive chemotherapeutic suppression of mutans streptococci in the setting of severe early childhood caries: An exploratory study. J Public Health Dent 2009;69:163-7.  Back to cited text no. 6
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DenBesten P, Berkowitz R. Early childhood caries: An overview with reference to our experience in California. J Calif Dent Assoc 2003;31:139-43.  Back to cited text no. 7
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Tanzer JM, Slee AM, Kamay B, Scheer ER.In vitro evaluation of three iodine-containing compounds as antiplaque agents. Antimicrob Agents Chemother 1977;12:107-13.  Back to cited text no. 8
    
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Caufield PW, Wannemuehler YM.In vitro susceptibility of Streptococcus mutans 6715 to iodine and sodium fluoride, singly and in combination, at various pH values. Antimicrob Agents Chemother 1982;22:115-9.  Back to cited text no. 9
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Zhan L, Featherstone JD, Gansky SA, Hoover CI, Fujino T, Berkowitz RJ, et al. Antibacterial treatment needed for severe early childhood caries. J Public Health Dent 2006;66:174-9.  Back to cited text no. 10
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Araujo AM, Naspitz GM, Chelotti A, Cai S. Effect of Cervitec on mutans streptococci in plaque and on caries formation on occlusal fissures of erupting permanent molars. Caries Res 2002;36:373-6.  Back to cited text no. 11
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Petersson LG, Maki Y, Twetman S, Edwardsson S. Mutans streptococci in saliva and interdental spaces after topical applications of an antibacterial varnish in schoolchildren. Oral Microbiol Immunol 1991;6:284-7.  Back to cited text no. 12
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Attin R, Tuna A, Attin T, Brunner E, Noack MJ. Efficacy of differently concentrated chlorhexidine varnishes in decreasing mutans streptococci and lactobacilli counts. Arch Oral Biol 2003;48:503-9.  Back to cited text no. 13
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Gerardu VA, Buijs MJ, ten Cate JM, van Loveren C. The effect of a single application of 40% chlorhexidine varnish on the numbers of salivary mutans streptococci and acidogenicity of dental plaque. Caries Res 2003;37:369-73.  Back to cited text no. 14
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Brown LR, White JO, Horton IM, Dreizen S, Streckfuss JL. Effect of continuous fluoride gel use on plaque fluoride retention and microbial activity. J Dent Res 1983;62:746-51.  Back to cited text no. 15
    
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Jeevarathan J, Deepti A, Muthu MS, Rathna Prabhu V, Chamundeeswari GS. Effect of fluoride varnish on Streptococcus mutans counts in plaque of caries-free children using Dentocult SM strip mutans test: A randomized controlled triple blind study. J Indian Soc Pedod Prev Dent 2007;25:157-63.  Back to cited text no. 16
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Ribeiro LG, Hashizume LN, Maltz M. The effect of different formulations of chlorhexidine in reducing levels of mutans streptococci in the oral cavity: A systematic review of the literature. J Dent 2007;35:359-70.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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