Mouthwash-“Best Shield of Oral Cavity”

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:

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.

• 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

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

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 .

Myths & Facts

Directions of Usage

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

Dry-mouth symptoms can influence rinse selection and tolerance, so individualise recommendations using the clinical xerostomia management guide.