Mouthwash-“Best Shield of Oral Cavity”
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Overview

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Oral health is a window to your overall health. Did you know that your oral health offers clues about your overall health — or that problems in your mouth can affect the rest of your body?

What's the connection between oral health and overall health?

Like other areas of the body, your mouth teems with bacteria — mostly harmless. However, your mouth is the gateway to your digestive and respiratory tracts, and some of these bacteria can cause disease. Normally the body's natural defenses and good oral health care, such as daily brushing, flossing and mouthwash keep bacteria under control. However, without proper oral hygiene, bacteria can reach levels that might lead to oral infections, such as tooth decay and gum disease.

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Introduction

Dental plaque is the main etiologic agent in the development and progression of gingival and periodontal diseases. Principal means of preventing the development and progression of various periodontal diseases is mainly through mechanical removal of plaque through regular tooth brushing. However, the interdental area and area below the gum remains uncleaned so, mouthwashes and interdental brushes may aid in controlling dental plaque and periodontal disease. Mouthwashes should never be used as sole means of oral hygiene, and it should always be used in conjunction with mechanical plaque control measures.

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More about Mouthwashes

The use of mouthwash to control plaque bacteria dates back around 5000 years when the Chinese recommended the use of child’s urine for the control of gingivitis.

Mouthwashes can be used for various preventative and therapeutic purposes,

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The patient's ability to perform good mechanical oral hygiene practices, oral hygiene status and the efficacy of a mouthwash and its potential adverse effects should be taken into consideration before recommending a particular mouthwash.

Definition

Mouthwash is a concentrated, clear aqueous solution with a pleasant taste, intended to cleanse and deodorize the mouth or buccal cavity.

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Classification

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Types

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Ingredients

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1. CHLORHEXIDINE

Chlorhexidine has broad spectrum antimicrobial activity. Chlorhexidine is a symmetrical bisbiguanide synthetic antiseptic consisting of four chlorophenyl rings and two biguanide groups connected by a hexamethylene bridge. The di-cationic nature of Chlorhexidine makes it extremely interactive with anions, which is relevant to its efficacy, safety and side effects.

It is available in three forms –

  • Digluconate
  • Acetate
  • Hydrochloride salts.

It is effective against both Gram positive and Gram-negative bacteria including aerobes and anaerobes, yeasts, fungi and lipid enveloped viruses. It increases the permeability of cell membrane followed by coagulation of cellular macromolecules.

Clinical usage:

Various preparations of Chlorhexidine mouthwashes are available across the globe. Chlorhexidine mouthwash containing 0.2% chlorhexidine should be used as 10ml volume per rinse, which delivers 20mg of total dose of chlorhexidine and those preparations containing 0.12% chlorhexidine to be used 15ml volume per rinse, which delivers 18mg of chlorhexidine. So, both of these formulations are effective, but the lower concentration of chlorhexidine minimizes its side effects while maintaining its benefits. To ensure good compliance and efficacy, the accepted length of time for rinsing is 30 seconds. Patients should be advised to rinse just before going to bed and after breakfast, with at least 30 minutes interval after tooth brushing.

Side effects:

  1. Brown discoloration of the teeth, restorative materials and tongue.
  2. Alters taste sensation especially for salt taste.
  3. Mucosal erosion with use of high concentration of Chlorhexidine rinse.
  4. Parotid swelling in rare cases.
  5. Increased rate of supragingival calculus formation.

2. BENZYDAMINE HYDROCHLORIDE

Benzydamine hydrochloride is known for its analgesic, anaesthetic, anti-inflammatory and antimicrobial properties. It affects the prostaglandin and thromboxane production and decrease pro-inflammatory cytokine production. Epstein et al. demonstrated that Benzydamine significantly reduces the duration, incidence and severity of radiation-induced mucositis [1]. Therefore, it is recommended for radiation-induced mucositis and ulcerative lesions like recurrent apthous stomatitis.

3. ESSENTIAL OILS

Mouthwashes based on essential oils contain

  • Thymol
  • Eucalyptol
  • Menthol in an alcohol solvent.

Action:

  • They are broad spectrum antimicrobial agents.
  • Decreases bacterial multiplication, aggregation and pathogenicity.
  • They act by destruction of bacterial cell and inhibition of bacterial enzymes.
  • They also have anti-inflammatory activity, prostaglandin inhibitory activity and antioxidants activity.

Sharma et al. stated that mouthwashes containing essential oils are effective in reducing oral malodour and gingivitis [2]. They can be recommended as an adjunct to mechanical plaque control measures especially in patients with gingival inflammation, even with regular tooth brushing and flossing. They are contraindicated in children because of risk of ingestion and in patients suffering from dry mouth and oral mucosal disease because of ethanol based irritation and dryness.

4. CETYLPYRIDINIUM CHLORIDE AND SODIUM BENZOATE

Cetylpyridinium chloride is a quaternary ammonium compound with moderate plaque inhibitory activity.

Action:

  • It acts by binding to bacterial cell membrane because of its cationic nature, thus causing disruption of cell membrane and leakage of intracellular components.
  • The reason behind their moderate plaque inhibitory activity as compared to chlorhexidine may be their rapid desorption from the oral mucosa and may also be related to their mono-cationic nature[3].
  • Sodium benzoate disperses carbohydrate, fat, protein thereby weakens plaque attachment which can then be easily removed by toothbrushing.

5. TRICLOSAN

Triclosan (2, 4, 4'-trichloro-2'-hydroxydiphenyl ether) is a non-ionic antiseptic compound shows anti-inflammatory property and has been used in many toothpastes and mouthwashes. Various studies have shown that Triclosan reduces the inflammatory reaction on the gingiva by sodium lauryl sulphate and reduce the severity and healing period of recurrent apthous ulcers. Gaffar et al stated Triclosan reduces the levels of inflammatory mediators (prostaglandins and leukotrienes) by inhibiting both cyclo-oxygenase and lipoxygenase pathways[4]. Triclosan also increases the binding ability of mouthwashes to the oral mucosa, thus being available for a longer period of time.

6. OXYGENATING AGENTS

Oxygenating agents such as hydrogen peroxide, sodium peroxyborate and peroxycarbonate act by liberating nascent oxygen to loosen debris, remove stains and kill anaerobic micro-organisms. They are bleaching agents having strong oxidising properties. They are also broad spectrum antimicrobial agents.

Indications:

  • Acute ulcerative conditions
  • Relieve soreness caused by dentures
  • Orthodontic appliances and for stain removal.

POVIDONE-IODINE CONTAINING MOUTHWASHES

Povidone-iodine is a broad spectrum antimicrobial having its affinity against bacteria, virus, fungi and protozoa. It is an iodophore in which iodine is loosely bound to povidone thereby delivering free iodine to bacterial cell membrane. It reduces plaque formation and decreases the severity of gingivitis and radiation mucositis. It is contraindicated in individuals having sensitivity to iodine and pre-existing thyroid disorder.

ANTIBACTERIAL PEROXIDASE MOUTHWASHES

They contain enzymes like lysozyme, lactoferrin, lactoperoxidase and glucose oxidase which act against bacterial peroxidise. They restore antimicrobial activity of saliva hence, useful in cases of dry mouth, gingival inflammation and oral malodour. Its long term use might pose a risk of dental erosion because of its low pH.

FLUORIDE CONTAINING MOUTHWASHES

These mouthwashes contain fluoride in various forms as either sodium fluoride (NaF) or acidulated phosphate fluoride (APF). They promote remineralisation of enamel with fluorapatitie and fluor-hydroxyapatite, making enamel resistant to acid attack.

Indications:

  • High risk of dental caries
  • Patients having xerostomia after undergoing radiation therapy
  • Undergoing orthodontic therapy.

Contra-indications:

Children less than six years of age because of risk of fluoride ingestion.

SODIUM BICARBONATE

It increases the salivary pH and suppresses the growth of aciduric bacteria. Therefore, it is recommended in patients with xerostomia and erosion.

ALCOHOL CONTENT OF MOUTHWASHES

Ethanol is used as a preservative and solvent in a concentration range of 5 %– 27 % in various commercially available mouthwashes. It has antimicrobial activity against various bacteria, fungi and viruses by causing protein denaturation and dissolution of lipids. Various studies have been done to determine the relationship between use of alcohol containing mouthwashes and the risk of developing oropharyngeal cancer. Mouthwashes containing significant amount of alcohol have number of disadvantages also.

Disadvantage:

  • Firstly, they can be accidently swallowed by young children.
  • Secondly, the use of alcohol containing mouthwashes may increase the alcohol content of exhaled air and could change the readings of the police breath test.
  • Thirdly, alcohol containing mouthwashes have also shown to reduce the hardness of composite and hybrid resin restorations and may also alter the colour of composite restorations.

The use of alcohol containing mouthwashes should be restricted to short term under supervision until long term studies are available. The use of alcohol containing mouthwashes should be discouraged for long term use.

Clinical Implications of Mouthwashes

Mouthwashes can be used in various clinical conditions.

They can be used as an adjunct to mechanical oral hygiene procedure in conditions like:

  • After subgingival scaling or root planning
  • In patients having inadequate oral hygiene
  • Post-scaling cervical hypersensitivity
  • Oral hygiene care

They can be used to replace normal toothbrushing which is not possible in various conditions like:

  • After periodontal surgical procedures
  • After intermaxillary fixation
  • During acute oral or gingival infection
  • For mentally or physically handicapped patients

Indications

1) Oral mucositis:

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Oral mucositis is a complication which can be seen in patients after head and neck radiation therapy, chemotherapy and in bone marrow transplant cases. It may occur from direct effect of cytotoxic drugs on oral epithelial cells in cancer patients. Maintenance of oral hygiene and plaque control measures are important factors in the management of oral mucositis. 0.12% or 0.2% Chlorhexidine mouthwashes can be used for this purpose but combination mouthwashes containing antiinflammatory, analgesic, antimicrobial properties and covering agents are much more useful.

2) Halitosis

Breath malodour is a common complaint among the general population which has a significant socioeconomic impact. Scully and Greenman stated that in 85% of cases, an oral cause can be found.

Extraoral causes-

  • ENT pathologies,
  • systemic diseases,
  • metabolic or hormonal changes,
  • hepatic insufficiency
  • renal insufficiency,
  • pulmonary diseases
  • GIT pathologies.

Intraoral causes –

  • Tongue
  • Tongue coating
  • Periodontal diseases
  • Deep carious lesions and
  • Dry mouth.
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  • A proper diagnosis is therefore essential and the treatment of oral malodour should preferably be cause related. Use of mouthwashes is a common practice in patients with oral malodour. The active ingredients in these mouthwashes are usually antimicrobial compounds like chlorhexidine, cetylpyridinium chloride, chlorine dioxide, hydrogen peroxide, essential oils and triclosan.

3) Xerostomia

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Xerostomia is also a common sign in older age individuals. Xerostomia / Dry mouth is not a disease, but a sign of an underlying disease or side effect of medications and radiation therapy for head and neck cancer treatment. Various changes occur in saliva after head and neck radiation therapy like decreased salivary flow, reduced pH and thick and pasty saliva; hence, excellent plaque control and oral hygiene measures are essential. Various symptomatic treatment measures are available like salivary stimulation, avoidance of dry sticky food, saliva replacement therapy and maintenance of good oral hygiene. Various preparations of mouthwashes containing chlorhexidine, cetylpyridinium chloride, triclosan, fluoride in non alcohol base preparations are usefull.

4) Periodontal diseases

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Gingivitis
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Periodontitis

Gingival and Periodontal diseases are one of the most common diseases in the world. Mechanical plaque control measures (toothbrushing and flossing) are of utmost importance in prevention of periodontal diseases. Chemical plaque control measures like use of mouthwash preparations containing 0.12% or 0.2% chlorhexidine, benzydamine chloride may also aid in prevention of periodontal diseases [5].

Myths & Facts

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Directions of Usage

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Conclusion

There are many mouthwashes available in market today. What is important is which mouthwash to be prescribed to which patient and when. So, the oral health practitioners should be aware of various etiologic factors and predisposing conditions affecting a particular oral lesion. The use of mouthwash should be limited to a smaller period of time depending on the lesion present and should always be used as an adjunct to mechanical plaque control measures (tooth brushing and flossing). Long term use of alcohol based mouthwashes should be discouraged. Mouthwash should not be used as luxury but should be considered as a “life savior”.

References

1) Epstein JB, Silverman SJr, Paggiarino DA, Crockett S, Schubert MM, Senzer NN; Benzydamine HCl for prophylaxis of radiationinduced oral mucositis: results from a multicenter, randomized, double-blind, placebo-controlled clinical trial. Cancer, 2001; 92: 875-85.

2) Sharma N, Charles CH, Lynch MC, Qaqish J, McGuire JA, Galustians JG; 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: 496-504.

3) Roberts WR, Addy M; Comparison of the in vivo and in vitro antibacterial properties of antiseptic mouthrinses containing chlorhexidine, alexidine, cetylpyridinium chloride and hexidine. J Clin Periodontol, 1981; 8: 295-310.

4) Gaffar A, Scherl D, Affitto J, Colman EJ; The effect of triclosan on the mediators of gingival inflammation. J Clin Periodontol, 1995; 22: 480-4.

5) Santos A; Evidence-based control of plaque and gingivitis. J Clin Periodontol, 2003; 30 Suppl 5: 13-6

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