Аннотация и ключевые слова
Аннотация (русский):
Предмет. Представлен опыт проведения профессиональной гигиены полости рта у пациентов с хроническим пародонтитом в сочетании с медикаментозно ассоциированным остеонекрозом челюсти. Цель — выявить особенности состояния полости рта пациентов с хроническим пародонтитом и бисфосфонатным остеонекрозом челюстей (БОНЧ) на фоне послеоперационной химиотерапии после применения двух отечественных ополаскивателей для полости рта (ОПЛПР). Методология. Проведено клиническое обследование полости рта 15 пациентов в возрасте от 50 до 66 лет, которые были разделены на две группы: основную (после проведенной резекции сегментов челюстей) и группу сравнения (по 5 и 10 человек соответственно). Стоматологическое обследование включало осмотр полости рта: состояние тканей пародонта и слизистой оболочки, определение интенсивности кариеса зубов и индексов гигиены и кровоточивости. Проведены исследования смешанной слюны (СС) до и после однократного и курсового ежедневного использования двух отечественных ополаскивателей на основе хлоргексидина биглюконата и бензидамина и экстрактов лекарственных растений. Результаты. Показатель рН после курсового применения ОПЛПР-1 у пациентов с БОНЧ сместился со слабокислотной (6,45±0,4 ед.) до слабощелочной (7,15±0,15 ед.) среды. Структура СС до применения ОПЛПР-1 была представлена мелкими конгломератами неправильной формы и отдельными древовидными кристаллами малых размеров, а после двукратного применения ОПЛПР-1 свойства СС улучшились и появились древовидные кристаллы средних размеров. После курсового применения ОППЛР-2 у этих пациентов выявлены кристаллопризматические структуры древовидной формы, определена тенденция к восстановлению структурных свойств СС. Выводы. После курсового применения ОПЛПР выявлена тенденция к восстановлению структурных свойств СС. Курсовое использование ОППЛР способствует стимуляции выделения СС, очищению и появлению ощущения свежести во рту. Последовательное применение ОППЛР-1 и ОППЛР-2 помогает облегчить состояние пациентов, особенно на фоне БОНЧ и химиотерапии.

Ключевые слова:
ополаскиватель полости рта, микроорганизмы, челюсть, бисфосфонатный остеонекроз, профессиональная гигиена


Malformations in the body organs and tissues of the head and neck rank sixth in the global cancer incidence structure and are among the ten most common tumor locations, the share of head and neck cancer being 2,8 % [1, 2, 4, 11, 12, 14—20, 29]. Treatment of cancer patients has a comprehensive nature, which includes a surgical excision of the tumor; chemical and radiation therapy, as well as orthopedic rehabilitation. The incidence of complications and their severity depend on multiple factors related to both radiation therapy and individual patient’s features [1, 2, 4, 11, 12, 14—18, 30]. Currently, the international standard for the treatment of patients with bone metastases prescribes the use of bisphosphonates (BP), primarily in the form of monthly intravenous injections [13, 21—30]. However, a long-term BP use resulted in adverse events such as bisphosphonate-related osteonecrosis of the jaw (BRONJ) [13, 15—30]. Osteonecrosis of the jaw represents a severe complication which may occur against any dental intervention in patients receiving a BP therapy [11, 13—17, 21, 22, 25, 27, 29]. Clinical symptoms may manifest themselves prior to any development diagnosed BRONJ: pain, tooth mobility, collateral soft tissue edema, mucosal hyperemia, paresthesia [13—15]. Risk factors BRONJ - include malignant diseases, chemotherapy, concomitant oral cavity diseases [13—15]. Periodontitis therapy in such patients represents a critical and serious task complicated by a poor hygiene. All of the above mentioned phenomena in the oral cavity significantly complicate the orthopedic rehabilitation stage and require an increased attention from the orthopedic dentist, since the prosthesis (more often being a removable structure) is an additional irritation source and may cause pain and discomfort [12, 15].

Professional oral hygiene (POH) – is the initial stage of the comprehensive dental therapy in such patients which includes antiseptic treatment of the oral cavity and the use of liquid hygiene products [1, 3—5, 7—11, 13]. The dentist needs to know how to reduce the negative manifestations, taking into account the characteristic changes in the organs and tissues of the oral cavity in case of BONJ and chronic periodontitis [1, 4, 5, 11—13].

Traditional prescriptions include solutions of antiseptic oral cavity rinses (OCR), which represent a mixture of active components, water, and flavoring agents. Therapeutic and prophylactic agents have an anti-inflammatory, hemostatic and cleansing action and are easy to use [1, 4, 11, 13]. The professional interest lies in determining the efficiency of oral rinses in part of changes in the mixed saliva (MS) parameters in patients with BONJ and chronic periodontitis.

Оbjective — identify the distinguishing features of the oral cavity condition in patients with a chronic periodontitis and against the postoperative chemotherapy after the use of two domestic oral rinses, OR-1: therapeutic – based on the chlorhexidine bigluconate – and the prophylactic OR-2 – based on the medicinal herb extracts. Evaluate the change in the hydrogen ion concentration and MS mineralizing ability after a course of the sequential use of these OCR

Materials and methods of research

The work has been performed at the Ural State Medical University, at the departments of therapeutic dentistry and dental diseases propedeutics; orthopaedic dentistry and general dentistry; as well as at the department of general chemistry. Fifteen patients in the age between 50 and 66 were examined in the outpatient settings: main group (1) - five patients after a previous jaw segments resection and a comparison group (2) — 10 patients. The patients from the main group underwent courses of chemotherapy at the radiological department of the State Budget-Financed Healthcare Institution of Sverdlovsk region “Sverdlovsk Regional Oncology Center”. The average disease duration was between 1 and 3 years [4—6].

The clinical dental examination included the collection and analysis of the medical history and patients’ complaints, oral cavity examination: dental caries intensity, condition of the periodontal tissues and oral mucosa; hygiene index by Greene-Vermillion (HI), sulcus bleeding index (SBI) (Muhlemann H.R., S. Son, 1975). For the characterization of periodontal tissues inflammation extent, the CPI index was used; condition of the salivary glands (sialometry), dental examination records were filled in [1, 4, 5, 11, 13]. Unstimulated MS served as the study material [4—6].

Qualitative MS analysis has also been performed using the following parameters: transparency parameters, color, viscosity, inclusions, acid-base equilibrium index (рН); microcrystalline MS parameters before and after the course (7 days) of regular use of the two OCR (as per the instructions). The MS viscosity has been determined using a pipette, slide glass, metal spatula, and ruler according to the previously described method, taking into account that normally MS stretches by no more than 5 mm [4, 5, 8, 11].

The pH of mixed saliva was measured using multi-purpose indicator test strips «Spesial Test Paper» (pH 4.5—9.0). The test strip was immersed into the “saliva lake” in the sublingual region for 3 seconds. The obtained result was compared with the control color scale. Normally, the pH of the MS is 6,4—7,8 ед. [4, 6, 8, 11].

MS was collected using sterile forceps and a slide glass. Ten minutes prior to the collection of the MS, the patient being examined rinsed the oral cavity with distilled water. Then, the MS was collected from the bottom of the mouth with forceps and distributed over the slide (diametr 10 мм). Further, the patient rinsed the mouth with the OCR, and the MS was collected after a single use and in 7 days of the regular use OCR [1, 3, 4, 5, 7—11]. The slides were dried at the same temperature (23-25 °C) and relative air humidity 58–60 % in the horizontal position on the free-form surface until they were completely dried. In 24 hours, the microscope (MBS-type binocular microscope “MS20” at a low power 7х8 in the reflected light examined the dried drops. The analysis of the MS samples structure and evaluation of the results were performed using 5 microcrystallization types - MCS [1, 4, 5, 11, 13].

Two domestic samples were selected for the study purposes. OCR -1 was based on two components – 0.15 % benzidamine hydrochloride solution (expressed anti-inflammatory and analgesic action) and 0.05 % chlorhexidine bigluconate solution (antimicrobial effect) [1, 7—11, 13]. OCR -1 was used for 7 days. Then, OCR -2, containing sage, chamomile, and witch hazel extracts (antimicrobial, anti-inflammatory action), potassium citrate, and xylitol was used (contributes to minimizing the tooth hypersensitivity), potassium and sodium pyrophosphates (prevents the tartar formation), lime and mint (deodorizing effect). OCR -2 is suitable for a regular daily use during two-three months (as per the instruction).

The buffer capacity of the MS [6] and each OCR were measured – preliminarily determined pH, then  to 10.0 mL of the OCR was added 1.0 mL of 0.01 n HCl, and pH was measured again [4—6, 9].

Statistical processing of the study results was performed using the Student’s t-distribution with a level of reliability p≤0,05 [1, 6].

Results and Discussion

The initial examination of the oral cavity in all patients after the jaw fragments resection revealed postoperative defects, scars, partial loss, and generalized increased dental abrasion, diagnosed periodontitis with a moderate severity, and initial xerostomia stage. Hard dental deposits (dark gray, dense, accumulated in moderate amounts, mainly on the contact and lingual surfaces of the lower incisors) were observed. The mucosa of the lips, cheeks, hard and soft palate, tongue, bottom of the mouth were pale pink, attenuated, with maceration foci (pic.1).


                                        a                                                                  b

Pic.1. Patient A. 66 age with a medication-associated osteonecrosis of the upper jaw left:

а — computed tomography; b — clinical view

Рис.1. Пациентка А. 66 лет с медикаментозно ассоциированным остеонекрозом верхней челюсти слева:

а — компьютерная томограмма; б — клиническая картина

After rinsing of the oral cavity with OСR-1 (with a low buffer capacity), all patients noted a slight increase in the MS secretion and a sensation of freshness in the oral cavity. The examination of the patients’ MS in the 1st group revealed that prior to the first use of ОСR-1, the рН values were 6,45±0,4 (weak acid medium), after the first use - 6,85±0,10 (neutral medium), and after a course of use of ОСR-1, the рН value shifted to the weakly alkaline side — 7,15 ±0,15.

In patients of group 2, the use of OCR-1 causes a shift in the pH≥7,0. Prior to the first use of OCR-1 in 80 % of patients in this group, the pH values ​​were 6.75± 0.10; after the use of OCR-1 in 80 % — from 7.03 up to 7.35, in 20 % of patients — 7.4 ± 0.10.

Qualitative MS analysis: colorless, no impurities, viscosity before and after the first use of OСR-1 was slightly increased (length of “threads” was more than 6 mm).

Evaluation of the MS structure: prior to the use of OСR-1 in patients of group 1, small conglomerates with an irregular shape and individual small “tree-like” crystals were found in the crystallization centers (4 type MCS MS; rate 1,35±0,4),on the MS drop periphery crystals were completely absent (5 type MCS MS; rate 0,5±0) (pic.2a).

After the two sessions of ОСR-1, in course of the professional hygiene of the oral cavity, the MS properties slightly improved, and medium-sized tree-like crystals appeared (3 type MCS MS; rate 2,1±0,55) (pic.2b). After three chemotherapy sessions, the crystallographic MS properties were impaired (5 type MCS MS; rate 0,25±0,05) (pic.2c).

After a course use of ОCR-2 in patients of the 1st group, tree-like crystal prismatic structures were found, a tendency to the recovery of the structural MS properties was determined. (3 type MCS MS; rate 2,75±0,75) (pic. 2d).


Pic. 2. Patient A. 66 age, change structural MS properties:

a — before use OCR (5 type MCS MS); b — after two use OCR-1; c — after three chemotherapy sessions; d — after use OCR-2

Рис. 2. Пациентка А. 66 лет, изменение структурных свойств СС:

а — до использования ополаскивателя (5 тип МКС СС); b — после двукратного применения ОПЛПР-1; c — по завершении 3-х сеансов химиотерапии; d — после применения ОППЛР-2

The same trend was revealed in patients of the 2nd group, however, their indices are higher: 30 % patients — 3 type MCS MS, rate 2,75±0,75; 70 % patients — 2-3 type MCS MS, rate 3,5±0,25.

The crystallography results showed that prior to the use of OCR in patients of the 1st group, small-sized crystals were found (4 type MCS MS, average rate 1,35±0,4). After the double use of OCR-1, middle-sized crystals were determined (3 type MCS MS, average rate increased to 2,1±0,65). After three chemotherapy sessions, the parameters worsened (5 type MCS MS; rate 0,5±0,15). After the course use of ОСR-2, an initial recovery of the structural MS properties was found (3 type MCS MS; rate 2,75±0,75).

Examination of the physical and chemical properties of the OCR showed that OCR-2 has the greatest buffer capacity by the acid. This OCR is composed of tetrapotassium pyrophosphate (К4P2O7) and acid salt of disodium pyrophosphate (Na2H2P2O7), which may form the buffer system, capable of maintaining a certain рН level. These compounds regulate the рН parameter and even slow down the tartar formation. OCR-1 has a significantly lower buffer action. Both OCR have a weak acid medium and рН value, corresponding to the GOST (Russian national standard) requirements. The use of OCR with a low buffer capacity expressly induces shifting of the рН≥7,0. The use of OCR-2 with a high buffer capacity support рН MS in physiological limits 7,0±0,5.


1. The course use of ОCR to a certain extent promotes MS excretion, cleaning of the oral cavity, and a sensation of freshness in the mouth. It is reasonable for patients from both groups, especially with a chronic periodontitis and xerostomia against BPON.

2. The use of the two ОCR improves the acid-base balance value: supports рН of the MS in the normal condition, promotes a higher mineralizing activity and increases the MS buffer capacity by acid to a greater extent as compared to the separate use thereof.

3. Sequential use of ОCR-1 and ОCR-2 helps alleviating the patients’ condition, especially against BONJ and chemotherapy. It is confirmed by clinical manifestations and expressed tendency to the recovery of the structural MS properties.

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