Therapeutic Mouthrinses
Improve patient awareness on this important aspect of oral care
Many patients find it difficult to achieve the necessary level of oral hygiene with mechanical methods of plaque control. This difficulty may be due to physical limitations (such as arthritis) or time constraints. However, even conscientious oral hygiene practices may not adequately control plaque throughout the oral cavity and in difficult-to-reach areas.
Therefore, therapeutic mouthrinses are considered integral to oral health. When used daily to supplement toothbrushing, flossing, and interdental cleaning, certain therapeutic mouthrinses have been shown to reduce both plaque and gingivitis.1 Dental assistants can play a key role in explaining how mouthrinses work and encouraging their patients to add this important step to their daily self-care.
The key to encouraging patients to incorporate an additional step—therapeutic mouthrinses—into their oral healthcare routine and busy schedule is effective communication. Table I provides some sample approaches to begin the discussion, to determine patients’ goals and concerns, and then to suggest an approach to meet their needs.2
To aid in these discussions, below is an excerpt from a recent overview on advances in oral rinse technologies, including key points to consider when talking to patients.3
Understanding Advances in Oral Rinse Technologies
Mouthrinses are available as over-the-counter (OTC) or prescription-only products and are categorized as either “cosmetic” or “therapeutic.” Cosmetic mouthrinses do not reduce plaque or gingivitis but may claim to act as mouth or breath fresheners. These claims are not typically supported by scientific evidence. The Food and Drug Administration requires randomized controlled clinical trials for mouthrinses that claim therapeutic benefits in reducing levels of plaque and gingivitis. The therapeutic class of oral mouthrinses includes those containing essential oil compounds, cetylpyridinium chloride (CPC), chlorhexidine, and delmopinol.
Essential Oils
Essential oils have been used in mouthrinses for many years, dating back to the 19th century. The first over-the-counter mouthwash sold in the United States contained four essential oils: thymol, menthol, eucalyptol, and methyl salicylate (oil of wintergreen). The original formulation had a 26.9% alcohol content, and newer formulations have 21.6% alcohol. The antimicrobial activity is derived from the fixed combination of essential oils, not from the alcohol, which makes a very minor contribution to the antimicrobial activity. A 30-second rinse, twice daily, penetrates biofilm, providing a significant antimicrobial effect on supragingival biofilm.
Clinical trials have demonstrated plaque reductions of 13.8% to 56.3%, and gingivitis reductions of 14% to 35.9% when using essential oils.4-10 A study involving flossing and brushing with the mouthrinse showed an additional 15.8% reduction in interproximal gingivitis compared to a reduction of only 7.7% in the flossing and brushing group not using the mouthrinse.9
Mouthrinses with essential oils have been used by millions of consumers since their introduction more than 100 years ago and this formulation remains one of the most commonly available and used OTC therapeutic mouthrinses today.11
Cetylpyridinium Chloride
Cetylpyridinium chloride (CPC) is a cationic surface-active agent with widespread antimicrobial activity, involving the rapid destruction of Gram-positive pathogens and yeasts. CPC is found in many mouthrinses, including those with therapeutic benefits and those with only cosmetic claims. A recent meta-analysis from a systematic review supported the plaque- and gingivitis-inhibiting effect of CPC-containing mouthrinses. It concluded that CPC rinses, when used as adjuncts to oral hygiene, provide a small but significant additional benefit in reducing both plaque and gingival inflammation.12
The formulation of CPC ingredients includes solubilizers, preservatives, stabilizers, coloring agents, etc. The specific formulations can have a considerable impact on the bioavailability of the CPC. Increased proven bioavailability correlates with a higher probability of effectiveness, extending anti-plaque activity and reducing gingivitis.
The formulations of CPC rinses with the ADA Seal of Acceptance, which have demonstrated efficacy, are a different type of antimicrobial with a similar effect as the essential oils in reducing plaque and preventing gingivitis. Because it does not contain alcohol, it is an appropriate alternative for patients for whom alcohol-containing rinses are either not preferred or medically contraindicated.
Chlorhexidine Gluconate
Chlorhexidine gluconate has been used as a medical and surgical disinfectant since the 1940s. In 1970 it was found to be effective for use within the oral cavity.13 This prescription-only mouthrinse was originally formulated with alcohol (approximately 11.6%) but now alcohol-free formulations are available. Patients undergoing treatment for alcoholism, pregnant or nursing women, diabetics, or those who choose to avoid alcohol for cultural or religious reasons may prefer the alcohol-free formulations.
Chlorhexidine gluconate binds via adsorption to the many surfaces within the oral cavity, as well as the pellicle and saliva. This may explain its persistence in the oral cavity (substantivity) and its mode of action. Based on the concentration of chlorhexidine, the bactericidal or bacteriostatic effects will compromise bacteria attaching to the oral surfaces and may be more effective as a plaque preventive agent, rather than a plaque removal agent.14
Chlorhexidine gluconate is considered to be the gold standard15 for bacterial reduction and plaque control in the management of gingivitis. Prescription mouthrinses that contain chlorhexidine gluconate are available in therapeutically equivalent formulations that contain either 11.6% alcohol or no alcohol.
While chlorhexidine gluconate is an extremely effective mouthrinse, it has some side effects. Teeth, dental restorations, and the dorsum of the tongue are affected by chlorhexidine gluconate staining and some dental patients experience taste alterations and nausea. Addy has explained staining in terms of a reaction between chromogens found in foods and beverages and the tooth-bound chlorhexidine gluconate. Avoidance of these foods and beverages during treatment with chlorhexidine gluconate, especially soon after its application, should reduce the degree of stain formation.16
Delmopinol
The most recent entry into the oral mouthrinse category is delmopinol hydrochloride. With a unique surfactant mechanism of
action, delmopinol inhibits bacterial adhesion to tooth and mucosal surfaces, and also inhibits cohesion between the bacterial cells themselves.
Mouthrinses containing delmopinol prevent bacteria from synthesizing the sticky glucan polysaccharide compounds that cause the adhesion to tooth and gum surfaces, and to the other bacterial cells nearby, and disrupt existing dental plaque biofilm colonies. When there are existing plaque colonies, the cohesive forces between the bacteria are reduced by delmopinol, which makes removal by mechanical means much easier.
This formulation has a very low alcohol content (1.5%) and is indicated for all patients—especially those prone to significant plaque accumulation and chronic gingivitis. It is utilized as an adjunct to normal brushing, flossing, and other mechanical means of dental plaque biofilm removal. Research indicates that delmopinol disrupts Streptococcus mutans and other cariogenic bacteria, as well as periodontal pathogens. This is very beneficial in terms of restricting development of caries and periodontal disease.
Delmopinol usage results in less staining than chlorhexidine and the modest amount of staining is easily removed by professional methods and by patients’ home care efforts. Clinical trials have shown that delmopinol 0.2% rinses reduced plaque by 9.3% to 35%, bleeding on probing by 18% to 36%, and gingivitis by 18%.17-19
Key Takeaways
• Patients who are unable to maintain adequate levels of plaque and gingivitis control can benefit from the supplementary use of any of the oral mouthrinses outlined in this article.
• It is important that patients understand that use of anti-plaque/anti-gingivitis agents is not a solution for good oral
hygiene but should be used in addition to mechanical hygiene procedures.
• Encourage patient compliance by recommending use of a well-designed toothbrush and adherence to proper biofilm control techniques.
• Recommending adjunctive biofilm control measures is necessary for most patients.
• Individual patient factors should be considered in determining the best method for biofilm control.
Mouthrinses are a necessary part of a daily home care regimen for the oral and general health of patients. Therapeutic mouthrinses are impactful beyond the oral areas available to mechanical biofilm control methods. This distinction makes mouthrinses essential players in the reduction of plaque and gingivitis that ultimately leads to beneficial oral health.
Excerpt from: Nagelberg RH. Compend Contin Educ Dent. 2011;32(S3)3-7.
References
1. Barnett ML. The rationale for the daily use of an antimicrobial mouthrinse. J Am Dent Assoc. 2006;137(suppl 3):16S-21S.
2. Goldie MP. The role of oral rinse technologies in a new daily oral healthcare regimen. Compend Contin Educ Dent. 2011;32(S3):9-12.
3. Nagelberg RH. Understanding advances in oral rinse technologies. Compend Contin Educ Dent. 2011;32(S3):3-7.
4. Overholser CD, Meiller TF, DePaola LG, et al. Comparative effects of 2 chemotherapeutic mouthrinses on the development of supragingival dental plaque and gingivitis. J Clin Periodontol. 1990;17(8):575-579.
5. Lamster IB, Alfano MC, Seiger MC, Gordon JM. The effect of Listerine Antiseptic on reduction of existing plaque and gingivitis. Clin Prev Dent. 1983;5:12-16.
6. Gordon JM, Lamster IB, Sieger MC. Efficacy of Listerine antiseptic in inhibiting the development of plaque and gingivitis. J Clin Periodontol. 1985;12(8):697-704.
7. DePaola LG, Overholser CD, Meiller TF, et al. Chemotherapeutic inhibition of supragingival dental plaque and gingivitis development. J Clin Periodontol. 1989;16(5):311-315.
8. Charles CH, Sharma NC, Galustians HJ, et al. Comparative efficacy of an antiseptic mouthrinse and an antiplaque/antigingivitis dentifrice. A six-month clinical trial. J Am Dent Assoc. 2001;132(5):670-675.
9. Sharma N, Charles CH, Lynch MC, et al. Adjunctive benefit of an essential oil-containing mouthrinse in reducing plaque and gingivitis in patients who brush and floss regularly: a six-month study. J Am Dent Assoc. 2004;135(4):496-504.
10. Charles CH, Mostler KM, Bartels LL, Mankodi SM. Comparative antiplaque and antigingivitis effectiveness of a chlorhexidine and an essential oil mouthrinse: 6-month clinical trial. J Clin Periodontol. 2004;31(10):878-884.
11. Axelsson P. Preventive Materials, Methods and Programs. Vol. 4. Surrey, UK: Quintessence Publishing Inc.; 2004:184.
12. Haps S, Slot DE, Berchier CE, Van der Weijden GA. The effect of cetylpyridinium chloride-containing mouth rinses as adjuncts to toothbrushing on plaque and parameters of gingival inflammation: a systematic review. Int J Dent Hyg. 2008;6(4):290-303.
13. Löe H, Schiott CR. The effect of mouthrinses and topical application of chlorhexidine on the development of dental plaque and gingivitis in man. J Periodontal Res. 1970;5(2):79-83.
14. Jenkins S, Addy M, Wade W. The mechanism of action of chlorhexidine. A study of plaque growth on enamel inserts in vivo. J Clin Periodontol. 1988:15(7):415-424.
15. Jones CG. Chlorhexidine: is it still the gold standard? In: Addy M, Moran JM, eds. Toothpaste, mouth rinse and other topical remedies in periodontics. Periodontol 2000. 1997;15:55-62.
16. Addy M, Moran J. Chemical supragingival plaque control. In: Lindhe J, Lang NP, Karring T, eds. Clinical Periodontology and Implant Dentistry. 5th ed. Oxford: Blackwell Publishing, Ltd.; 2008:734-765.
17. Claydon N, Hunter L, Moran J, et al. A 6-month home-usage trial of 0.1% and 0.2% delmopinol mouthwashes (I). Effects on plaque, gingivitis, supragingival calculus and tooth staining. J Clin Periodontol. 1996;23(3 Pt 1):220-228.
18. Lang NP, Hase JC, Grassi M, et al. Plaque formation and gingivitis after supervised mouthrinsing with 0.2% delmopinol hydrochloride, 0.2% chlorhexidine digluconate and placebo for 6 months. Oral Dis. 1998;4(2):105-113.
19. Hase JC, Attstrom R, Edwardsson S, et al. 6-month use of 0.2% delmopinol hydrochloride in comparison with 0.2% chlorhexidine digluconate and placebo. (I). Effect on plaque formation and gingivitis. J Clin Periodontol. 1998;25(9):746-753.
