Moffitt Restorative Dentistry


Mar 23 2016

Mouth Rinses
Achieving optimal health often involves changing longstanding habits, which is a challenging process. As a dental professional working to encourage healthier habits, patients may struggle with making changes. When planned habit changes can dovetail with current behaviors, implementation is more likely. If using a product or device is already an established behavior, it may be easier for patients to switch to a different type within the category than to adopt an entirely new behavior.
Many Americans use mouthrinses, although the exact reasons for purchase are unclear. Consumers may determine they need to do more than “just brush,” or they may use mouthrinse to appease the guilt of not flossing.
Fresh breath is often a concern of patients, and advertising has established a link between mouthrinse use and the elimination of breath malodor. Cosmetic mouthrinses often promise benefits such as plaque removal, fresher breath, brighter teeth, and cleaner mouth. Although mouthrinses with these claims must demonstrate safety, their efficacy is not regulated by either the federal Food and Drug Administration (FDA) or the American Dental Association (ADA).
Therapeutic mouthrinses, on the other hand, address a disease process, such as gingivitis or caries. Currently, the use of mouthrinse to treat periodontitis is not supported by evidence. Mouthrinses with therapeutic claims must exhibit proof of their safety, and they need to obtain approval from the FDA. Consumer mouthrinses can also seek the ADA’s Seal of Acceptance as proof of the product’s safety and efficacy, but this is optional.
The sheer number of available mouthrinse products has created as much confusion for the average consumer as toothpaste selection. For both product categories, patients appreciate knowing which brand and type are optimal for their particular oral conditions, while also being cost-effective. Oral health care providers are viewed as product experts who can help patients sort through the options. For those who already have an established mouthrinse routine, recommending a more beneficial formulation won’t require adoption of a new behavior. Following a thorough oral health assessment, clinicians can offer an evidence-based and patient-centered mouthrinse regimen to address specific oral health needs.
Mouthrinsing is not a substitute for mechanical plaque biofilm control because it does not adequately penetrate plaque biofilm, supragingivally or subgingivally. However, the benefits of mechanical plaque control can be extended with the addition of a therapeutic mouthrinse. Mouthrinsing is a simple delivery system that allows a chemotherapeutic agent to reach either hard or soft tissues. Relatively inexpensive, mouthrinses are user-friendly because they require little time, effort, and skill, and most are over-the counter (OTC) purchases.
This biofilm matrix protects bacteria from antimicrobial agents. However, freefloating bacteria, not encased in biofilm matrix, are more susceptible to attack than those protected within biofilm. Consequently, mouthrinse antimicrobial agents can have the greatest impact on free-floating salivary bacteria in the early stages of attaching to teeth, gingiva, and other mucosal surfaces. When undisturbed, these free-floating supragingival bacteria, can “seed” gingival areas, where they may progress to complex periodontal disease associated subgingival biofilm colonies that damage gingival and periodontal health. This explains why antibacterial mouthrinses may have their greatest impact against nonbiofilm bacteria that still cling to oral surfaces following mechanical plaque removal.
Three factors often limit the efficacy of self performed mechanical plaque biofilm removal: limited capacity of the available physical removal methods, less than optimal skill level, and inconsistent oral hygiene habits. The combination of these three factors, along with immune system considerations, hinder efforts to prevent and control gingivitis and periodontal diseases.
Mouthrinses are indicated for gingivitis, rather than periodontitis, because once an established biofilm overpowers the immune system causing periodontal pocketing/bone loss, the efficacy of an antibacterial mouthrinse depends on full access to the depth of periodontal pockets where the anaerobic pathogenic bacteria reside, as well as penetration of the complex biofilm. Because the fluid from rinsing penetrates no further than 1.5 mm subgingivally, it does not reach the intended bacterial populations. In addition, bacteria contained deep within biofilm are resistant to antimicrobial agents. The bacteria contributing to gingivitis, however, are located supragingivally and slightly subgingivally, so they are easily accessible to the mouthrinse solution. Addressing gingivitis is critical because of its potential to progress to periodontitis.
Essential oil mouthrinse is an OTC product that has been in use for more than 100 years. Its beneficial action results from disruption of the cell wall and inhibition of bacterial enzymes. This is facilitated by two phenol related essential oils, thymol and eucalyptol, which are combined with menthol and methylsalicaylate. A long history has established safety with no development of opportunistic bacteria. Seven RCTs conducted over 6 months with unsupervised oral hygiene compared to a placebo or negative control have shown plaque reductions from 14.9% to 36.1% and gingivitis reductions from 9.4% to 35.9%, with greatest reductions seen when compared to a negative control. When the accompanying oral hygiene is standardized, even greater reductions are demonstrated. Essential oil mouthrinse provides plaque and gingivitis benefits when used with unsupervised brushing, compared to control or placebo, although it is not as effective as chlorhexidine due to chlorhexidine’s high substantivity.
Prescription mouthrinses containing 0.12% chlorhexidine gluconate are available in both an alcohol free and an 11.6% alcohol formulation. Both formulations are equally effective and disrupt the bacterial cell membrane, causing precipitation of the cytoplasm and resulting in bacterial death. Chlorhexidine has greater substantivity, or staying power, than any of the other OTC mouthrinses, which extends its antibacterial effect, but also contributes to more extrinsic tooth staining. Extensive research over many years has documented the antiplaque and antigingivitis efficacy of this mouthrinse. Plaque reductions of 35% to 61% and gingivitis reductions of 37% to 40% have been shown. Studies comparing chlorhexidine mouthrinse to essential oil and delmopinol rinses showed that rinsing with chlorhexidine achieved the greatest plaque and gingivitis reductions.
Because so many patients already use a mouthrinse, recommending a therapeutic product that best meets their needs capitalizes on an established behavior. This may encourage improvement without the challenge of changing self-care habits. Therapeutic mouthrinse is a user-friendly component of a self-care regimen that does not require complex dexterity skills.

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