Mouthwashes

• What are ideal properties of a mouthwash?

  • Should inhibit microbial colonisation of the tooth surface

  
  

  • Should eliminate plaque already present by dissolution or alteration

  
  

  • Inhibit the calcification of plaque to form calculus
• What are some limitations of existing mouthwash preparations?

  • Many have a transient effect whilst they are in the mouth

  
  

  • Insufficient concentration to kill bacteria but any higher would damage epithelial cells

  
  

  • Do not penetrate into periodontal pockets

  
  

  • Do not penetrate interdentally

  
  

  • Can have side-effects
• Bacteria in biofilm is protected by..

  an impervious protective coat
• What is the gold standard mouthwash?

  Chlorhexidine gluconate (Corsodyl)
• What are properties of Chlorhexidine?

  Active for 24 hrs

  
  

  Binds tenaciously to dental and mucosal surfaces

  
  

  Substantive

  
  

  Inhibits plaque formation and prevents gingivitis

  
  

  Kills bacteria and fungi and is broad spectrum leading to 95% bacterial reduction

  
• What are Chlorhexidine concentrations?

  
• What does increasing the volume of a lower percentage of CHX do?

  Yields approx. the same dose

  
• What is substantivity?


  "Refers to the amount of time that an active ingredient remains effective after being applied to the area of treatment"

  
  

  "Pertaining to the capacity of an antimicrobial agent to continue its therapeutic activity for a prolonged period of time"
• Chlorohexidine (Corsodyl) is the only mouthwash that is retained in the mouth for:

  24 hours
• What is the bis - biguanide molecule?

  • Dicationic agent

  
  

  • Binds to anions i.e. pellicle and oral mucosa

  
  

  Binds to acidic protein groups e.g phosphates, sulphates and carboxyl ions. (Present in salivary glycoproteins
• CHX adsorbs to...

  epithelium and tooth surface
• What are the anti-bacterial actions of CHX?

  Binds to bacterial capsules (polysaccharide in nature)and therefore reduce bacterial binding to tooth tissue

  
  

  Kills bacteria by disorientation of lipoproteins in cell walls leading to increased permeability and cell lysis

  
  

  Can cause intracellular coagulation - its main bacteriocidal action

  
  

  Kills 95% of oral micro-organisms but does not permanently change the oral flora
• When is Corsodyl best used?

  • Following surgery where mechanical plaque control isimpossible, e.g. intermaxillary fixation

  • Acute mucosal conditions, e.g. severe ulceration

  • Pre-operatively to reduce bacterial splatter

  • Pre-operatively to reduce the incidence of dry sockets

  • Full mouth disinfection during non-surgical root surface debridement

  • Denture stomatitis

  • Special needs patients whose oral care has to be administered by non-dental professional care givers and used in the spray form

  • Patients in intensive care
• Can CHX be delivered as a gel or spray?

  Yes - CHX can additionally be delivered using a 1% gel or 0.2% spray
• What are the disadvantages of CHX?

  • Staining
  • Increased calculus formation
  • Taste disturbances
  • Mucosal desquamation
  • Parotid swelling rare

  
• How does CHX stain?

  denatures the pellicle protein by splitting disulphide bridges. The sulphadryl groups exposed bind tin and iron ions

  
  

  Reacts with ketones and aldehydes in dietary breakdown products to produce coloured compounds
• How does CHX interact with toothpaste?

   Cationic antiseptic reacts with anionic detergents of the toothpaste

   They cancel each other out

  Do not use Corsodyl after using toothpaste
• What are properties of Corsodyl Daily?

  Reduced Chlorhexidine strength but still active (0.06%)

  
  

  Reduced staining?

  
  

  250 ppm fluoride for tooth protection

  
  

  Higher than Fluoriguard daily

  
• What are properties of Alcohol Free CHX?

  As effective as Corsodyl

  
  

  Contains 0.2% Chlorhexidine,

  the same as Corsodyl

  
  

  A useful alternative for patients not wanting alcohol
• What are limitations of Corsodyl?

  No good on teeth with plaque already present

  
  

  Does not penetrate the biofilm

  
  

  Does not penetrate interdentally

  
  

  Does not penetrate subgingivally

  
  

  Contains alcohol (non-alcohol formulations of Corsodyl

  available)
• What mouthwashes contain the antiseptic Cetylpyridinium Chloride?

  - Plax

  - Search

  - Supermarket brands

  - Sensodyne

  - Actibrush
• What is a major disadvantage of Cetylpyridinium Chloride mouthwashes?

  They are not substantive

  
  

  Effects are too short lived for any meaningful effect
• What are essential oil mouthwashes?

  Kill 99.9% of oral gram +ve and-ve bacteria

  
  

  Are able to penetrate and kill plaque biofilm

  
• Do essential oil mouthwashes have a role?

  Patients who brush twice daily

  Floss once daily

  Rinse after brushing

  
  

  1. Have 56% less plaque accumulation compared to brushing alone

  
  

  2. Improved gingival (gum) health
• Rinsing is an adjunct to a OH regime rather than...

  a substitute for brushing and/or interdental cleaning
• What is the optimal rinsing time?

  30 seconds
• Can alcohol based mouth washes cause cancer?

  Ethanol in the mouthwash may increase the permeability of the mucous membrane to carcinogens such as nicotine

  
  

  Based on a literature review carried out by Prof.McCullough in Australia

  
  

  Smokers 9 times more likely to acquire oral cancer

  
  

  Non-smokers 5 times more likely to acquire oral cancer
• Ethanol has never been found to be ....

  carcinogenic either in laboratory animals or humans
• What are contra-indications to alcohol based mouthwashes

   Recovering Alcoholics – “May create the desire” for alcohol again

   Patients taking Metronidazole as swallowing may cause gastrointestinal upset
• Does Listerine cause acid erosion?

   pH is below 5.5 – “ The critical pH” the point at which demineralization of the tooth surface can theoretically occur

   Does not significantly alter the salivary pH levels

   No significant effect on plaque calcium and phosphate content

  Mouthwash does not have any negative effect on the ability of saliva to act as a buffer protecting enamel from demineralisation
• What is a water-based alternative mouthwash?

  Dentyl (alcohol free)

  
• What is Dentyl comprised of?

  Water based phase, cetylphydium chloride and oil base of essential oils.

  
• What doesListerine Total Care Contain?

  Essential oils that penetrate the biofilm and kill plaque bacteria

  Zinc chloride which reduces calculus formation and staining

  Fluoride which helps to reduce root caries

  Essential oils that neutralise products causing halitosis
• Should we be eliminating bacterial populations from the rest of the oral cavity?

  Cheeks, throat and the tongue all harbour bacteria that can recolonise "clean" tooth surfaces
• What is CB12?

  ◦ Contains:

  Chlorhexidine diacetate 0.025%

  Zinc acetate 0.3%

  Sodium fluoride 0.05%

  
  

  ◦ Prevents formation of hydrogen sulphide, methyl mercaptan and dimethyl sulphide
• What are the CHX concerntrations?

  • 0.2% 10ml corsodyl
  • 0.2% 10ml alcohol free
  • 0.12% 15ml CHX