The Role of Oral Rinse Technologies in a New Daily Oral Healthcare Regimen
Maria Perno Goldie, RDH, MS
The simple addition of a therapeutic mouthrinse to the at-home dental hygiene regimen is beneficial to most people, resulting in incremental reductions in plaque and gingivitis.1 Very few people are able to achieve high levels of plaque removal on a consistent basis, as certain tooth surfaces tend to receive little or no attention during brushing.2 Therefore, it is not surprising that the prevalence of gingivitis is reported to be 50.3% in adults between 30 and 90 years old.3
Therapeutic mouthrinses are therefore helpful for many patients—not only for those who are unwilling or unable to comply with recommended mechanical plaque control at home. There is growing clinical evidence that therapeutic mouthrinses, which have the ability to reach all surfaces of the oral cavity, provide adjunctive benefits to mechanical methods in controlling dental plaque biofilm and reducing the extent and severity of gingivitis.4
Limits to Mechanical Plaque Removal
For many people, it is difficult to adequately comply with recommended mechanical methods of plaque control and to achieve the necessary level of oral hygiene. Tooth brushing removes up to 50% of plaque biofilm,5 and is even more effective when used in combination with flossing. While in some patients, this difficulty may be due to limited dexterity (eg, a condition such as arthritis), there are others who may simply not be motivated or may not be able to devote the time necessary due to other perceived priorities in their lives. Such inadequate home care places these patients at a greater risk of developing gingivitis, which may progress to periodontitis in approximately 20% of patients.6 Because it cannot be predicted which patients will progress to periodontitis, it is important to reduce both plaque and gingivitis in all dentate patients.
However, even conscientious self-care using recommended mechanical methods may not adequately control plaque and prevent gingivitis. The dentogingival areas account for approximately only 20% of the total surface of the oral cavity.7 These areas can be recolonized by bacteria carried via saliva from distant mucosal sites, such as the tonsils and dorsum of the tongue.8 Adjunctive anti-plaque agents, such as those in therapeutic mouthrinses, can help control these areas not usually reached by mechanical means and reduce the overall microbial burden throughout the oral cavity.
The Adjunctive Role of Mouthrinses
Innovative therapeutic mouthrinses, as well as those that have been available for decades, offer another layer of protection in the oral and general health of patients. The concept of mouthrinses is not new; they have been used for thousands of years, as mouthrinse ingredients containing salt, alum, and vinegar have been associated with Chinese, Indian, and Greek and Roman cultures.9 Although such rinses were historically used to freshen breath, there is evidence that modern therapeutic rinses may improve health. Therapeutic rinses may control oral biofilm, and biofilm is said to cause 70% to 80% of all human infections.10 In 2006, over $81 billion was spent on diseases connected to oral biofilm—more than heart disease, diabetes, or any of the other major diseases.11
Dental plaque exists as a complex biofilm in which many species of bacteria co-exist in highly organized and structured communities. The key to plaque biofilm control lies in maintaining a state of balance in which disease-causing organisms are suppressed and overwhelmed by healthy organisms. Frequent disruption prevents the maturation of the biofilm, and may result in the dilution of cell signals, which mediates metabolic inactivity and antibiotic resistance within a biofilm.12
Therapeutic mouthrinses are effective through one of two mechanisms of action. Traditionally the therapeutic agents, commonly referred to as antimicrobial agents, act directly against the bacteria, disrupting the metabolism and leading to impaired action or cell death. Newly introduced rinse technology has little direct effect on bacteria metabolism and growth, but is effective on the mechanisms of attachment to oral surfaces and other bacteria.13 Bacteria produce a sticky matrix and aggregate to create colonies and form the early building blocks of biofilm (bacteria living together in a sticky matrix, as in dental plaque). The recently available new therapeutic rinse agent is surface-active, anti-adhesive, and functions by disrupting the mechanism that allows the bacteria to adhere to the tooth surface (G•U•M® PerioShield™, Sunstar Americas, Inc., www.sunstaramericas.com) and enables mature biofilm masses to be disrupted and removed more easily by regular mechanical plaque control.
Therapeutic mouthrinses contain active agents that have been shown in randomized controlled trials to reduce the levels of both plaque and gingivitis.3 Agents found in the over-the-counter mouthrinses in this category include the phenol-related essential oils (eg, thymol, eucalyptol, menthol, and oil of wintergreen), such as those found in the long-established mouthrinse Listerine® (Johnson and Johnson, www.jnj.com); the quaternary ammonium compounds such as cetylpyridinium chloride (CPC), found in Crest® ProHealth® (Procter & Gamble, www.pg.com); and the amine alcohol delmopinol hydrochloride, a new approach to biofilm control found in G•U•M PerioShield. Available by prescription is the bisbiguanide antiseptic chlorhexidine digluconate 0.12%, which is formulated with 11.6% alcohol and available as Peridex™ (3M ESPE, http://solutions.3m.com), and G•U•M® Chlorhexidine Gluconate Oral Rinse (Sunstar Americas, Inc.), which is uniquely free of alcohol. There are other brands also available.
Educating Patients about Everyday Plaque Control
Good oral hygiene, adequate plaque control, and management of inflammation are fundamental not only to oral health but also to general health.14 Dental professionals are in a unique position to influence their patients’ health decisions and practices but should be aware that not all patients will be receptive to their efforts. Oral health literacy, like general health literacy, is highly variable in human populations and appears to be related to oral health outcomes. Low literacy may present a barrier to oral health education.15
The use of therapeutic mouthrinses should be adjunctive to mechanical home care, including the role of toothbrushing and interdental cleaning. The dental professional should provide patients with an explanation of the link between dental plaque biofilm and periodontal disease but should also mention the link between oral and systemic disease. Patients need to know how preventing the biofilm from adhering to the teeth and soft tissue, as well as removing the biofilm that has become attached, is essential not only to their oral health, but also possibly to their general health. Dental professionals should continue to reinforce the message for proper mechanical methods, and patients should be made aware of the benefits of using a mouthrinse as an adjunct to mechanical methods. Dental professionals can also explain why a patient may need to start treatment with the short-term use of a prescription chlorhexidine rinse, which targets disease resolution but with prolonged use causes staining,16 before switching to a routine maintenance rinse such as PerioShield to prevent biofilm attachment and build-up. Instruction on proper patient usage helps achieve a full benefit gain, whether the product is available by prescription or over-the-counter.
To encourage compliance, an in-office mouthrinse trial is recommended. After a procedure has been performed in the office (eg, scaling and root planing, periodontal debridement, routine maintenance), patients can be urged to rinse properly in the office with the recommended therapeutic agent while listening to an explanation of how the mouthrinse will treat or prevent gingivitis.
Assessment of Attitudes and Behaviors
A change in patient attitude and behavior is often desirable when periodontal disease is being treated.17 In planning interventions that encourage patient self-care, it is also important to collect basic information regarding self-care behavior and perceptions. The information gathered relative to a patient’s values and beliefs may be useful in designing effective oral healthcare interventions. The focus should not just be on the teeth and gingival tissues, but also their general overall health. To provide insight and guidance, dental professionals can use conceptual models such as a health belief model (HBM), a health locus of control (LOC) model, or a self-efficacy model to gain an understanding of how patients feel about their self care and how much control they have over it.18-23
Patient oral hygiene regimes may be researched through questioning: How often do you brush? What toothpaste do you use and why? How often do you floss? They should also be asked whether they have fluoride concerns and if they use mouthrinse. The dental professional should also inquire about patient stress levels and diet, as both can affect periodontal disease.24,25 Asking patients about the foods they eat, the frequency and types of foods eaten between meals, and how they feel about their diet will provide the dental professional with the background to create an individualized and effective health maintenance and improvement program for patients. Table 1 provides examples of questions to determine patient perceptions of oral conditions and willingness to improve oral health.
Changing Patient Behavior
Although it may seem simple to ask patients to add a 30-second rinse to their daily regimen, it can be a challenge to convince people to change their behavior, to adopt something new and different. Changing patients’ behavior starts with effective communication. A method that has been used with success in changing behavior is motivational interviewing (MI), which arose through a convergence of science and practice. The objective of MI is to empower patients by encouraging hope and optimism. It involves listening with empathy to explore and gain an understanding of the patient’s own motivations and to overcome ambivalence about making the desired changes. MI theorizes that the extent to which people verbally defend their resistance is inversely related to behavior change, and the extent to which they verbally argue for change is directly related to behavior change. Two specific active components include a relational component focused on empathy and the interpersonal interaction, and a technical component involving the differential evocation and reinforcement of behavioral change talk.26
Using this approach, the dental professional can engage patients in meaningful interaction, while exploring their values and beliefs about oral and dental health, examining pros and cons related to changing oral health behaviors, and articulating and resolving ambivalence to change in a nonjudgmental environment. Strategies are aimed at accessing the patient’s own motivation towards behavior change to allow them to become invested in the change process, which can result in better health outcomes. They are also designed to elicit the information needed to effectively influence patients’ behavior, starting with knowledge of the reasons they are resistant, and learning about their motivations to determine how to overcome the resistance. Ask patients who say they do not have time to rinse, “Do you have 30 seconds, twice a day, to improve your health?”
It is important to explore new daily regimens for new oral healthcare at the practice and patient levels in keeping with insights gained about the patient’s goals and motivation. Dental professionals can also gain patients’ trust and influence their behavior by offering other types of recommended products based on science. Rather than merely telling patients to use a rinse, clinicians are advised to recommend individual rinses that specifically target patients’ needs (eg, the best type of rinse for their control of plaque and gingival health). Patients concerned about the regular use of an antimicrobial agent and its effect on the overall microbiota and ecosystem of the oral cavity may prefer an anti-adhesive rinse that simply interferes with the plaque accumulation and biofilm formation. One such product is PerioShield, which is uniquely formulated to control plaque by inhibiting attachment. The dental professional should also discuss the importance of using a well-designed toothbrush with a proven fluoride toothpaste and demonstrate the correct toothbrushing technique.
The key to convincing patients to incorporate therapeutic mouthrinses into their established oral healthcare routine is communication. It is important to listen to patients, determine their goals and concerns, and then define and propose a regimen that can meet those needs. An anti-plaque rinse may be suggested for patients concerned about the long-term effects of antimicrobials on the normal flora. Placing special emphasis on the link between periodontal disease and systemic disease may be recommended for health-oriented patients when recommending an anti-plaque and anti-gingivitis treatment. The goal is to empower patients to overcome obstacles by taking control of their oral and overall health.
The author has received an honorarium from Sunstar Americas, Inc.
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About the Author
Maria Perno Goldie, RDH, MS
Seminars for Women's Health
San Francisco, California