The proper control of oral diseases requires methodical patient assessment, critical thinking, and thorough understanding of mechanical and chemical biofilm removal modalities by oral health professionals.1 The addition of appropriate adjunctive aids, such as mouthrinses, may improve patients’ oral hygiene. However, patients need individualized recommendations. This requires a thorough understanding of available products and knowledge of the clinical effectiveness of rinses’ active ingredients. Patients often judge the effectiveness of a mouthrinse by taste or flavor, and may inadvertently choose a product with low efficacy.2 Individualized patient education on the complex nature of oral bacteria provides the greatest opportunity for long-term oral health and disease management.
While the use of mechanical plaque control methods technically enables patients to maintain adequate levels of oral hygiene, clinical experience and research indicate that the level of efficacy with these methods is often lacking.3,4 The need for an adjunctive method to support mechanical plaque removal—controlling bacterial plaque and preventing caries—provides the foundation for introducing therapeutic mouthrinses.3
Fluoride has been the gold standard for caries prevention for decades. Various types of fluorides exist, but the most common formulations include neutral sodium fluoride solutions ranging from 0.05% (200 ppm) to 2% (900 ppm).5,6 The effectiveness of fluoride comes from its bacteriostatic properties by inhibiting the enolase enzyme of the glycolytic pathway.6
Sodium fluoride mouthrinse inhibits caries by affecting the activity of cariogenic bacteria in the oral cavity. It has a neutral pH with bacteriostatic properties that make tooth structure more resistant to acid dissolution via the formation of fluorapatite.6 The most effective method of using this mouthrinse is to choose a low potency, high frequency regimen of 0.05% sodium fluoride rinse used daily or a high potency, low frequency regimen of 0.2% sodium fluoride rinse (prescription).7 Patients at high caries risk, including those with active coronal and or root surface caries, an inability to maintain proper oral hygiene, or orthodontic appliances, are typically best served by the low potency, high-frequency regimen.
Patients with xerostomia caused by diseases, medication use, or chemotherapy/ radiation will benefit from a sodium fluoride mouthrinse regimen.7 Among the various caries prevention methods, mouthrinses have been found to be one of the safest and most effective methods, especially in children age 6 and older, as they have the ability to deliver therapeutic ingredients to all accessible surfaces in the mouth, including interproximal surfaces.4
The literature is unclear on the most effective use of fluoride mouthrinses. Previous research often compares the effectiveness of fluoride rinses with fluoride dentifrices.8 Current studies assess the efficacy of fluoride mouthrinses when used as an adjunct to fluoride dentifrices and other fluoride products. A 2014 study investigating the remineralization effects of fluoride mouthrinses observed greater remineralization effects on proximal carious lesions when the frequency of fluoride mouthrinse was increased when used in combination with a fluoride toothpaste.8 The use of fluoride rinses as adjuncts has been shown to be effective in reversing and preventing root caries.9
The incorporation of fluoride into antimicrobial mouthrinses—even used once daily—may improve caries control and increase remineralization. Mouthrinses should be used post-toothbrushing, as rinsing with water or nonfluoride rinses may remove beneficial residual fluoride.8,9
Antiseptic mouthrinses are used to reduce plaque accumulation and inflammation of gingival tissues. They inhibit microbial reproduction and cellular metabolism, producing cell death. An antiseptic rinse can be effective throughout the oral cavity, including areas commonly missed in the mechanical disruption of biofilm. However, they are most effectively used as adjuncts to biofilm removal. Studies have found some antiseptic rinses are bactericidal in saliva and soft tissues, including the tongue and oral mucosa, which harbor pathogenic bacteria.10 However, for patients with periodontitis who have deep probing depths, rinses will not reach the depth of the pocket.
The daily disruption of plaque and biofilm is necessary for gingival health. However, mechanical oral hygiene procedures performed at home may be insufficient for completely preventing gingival diseases.11 Rinses containing chlorhexidine gluconate (CHX) are shown to reduce Streptococcus mutans and Lactobacillus in saliva.12 While CHX rinses reduce the presence of certain bacteria, limited studies report its effectiveness for caries control. The bactericidal and bacteriostatic properties make CHX rinses most effective for the disruption of plaque and treatment of gingival diseases.12 Once absorbed, CHX shows a consistent bacteriostatic action lasting 12 hours.11 Daily use of CHX mouthrinse has been shown to be an effective adjunct to mechanical biofilm removal. A 2014 randomized controlled trial found the addition of rinsing even once daily with 0.06% CHX in conjunction with twice daily brushing had greater plaque reduction after 8 weeks than toothbrushing alone.13 Previous formulations of CHX rinse contained alcohol. With a growing number of patients requiring alcohol-free products, an alcohol-free version is now available. A recent study showed the alcohol-free CHX rinse had similar efficacy.13
The quaternary ammonium compound cetylpyridinium chloride (CPC), when used as an adjunct to oral hygiene, provides benefits in reducing plaque and gingival inflammation when compared with toothbrushing alone.14 CPC has a long history of safe and effective use as an antimicrobial agent, and does not disturb the balance of the oral microflora.14,15 It exhibits antimicrobial activity against Gram-positive bacteria by binding to the phosphate groups of lipid cell walls, damaging the cell membrane, and inhibiting the cell’s metabolism.15 A recent study supports the effectiveness of CPC in reducing Prevotella, a bacterium related to endodontic, gingival, and periodontal infections.14 Rinsing with a CPC rinse three times daily has been shown to significantly reduce dental plaque scores.15
Mouthrinses containing essential oils (EO) reduce bacterial vitality, thickness, and density of oral biofilm.16 Common over-the-counter EO rinses include combinations of thymol (0.064 %), eucalyptol (0.092 %), methyl salicylate (0.060 %), and menthol (0.042%).17 The effectiveness of EO comes from the ability to disrupt cell wall formation, inhibit enzymatic activity of bacteria, and prevent bacterial aggregation.17
A recent study found biofilm microbes throughout the entire thickness of the biofilm were most susceptible to the antimicrobial activity of the EO mouthrinse compared to dentifrice slurries after a 30-second treatment.16 It was found that moving the EO rinse forcefully around the mouth with the cheeks when projecting it onto the biofilm is probably of prime importance for reducing bacterial biofilm vitality.17 A single application of EO mouthrinse presents high antibacterial activity and penetration capacity and is an effective adjunctive antimicrobial agent against oral biofilms.17
PATIENTS WITH XEROSTOMIA
Saliva plays an important role in the protection of the hard and soft tissues of the oral cavity. Xerostomia is a common side effect of many systemic diseases, such as Sjögren syndrome, chemotherapy/radiation therapy, and medication usage. Chronic xerostomia and hyposalivation can lead to significant oral disorders and reduce quality of life. Older adults tend to experience xerostomia due to salivary disorders caused by systemic conditions.18 Additionally, patients with hyposalivation are predisposed to developing mucosal candidiasis, which can present with a pseudomembrane, erythema of the underlying tissues, and/or a burning sensation of the tongue or other intraoral soft tissues.18
Therapeutic mouthrinses can serve as important adjunctive aids for patients with chronic dry mouth. These individuals are at high risk for caries, so using a sodium fluoride mouthrinse is beneficial. Incorporating a mouthrinse with a neutral pH and rinses containing carboxymethylcellulose may help decrease the effects of xerostomia. Rinses with plant-based ingredients may also provide relief from dry mouth symptoms.19,20
Other ingredients not found in traditional mouthrinses may address specific needs of individual patients. While not an antimicrobial, delmopinol hydrochloride interferes with the ability of plaque to adhere to the tooth surface. Mouthrinses with delmopinol may be helpful for patients who have difficulty with plaque control.21–23
Patients often request a more holistic approach to their care and several mouthrinse products are free of preservatives, colors, artificial sweeteners, and stabilizers.21 Mouthrinses containing natural botanicals, such as peppermint oil, tea tree oil, and aloe vera, may offer oral health benefits. Chitosan-argininamide is a new ingredient in the mouthrinse realm that is designed to eliminate oral debris and improve gingival health.24,25
Mouthrinses used as oral hygiene adjuncts may provide benefits by reducing or controlling plaque, gingivitis, caries, and xerostomia. The effectiveness of therapeutic mouthrinses is dependent on patient need and compliance, concentration of the active agent, dosage, substantivity, and interactions with other medications. Oral health professionals need to be well versed in therapeutic mouthrinses to be able to make individualized recommendations.
- Francisco EM, Johnson TL, Freudenthal JJ, Louis G. Dental hygienists’ knowledge, attitudes and practice behaviors regarding caries risk assessment and management. J Dent Hyg. 2013;87:353–361.
- Marchetti E, Casalena F, Capestro A, Tecco S, Mattei A, Marzo G. Efficacy of two mouthwashes on 3-day supragingival plaque regrowth: A randomized crossover clinical trial. Int J Dent Hyg. 2015;15:73–80.
- Barnett M. The role of therapeutic antimicrobial mouthrinses in clinical practice: Control of supragingival plaque and gingivitis. J Am Dent Assoc. 2003;134:699–704.
- Alexander DC. Therapeutic mouthrinses: reaching beyond mechanical plaque control for reduction in dental plaque and gingivitis. Available at: cdeworld.com/courses/4922-Therapeutic_Mouthrinses:Reaching_Beyond_Mechanical_Plaque_Control_for_Reduction_in_Dental_Plaque_and_Gingivitis?c=305. Accessed October 24, 2018.
- Twetman S, Keller MK. Fluoride rinses, gels and foams: an update of controlled clinical trials. Caries Res. 2016;50:38–44.
- Sharma A, Agarwal N, Anand A, Jabin Z. To compare the effectiveness of different mouthrinses on Streptococcus mutans count in caries active children. J Oral Biol Craniofac Res. 2018; 8:113–117.
- Adair S. The role of fluoride mouthrinses in the control of dental caries. Pediatr Dent. 1998;20:101–104.
- Songsiripradubboon S, Hamba H, Trairatvorakul C, Tagami J. Sodium fluoride mouthrinse used twice daily increased incipient caries lesion remineralization in an in situ model. J Dent. 2014;42:271–278.
- Latimer J, Munday JL, Buzza KM, Forbes S, Sreenivasan PK, Mcbain AJ. Antibacterial and anti-biofilm activity of mouthrinses containing cetylpyridinium chloride and sodium fluoride. BMC Microbiology. 2015;15:169.
- DePaola L, Eshenaur Spolarich A. Safety and efficacy of antimicrobial mouthrinses in clinical practice. J Dent Hyg. 2007;81:1–16.
- Leeuwen MV, Rosema N, Versteeg P, Slot D, Hennequin-Hoenderdos N, Weijden GV. Effectiveness of various interventions on maintenance of gingival health during 1 year—a randomized clinical trial. Int J Dent Hyg. 2016;15:E16–E25.
- Wyatt CC, Macentee MI. Caries management for institutionalized elders using fluoride and chlorhexidine mouthrinses. Community Dent Oral Epidemiol. 2004;32:322–328.
- Zimmer S, Korte P, Verde P, Ohmann C, Naumova E, Jordan R. Randomized controlled trial on the efficacy of new alcohol-free chlorhexidine mouthrinses after 8 weeks. Int J Dent Hyg. 2014;13:110–116.
- Teng F, He T, Huang S, et al. Cetylpyridinium chloride mouth rinses alleviate experimental gingivitis by inhibiting dental plaque maturation. Int J Oral Sci. 2016;8:182–190.
- Leeuwen MV, Rosema N, Versteeg P, Slot D, Winkelhoff AV, Weijden GV. Long-term efficacy of a 0.07% cetylpyridinium chloride mouthrinse in relation to plaque and gingivitis: A 6-month randomized, vehicle-controlled clinical trial. Int J Dent Hyg. 2014;13:93–103.
- Serbiak B, Fourre T, Geonnotti AR, Gambogi RJ. In vitro efficacy of essential oil mouthrinse versus dentifrices. J Dent. 2018;69:49–54.
- Quintas V, Prada-López I, Carreira MJ, Suárez-Quintanilla D, Balsa-Castro C, Tomás I. In situ antibacterial activity of essential oils with and without alcohol on oral biofilm: a randomized clinical trial. frontiers in microbiology. J Oral Microbiol. 2018;10:1495975.
- Turner M, Ship J. Dry mouth and its effects on the oral health of elderly people. J Am Dent Assoc. 2007;138:15S–20S.
- Gadalla H. Treating dry mouth. Dimensions of Dental Hygiene. 2018;16(7):25–30.
- Trushkowsky R. Xerostomia management. Dimensions of Dental Hygiene. 2014;12(3):3–39.
- Gregoire M, Karalunas K. A closer look at mouthrinses. Dimensions of Dental Hygiene. 2017;15(11):21–25.
- Zee K, Rundegren J, Attström R. Effect of delmopinol hydrochloride mouthrinse on plaque formation and gingivitis in “rapid” and “slow” plaque formers. J Clin Periodontol. 1997;24:486–491.
- Neilands J, Troedsson U, Sjödin T, Davies JR. The effect of delmopinol and fluoride on acid adaptation and acid production in dental plaque biofilms. Arch Oral Biol. 2014;59:318–23.
- Gómez Chabala LF, Cuartas CEE, López MEL. Release behavior and antibacterial activity of chitosan/alginate blends with aloe vera and silver nanoparticles. Mar Drugs. 2017;15:E328.
- Varshosaz J, Taymouri S, Minaiyan M, Rastegarnasab F, Baradaran A. Development and in vitro/in vivo evaluation of HPMC/chitosan gel containing simvastatin loaded self-assembled nanomicelles as a potent wound healing agent. Drug Dev Ind Pharm. 2017:1–31.
From Dimensions of Dental Hygiene. November 2018;16(11):14,16,18.