Oral Hygiene and Mouthwashes

Oral Hygiene and Mouthwashes

Overview

The primary objective of this presentation is to educate the audience on the appropriate use of mouthwash and its limited role in plaque control. By the end of the presentation, attendees should be able to give advice to patients regarding mouthwash usage, emphasizing that it should complement rather than replace mechanical cleaning methods, noting specific instances where mouthwashes may be indicated.

Objectives

• Learn to give appropriate advice regarding mouthwash use, especially highlighting its limitations in plaque control through mechanical cleaning methods, but also recognizing specific indications.

Key Points

Role of Mouthwash

• Adjunctive Use: Mouthwashes are designed to be adjuncts to mechanical cleaning methods, meaning they aid but do not replace effective self-performed plaque removal. This secondary role needs to be emphasized to patients.

• Use in Inadequate Cleaning: They may be beneficial in situations with persistent inadequate mechanical cleaning, though this is not ideal.

• Cosmetic Use: Regular usage can also serve cosmetic purposes, such as providing fresher breath. However, their use needs to be targeted so that it doesn't interfere with the other mechanical methods of cleaning.

• Limited Effectiveness: Specialized products, such as those purporting to be whitening, are often unlikely to be effective.

Mouthwash Varieties

Patients encounter a bewildering array of mouthwash products. It is important to understand their ingredients and purported achievements.

• Colgate Peroxyl: £4.99

• Corsodyl: Ranges from £4.95 to £5.99

• Listerine (various types): Typically priced around £2.99 to £5.99 depending on the variant.

  • Various mouthwashes priced at £3.49 to £13.99 depending on special features like whitening effects or added alcohol.

Ingredients of Mouthwash

Basic Ingredients

• Water: Primary solvent in mouthwash.

• Alcohol: Serves as a carrier for active ingredients; found in some formulations. Many alcohol-free formulations are now available for both health and religious reasons. There is some data suggesting alcohol-free versions may have a reduced effectiveness, particularly for essential oil mouthwashes, due to the interaction with alcohol in helping other ingredients. Conversely, concerns have been raised about alcohol-containing mouthwashes increasing the risk of oral cancer. While evidence is conflicting, current evidence suggests that patients who use mouthwash at least 3 times a day and swirl it for an extensive period may be at a slightly increased risk. Most patients are unlikely to fall into this category. If patients do use it that frequently, it suggests inappropriate use, and advice should be given, perhaps recommending an alcohol-free version.

• Sweeteners: Including sorbitol, sucralose, and sodium saccharin to improve taste.

• Preservatives: Such as sodium benzoate and benzoic acid to maintain shelf life.

• Surfactants: Like Sodium Lauryl Sulfate (SLS) to aid in spreading the solution.

• Colourings: Synthetic dyes may be used for aesthetic purposes.

Active Ingredients in Mouthwash

Antiplaque Agents

• Most antiplaque agents are antimicrobial, hindering bacterial proliferation, stopping bacterial plaque from forming, or simply retarding its effect.

• Antiadhesive Agents: Ideally, a product would completely hinder the formation of a pathogenic or dysbiotic biofilm and prevent its reformation. However, such mouthwash agents are not widely available or safe for oral use, as those with properties close to achieving this either have intolerable side effects (e.g., very strong or bitter taste) or safety issues. Therefore, the mechanical removal of plaque via tooth brushing and effective interdental cleaning (with interdental brushes or floss) is the most important method for disrupting biofilm.

Specific Active Ingredients

• Chlorhexidine:

  • A cationic bisbiguanide, dicationic molecule with a strong affinity to skin and mucous membranes. It is used as a general disinfectant on the skin and in the mouth preoperatively, prior to its use as a mouthwash for many years.

  • Because of its binding property, one end of the molecule binds to skin or mucous membranes, leaving the other end free to bind to microbes. This leads to antimicrobial activity against a broad range of microorganisms including gram-positive and gram-negative bacteria, yeasts, dermatophytes, and some lipophilic viruses.

  • Acts bacteriostatic at low concentrations (hindering proliferation without killing) and bactericidal at higher concentrations (causing lysis) by disrupting the integrity of bacterial cell membranes.

  • The molecule itself, when absorbed into the mouth, attaches onto the tooth surface and the soft tissue surfaces (substantivity). It stays there and is able to bind onto any bacteria, disrupting them and preventing plaque formation from occurring. After a single rinse, it remains in the saliva and on soft tissues, maintaining its bactericidal activity for up to 5 hours, and a bacteriostatic effect for even longer, such as half a day, enabling long-term reduction of bacterial load.

• Essential Oils: Found in products like Listerine, composed of eucalyptol, menthol, thymol, and methyl salicylate, effective against numerous anaerobic bacteria. These have been heavily studied and shown to reduce bacterial numbers, with a persistent effect, but not to the magnitude exhibited by chlorhexidine.

• Cetylpyridinium Chloride (CPC): Quaternary ammonium compound present in several formulations, effective but less substantive than chlorhexidine. Most other major brands will have CPC as the antibacterial compound; however, these are even less effective in terms of being maintained in the mouth, and therefore, their use needs to be more frequent to reduce plaque formation and aggregation.

• Hydrogen Peroxide (Peroxyl 1.5%): Has a foaming action and can be useful for necrotizing conditions where there is rapid infection of periodontal tissue. Because of the ingress of anaerobic bacteria within the tissue itself, hydrogen peroxide is thought to be helpful in these relatively rare occurrences.

Effectiveness of Chemical Agents

• Substantivity is crucial for the effectiveness of mouthwashes, with some providing preventive rather than therapeutic action. Regular use is needed otherwise for antiplaque formation effects to be noticeable.

• However, none of the mouthwashes available can actually remove plaque actively; they are more of a preventative nature. If an established biofilm is in the mouth, mouthwash cannot compensate for poor mechanical removal. If a patient is not brushing their teeth correctly and removing plaque effectively, the mouthwash will not remove the plaque left behind, though it may slightly slow down further formation.

Comparison: Chlorhexidine vs Other Mouthwashes

• Chlorhexidine's mechanism allows it to persistently bind to oral surfaces (substantivity), providing prolonged antimicrobial action against bacteria, unlike non-chlorhexidine alternatives which do not adhere well. Once non-CHX agents are expectorated, their effects are relatively short-lived. The inherent nature of the chlorhexidine molecule gives it an advantage in terms of being persistent in the oral region to interact with bacteria and hinder plaque formation.

• Although 0.2% chlorhexidine-containing mouthwashes have a strongly beneficial effect in the short term for preventing plaque accumulation, this is not sustainable over the long term due to their side effects. If used on a long-term basis, the beneficial effects tend to equalize with essential oil-containing mouthwashes.

Management of Dental Conditions

Guidelines for Gingival Inflammation

Per BSP S3 guidelines, based on Figuero et al Sys RV JCP (2019):

• Adjunctive antiseptics, particularly chlorhexidine mouth rinses, are recommended for limited periods (usually up to two weeks maximum) in conjunction with mechanical debridement for periodontitis treatment. This advice reiterates the importance of self-performed mechanical biofilm removal. Mouthwashes can be used as part of a personalized, patient-centered treatment approach, taking into account all relevant patient factors.

Clinical Use of Chlorhexidine

• Chlorhexidine Concentrations: Available concentrations in the UK include 0.2% and 0.06%.

  • The 0.06% formulation is alcohol-free and suitable for daily use, designed to reduce plaque buildup.

  • The 0.2% formulation is for short-term use in specific clinical scenarios, such as post-surgery. It may also be used as a short-term substitute (not ideal and relatively rare) when professional mechanical plaque removal has made effective mechanical cleaning uncomfortable for the patient.

Patient Considerations for Mouthwash Use

BSP S3 Guidelines

• Before introducing chlorhexidine, optimize mechanical plaque control and consider:

  • Patient's medical status.

  • Discomfort during mechanical cleaning.

  • Potential adverse effects:

    • Staining: Due to its substantivity and binding to chromogenic substances in the diet (e.g., tea, coffee), noticeable staining of the teeth is common, even with relatively short-term use.

    • Taste Changes: It has a fairly unpleasant taste, particularly the 0.2% concentration, and can cause taste disturbance, making eating and drinking unpleasant, as well as a burning mouth sensation.

    • Oral Tissue Reactions: Can cause peeling of the oral epithelium, tingling effects, and some reactions around the mouth, though these are fortunately relatively rare.

    • Compromised Patients: In head and neck cancer patients who have undergone radiotherapy and have reduced salivary flow, chlorhexidine can react adversely with the dry soft tissues, potentially causing more discomfort, which needs to be balanced.

    • Rare Occurrences: Patients may rarely experience swelling of the parotid glands. These are important to advise patients of prior to use, as regular use is generally precluded.

    • Allergy & Anaphylaxis: Very rare but severe instances of allergy to chlorhexidine, including anaphylaxis and associated fatalities, have occurred. Dental professionals should be aware of this and inform patients.

    • Calculus Formation: With prolonged use, once staining manifests, enhanced supragingival calculus formation (tacky and difficult to remove professionally or by the patient) can occur, making its use counterproductive.

  • Cost and patient acceptability.

  • Duration of usage usually recommended for 1-2 weeks.

Supportive Periodontal Care

• In certain cases, adjunctive antiseptics may help manage gingival inflammation in supportive periodontal care scenarios. There is no cure for periodontitis, which is a chronic condition with a risk of recurrence; supportive periodontal care aims to reduce this risk. The potential role of mouthwashes here is adjunctive and secondary to effective self-performed mechanical plaque removal, similar to specific instances during the active phase of treatment.

• Factors to consider for patients receiving supportive periodontal care where mouthwash might be beneficial include their capability and capacity for effective oral hygiene at that time point.

• Tooth brushing with fluoride toothpaste is essential for all patients, with personalized approaches for those struggling with biofilm control. However, mechanical plaque removal should do most of the work in preventing disease progression in successfully treated patients; chemical agents may be indicated when this is not possible.

Selection of Mouthwash

Key factors in selecting a specific toothpaste or mouthwash include:

• Cost and taste preferences of patients.

• Unwanted effects such as staining or burning sensations. Alcohol-free versions may mitigate oral cancer risk concerns associated with excessive use of alcoholic mouthwash.

• Consideration of the impacts on the oral microbiome: Previously considered relatively risk-free, increased knowledge of the oral microbiome's role in health suggests potential adverse effects from indiscriminately disrupting the biofilm. Mouthwashes are not specific in nature and can disrupt beneficial commensal microbes.

• Particularly on the nitric oxide pathway and potential effects on blood pressure (a noted trend of a slight increase from 103 mmHg to 106 mmHg in a short-term study). The disruption of nitrate-producing bacteria, important in this pathway, by regular mouthwash use may interfere with blood pressure regulation.

Fluoride Mouthwash Recommendations

• It is notable that in the NHS England document, "Delivering Better Oral Health," none of the antiseptic or antiplaque mouthwashes are mentioned. The only mouthwash explicitly recommended is fluoride mouthwash for caries prevention, enhancing the efficacy of fluoride toothpaste, as it helps re-mineralization.

• Recommended for patients over 8 years of age with higher caries risk.

• Dosage: 10ml for 1 minute, used at a different time from brushing (e.g., lunchtime) to avoid interfering with the higher concentration of fluoride from toothpaste and washing it out.

Ideally, fluoride mouthwash should be prescribed or advised by a dentist specifically.

Summary of Findings

• Mouthwashes should not replace mechanical cleaning but can provide adjunctive benefits. It is crucial to emphasize to patients that mouthwashes are not a substitute and generally do not offer equal or significant benefits to mechanical cleaning for most products. Evidence suggests that for most products, this is not the case, and there are side effects and potential side effects associated with their regular use.

• If used, mouthwash should be utilized at a distinct time from brushing to maximize effectiveness. For example, lunchtime might be a better time, avoiding mornings and evenings when tooth-brushing occurs completely, to prevent washing out the fluoride from the toothpaste.

• Chlorhexidine may offer benefits in specific, limited circumstances but is intended for short-term usage only due to its potential side effects. It is important to emphasize that mouthwashes are unlikely to have a significant additional benefit in terms of improving a periodontal condition, reinforcing that a patient's own mechanical cleaning methods are of paramount importance.

• Patients may use mouthwashes for cosmetic reasons, which is acceptable, as long as it is done at a time where it does not interfere with the beneficial effects of fluoride during regular home care.