Congrès IAHD 2000

Evolution of local chemical therapies in buccal diseases treatment

Eduardo SABA-CHUJFI, D.D.S., MSc. D., Ph. D.
Professor and Chairman, Periodontology Department, Faculty of Dentistry, University Camilo Castelo Branco, São Paulo, Brazil.
Silvio Antonio DOS SANTOS PEREIRA, D.D.S., MSc. D.
Assistant Professor, Periodontology Department, Faculty of Dentistry, University Camilo Castelo Branco, São Paulo, Brazil. e-mail :


PREHISTORY (… - 2,000 B.C.)

Although the Prehistory is considered the period that precedes the appearance of the writing (2.000 B.C.), we observed that the descriptions didn't leave any evidence or track that the prehistoric man was aware and concerned about the oral hygiene cares and current alterations of the periodontal diseases.

ANTIQUITY (2,000 B.C. – 476 A.C.)

The search for the cure of some clinical signs of the periodontal diseases, as inflammation in periodontal tissues, tooth mobility and calculus, appeared with the human instinctive reactions to minimize or to eliminate these aspects. The therapies begin based in the experimentation of substances and mixtures of elements provided from the animal, vegetable and mineral realm.

According to Merritt (1930), among the writings of the Chinese, some of which date back more than 2,000 years B.C., frequent mentions are made regarding teeth and gum diseases. Among the several remedies advocated for the treatment of those cases in which "the teeth often fall out and the breath becomes fetid" we found out "the urine* of a child used as a mouthwash" (MERRITT,A.H. Periodontal diseases. New York: Macmillan; 1930: p.1-17).

* antiseptic action

According to HOFFMANN-AXTHELM(1981), in 1937, Ebers, studying the Egyptian codices in papyrus leaf (1550 B.C.), found several formulations to buccal hygiene and among them a mixture of small particles of triturated stones*, ocher* and honey**, that should be put on the teeth and rubbed with the fingers (HOFFMANN-AXTHELM,W. History of dentistry. Chicago: Quintessence Publishing Co., Inc.; 1981:435).

* stones and ocher - abrasive action

** honey – emollient, refreshing and tonic

According to Morris Jastrow (1914), our knowledge about the Babylonians and Assyrians and their medicine is derived, almost exclusively, of the existent clay plates from the king's Ashurbanipal of Assyria Palace (Asia, in current Iraq), who ruled from 668 - 626 B.C., and which was discovered by Austen Henry Layard in 1849. The Babylonians and Assyrians extolled several prescriptions for gingival tissues inflammation, swelling and ulcerations in alveolar mucosa. We can mention, for example, several plants as an onion* variety, mixed with oil and placed on mouth or turnip** seeds for swollen cheek (JASTROW,M. The medicine of the babylonians and assyrians. Proc Soc Med 1914; 7:109-76).

* Allium cepa – antiinflammatory and hemostatic action

** Brassica napus - antiinflammatory properties

According to SMITH (1958), Hippocrates (460 B.C.) in his second book gave some prescriptions against bad breath as follow: when a woman's mouth presents unpleasant breath, and her gums are unhealthy, you had to burn, separately, one hare head* and three mice head*. After that reduce a piece of marble* into small particles and mix these ingredients in equal portions. This mixture should be placed over the teeth and gums surfaces, rubbed with a cotton-wool against them, and afterwards rinse the mouth with water. Soak the dirty cotton-wool in honey** and rub the teeth and gums again. Mix anis*** seed with myrrh# and immerse these compound in pure white wine##. The mouth is then rinsed for a period of time. The prescription described, besides promoting dental cleaning, has the capacity of providing a very pleasant breath (SMITH,M. A short history of dentistry. London: Allan Wingate Ltd.; 1958: p.7-28).

* ash and marble - abrasive action

** honey – emollient, refreshing and tonic

*** Pimpinella anisum – refreshing, antiseptic, tonic, and freshening of breath

# Commiphora abissinica – stimulant and freshening of breath

## wine – bactericidal (alcohol)

In 300 B.C., Carystos, mentioned by HOFFMANN-AXTHELM(1981), emphasized a previous water mouthwash before a mint* juice massage made with the fingers. According to the author, it was made to improve the buccal hygiene (HOFFMANN-AXTHELM,W. History of dentistry. Chicago: Quintessence Publishing Co., Inc.; 1981:435p).

* Mentha piperita – tonic / antiseptic properties

According to FOSTER(1879), Aulus Cornelius Celsus, in 38 A.D., recommended to chew pears and apples not very ripe*, and to keep their juice in the mouth. It was recommended for periodontal diseases (FOSTER,E.W. Celsus concerning the teeth. Dent. Cosmos 1879; 21: 235-41).

* astringent action

Between 79 and 23 B.C., Caius Plinius Secundus, according to MERRITT(1930), recommended as a good tooth-cleaning the use of a goat feet ashes compound*. Another tooth-cleaning agent was prepared with feces from a sheep tail rolled up in little balls*. It was dried, reduced into powder and rubbed against the teeth. It was widely useful against the loosening teeth (MERRITT,A.H. Periodontal diseases. New York: Macmillan; 1930: p.1-17).

* abrasive action

According to LINDSAY(1933) the Japanese recommended to rub the gum with the fingers and mouthwash with child's urine* for gum diseases (LINDSAY,L. Short history of dentistry. London: John Bale, Sons and Danielson, Ltd.; 1933: p.7-93).

* urine - antiseptic action

In 1940, Gall, according to HOFFMANN-AXTHELM (1981), researching the medicine of the Aztec people, verified that they recommended for a good buccal hygiene the use of mouthwashes with cold water or children's urine* associated to cloth polishing with pieces of coal** and salt***(HOFFMANN-AXTHELM,W. History of dentistry. Chicago: Quintessence Publishing Co., Inc.; 1981: 435p).

* urine – antiseptic action

** coal - to absorb toxins, to reduce the hyperacidity and abrasive action

*** salt – abrasive action

SMITH(1958), affirmed that Galen (A.D. 130 - 200) used to combat periodontal tissues inflammation recommending to keep in the mouth lentil* oil, moderately warm, or hyoscyamus** roots boiled in vinegar. It would also be beneficial to cover the inflamed gums with a powder prepared with 1 part of salt*** and 4 parts of alum#, followed by a wine## mouthwash (SMITH,M. A short history of dentistry. London: Allan Wingate Ltd.; 1958: p.7-28).

* Ervum lens – antiinflammatory property

** Hyoscyamus niger – analgesic and sedative properties and vinegar – astringent action

*** salt – abrasive action

# alum – stone ume – astringent action

## wine – bactericidal (alcohol)

MIDDLE AGE (A.D. 476 – 1453)

Between 860 - 930 A.D., Rhazis, a doctor, alchemist and Persian philosopher of Muslim religion, mentioned by HOFFMANN-AXTHELM (1981), exercised the Medicine in Baghdad (Iraq). For a good buccal hygiene, he emphasized the use of small branches of "miswak" and a tooth-cleaning preparation containing a mixture of deer horn ashes*, lentil**, salt*, alum***, myrrh# and honey## (HOFFMANN-AXTHELM,W. History of dentistry. Chicago: Quintessence Publishing Co., Inc.; 1981: 435p).

* deer horn ashes and salt – abrasive action

** Ervum lens – antiinflammatory properties

*** alum – stone ume – astringent action

# C. abissinica – stimulant and freshening of breath

## honey – emollient, refreshing and tonic

According to SMITH (1958), between 980 - 1037 A.D., Avicenna, a Persian, pointed out that dental calculus could be removed using a tooth-cleaning preparation containing: meerschaum*, salt*, burnt shells of snails* and oysters*, ammoniac**, gypsum* and verdigris*** with honey#. He affirmed, also, that very hard tooth powders could damage the teeth surface, and must be avoided (SMITH,M. A short history of dentistry. London: Allan Wingate Ltd.; 1958: p.7-28).

* meerschaum, salt, burnt shells of snails and oysters, and gypsum – abrasive action

** ammoniac – detergent

***verdigris – astringent and caustic action

# honey – emollient, refreshing and tonic

MODERN AGE (1453 – 1789)

According to SMITH (1958), in 1458, Giovanni of Arcoli, a teacher from Bologna, Italy, recommended a tooth-cleaning preparation composed by a mixture of honey* and sugar**, or burnt salt** and honey* and an equal amount of razel-nut#. This preparation was used by rubbing it against the tooth and gums with a cotton-wool (SMITH,M. A short history of dentistry. London: Allan Wingate Ltd.; 1958: p.7-28).

* honey – emollient, refreshing and tonic

** sugar and salt – abrasive action

# Corylus avellana – detergent and depurative

In 1558, the word "dentifrice" came into the English language for the first time (Fischmann SL, Hare’s teeth to fluorides, historical aspects of dentifrice use. In: Embery G; Rolla G, Clinical and Biological Aspects of Dentifrices. Oxford Medical Publications; 1992: p1-8).

According to Ring (1961), in the Columbian Magazine of 1789 the following news item appeared: "A newly discovered remedy for the scurvy of the gums. Take a half pint of red sage* tea, add a piece of alum** - the size of a large nutmeg, and a table spoonful of honey***and ammoniac#; the same of vinegar. Set it on a slow fire, until the allum is dissolved. This was used to wash the mouth often. If the person is loosing the teeth add more honey***, vinegar###, alum** and port wine## (RING,M.E. History of dental prophylaxis. J. Amer dent Ass, 1961; 75: 892-5).

*Salvia officinalis - tonic, astringent and hemostatic action, freshening of breath

** alum – stone ume – astringent action

*** honey – emollient, refreshing and tonic

# ammoniac – detergent

## port wine - bactericidal (alcohol)

### vinegar - astringent action


According to BIER (1981), the Antiseptic Era was inaugurated by Joseph Lister in 1867, when he published the paper: "On the Antiseptic Principle of the Practice of Surgery" where he used as a disinfecting solution the fenilic acid. At that time, a fenilic acid steam was sprayed over the surgical field, the surgeon’s hand were involved in the same solution, and any object passed by the assistant as well (BIER, O. Bacteriologia e imunologia em suas aplicações à medicina e à higiene. São Paulo: Melhoramentos; 1981: p.1-7a).

According to BURNETT et al. (1978), Miller is considered the father of the oral microbiology. Author of the Chemical-parasitic Theory of dental decay, he was one of the first to apply the basic sciences in order to heal oral diseased. As a researcher, Dr. Miller wrote the first text book on oral microbiology, published in Germany, in 1889, and in the United States, in 1890, titled "The Microorganisms of the Human Mouth" (BURNETT,G.W.; SCHERP,H.W.; SCHUSTER,G.S. Microbiologia oral & doenças infecciosas. Trad. por José Carlos Borges Teles. Rio de Janeiro: Guanabara Koogan; 1978: 756p).

To Antony J. Preston, (Dent Update 1998; 25: 247-253) dentifrices which contain active components became known as "therapeutic" dentifrices. The first symposium to evaluate therapeutic dentifrices was held by the American Dental Association (ADA) in 1953. Several components were considered, including ingredients which were purported to be bactericidal, bacteriostatic, enzyme-inhibiting or acid-neutralizing.

Through studies on the microbiology of the bacterial plaque, DAWES et al, in 1963, affirmed that several strains of bacteria have potential to develop itself in a short period of time and in the absence of an appropriate control of bacterial plaque, demonstrating the importance of the buccal hygiene, emphasized in all of the humanity's history. Only with the studies of LÖE et al (1965) and THEILADE et al (1966) it was demonstrated the direct relationship between bacteria and inflammatory tissue response in periodontal tissues, with the development of clinical signs that were denominated gingivitis (DAWES,C.; JENKINS,G.N.; TONGE,C.H. The nomenclature of the integuments of the enamel surface of teeth. Br dent J 1963; 16: 65-8; LÖE,H.; THEILADE,E.; JENSEN,B. Experimental gingivitis in man. J. Periodontol 1965; 36: 177-87; THEILADE,E.; WRIGHT,W.H.; JENSEN,S.B.; LÖE,H. Experimental gingivitis in man. II. A longitudinal clinical and bacteriological investigation. J periodont Res 1966; 1: 1-13).

According to JEFFCOAT, MK et al (1997) in the late 1960s, periodontal investigators began to identify several antimicrobial agents such as antiseptics that were, in general, excellent candidates for suppressing a broad range of the oral microbial flora. These agents included triclosan, chlorhexidine, sanguinarine, metal salts, enzymes, and phenolic compounds (JEFFCOAT, MK; McGUIRE, M.; NEWMAN, MG JADA; 1997; 128: 713-724).

The concept of treating periodontitis as a bacterial infection became of interest in the early 1970s in part due to the substantial body of data indicating that periodontitis is caused by a few specific pathogens (ELLEN, RP; McCULLOCH, CAG Periodontol 2000, 1996; 10: 29-44).

To GOODSON et al. (1991), in the late 1970s, the concept of delivering antibiotics locally to the periodontal pocket was introduced. Investigators hypothesized that it should be possible to deliver a dose of an antibiotic directly to the infected site that would virtually sterilize the pocket and eliminate those bacteria that were periodontal pathogens (GOODSON, JM; CUGINI, MA; KENT, R et al. J Periodontol Res 1991; 10, 29-44).

According to VAN WINKELHOLFF et al (1996), in the 1980s and 1990s, a number of reports suggested that agents such as tetracycline, metronidazole, doxycycline, amoxicillin, and amoxicillin plus metronidazole or clindamycim could be beneficial in the treatment of chronic and aggressive periodontitis (VAN WINKELHOLFF, AJ; RAMOS, TE; SLOTS J Periodontol 2000; 1996: 10, 45-78).

Antimicrobial agents, delivered by mouthrinse, gels or toothpaste, can be used to maintain bacterial plaque at levels compatible with oral health by reducing existing plaque, preventing the formation of new plaque, selectively inhibiting those particular bacteria that are associated with disease, and inhibiting the expression of virulence determinants (MARSH, PD J Dent Res 1992: 71: 1431-1438).

A typical dentifrice contains: an active component, abrasives, detergents, binding agents, humectants, preservatives, flavouring and sweetening agents (PRESTON, A.J. Dent Update 1998; 25: 247-253).

Mouthrinses are the simplest vehicles for antiplaque agents, where the most used is a water-alcohol mixture to which flavor, non-ionic surfactant and humectant are added to improve its cosmetic properties (PADER, M., Oral Hygiene Products and Practice. New York: Dekker, 1988: 9-20).

According to JEFFCOAT et al (1997) in recent years, there has been considerable interest in the application of antimicrobial agents directly in the periodontal pocket, thereby eliminating or reducing many of the adverse side-effects associated with systemic antibiotics (JEFFCOAT, MK; McGUIRE, M.; NEWMAN, MG JADA; 1997; 128: 713-724).

"Neither the nature nor the history can tell us what we should do. The facts, been of the nature or history, can not decide or determinate the ways we should take. We give purpose and sense to the nature and the history by ourselves." (POPPER, 19



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