Consumers and dental professionals are challenged to select effective oral care products for caries risk management and gingivitis reduction. Although mechanical plaque control is the best approach for prevention and treatment of gingivitis, fluoride is the most effective caries preventive agent. Some antimicrobials may counteract caries preventive agents whereas others are synergistic. This article provides an evidence-based overview of available products and appropriate recommendations for low, moderate, and high caries risk while considering needed agents for gingivitis control. A practical approach for patients and practitioners is emphasized.
Mouthrinses: Antimicrobial and Antigingivitis
Mouthrinses are used to promote fresh breath, prevent/control caries, reduce plaque biofilm and prevent/reduce gingivitis. Cosmetic mouthrinses temporarily reduce halitosis and leave a pleasant taste; therapeutic rinses have active ingredients to reduce plaque, gingivitis, and dental caries.
Antimicrobial rinses are recommended for gingival inflammation, preventIion of destructive periodontal disease, post-surgical use during healing and peri-implant inflammation. An antimicrobial ingredient is not always necessary. Most of the time, it is best to try mechanical oral hygiene improvements first because all antimicrobials have costs and potential side effects.
An initial recommendation is made for certain patients: immunocompromised; oral hygiene challenges, disabilities, extensive dental restorations; severe inflammation/bleeding, or inability to adequately control plaque by mechanical means. Three active antiplaque agents in oral rinses are the most commonly employed and have been documented for safety and effectiveness: 0.12% chlorhexidine gluconate, cetylpyridium chloride/CPC, and essential oils.
Meta-analyses of 6-month studies and recent research findings are presented in this course to document effectiveness of chlorhexidine 0.12% (CHX) in reducing plaque and gingivitis by 50-55%. An alcohol-free formulation is available for patients who need or desire that option. CHX also has been shown to have benefits during periodontal therapy, reducing halitosis and inflammation during healing after periodontal therapy.(1-4)
Essential oil mouthrinses (EO) are formulated with and without alcohol. Evidence supports effectiveness of the antiseptic formulation (with alcohol) as therapeutic for gingivitis. A meta-analysis of 6-month studies demonstrated antiplaque and antigingivitis effectiveness of EO about 60% of CHX, or a 30-35% reduction.(1,2) Alcohol-free EO formulations kill germs that cause bad breath and may contain fluoride for caries prevention. Post-procedural rinsing after periodontal therapy has been shown to reduce bacteremia in subjects with gingivitis. CHX and EO mouthrinses reduce peri-implant bleeding and inflammation.(4-5)
A meta-analysis of 6-month studies showed that studies of cetylpyridium chloride (CPC) had mixed results, perhaps related to various concentrations studied: 0.05%, 0.045%, and 0.07%. Differences in studies precluded strong evidence-based conclusions; however, the strongest evidence supports the 0.07% formulation for reducing plaque and gingivitis.(1-4)
A systematic review of oral rinsing and halitosis found that CHX & CPC mouthrinses reduce halitosis-producing bacteria on the tongue.(6,7) Mouthrinses with chlorine dioxide, zinc, chlorine dioxide plus zinc neutralize volatile sulfur compounds associated with bad breath. Stannous fluoride and triclosan copolymer in dentifrices are effective against halitosis.(7)
Dentifrices also are cosmetic and/or therapeutic for caries prevention, desensitization, antimicrobial action, anti-calculus, and whitening. Mechanisms of action of various formulations are reviewed in this course.
Fluoride dentifrices have been shown to prevent caries in children and adolescents.(8,9) Antimicrobial effectiveness for reduction of plaque and gingivitis has been shown with triclosan copolymer toothpaste and stannous fluoride dentifrices or gels.(10-12)
Dentifrices also have been marketed for reducing dentinal hypersensitivity. Two primary mechanisms: prevention of neural signals or blocking dentinal tubules. Active ingredients include: potassium nitrate, strontium salts and fluoride, Pro-Argin Technology (arginine, 1450 ppm F and calcium carbonate), amorphous calcium sodium phosphosilicate, 0.4% stannous fluoride gel, and 0.45% stannous fluoride dentifrice. Advantages and evidence supporting each of these choices are reviewed in this course.
Combinations of Agents for Caries and Gingivitis or Halitosis
The general rule is to obtain desired effects with as few agents and steps possible for increased compliance, less cost, and side effects. CHX has been shown to reduce S mutans; however, fluoride is needed for remineralization. CHX and fluoride use should be separated by one hour. A recent review indicated that CHX has not been shown to prevent enamel caries; however, supported CHX for prevention of root caries.(13)
Fluoride varnish and chlorhexidine-thymol varnish also have been shown to be effective in prevention of root caries in children and geriatric adults respectively.(14,15) A 3-year clinical trial showed CHX and fluoride in a caries risk assessment program reduced S mutans and resulted in about a 25% reduction in caries in high risk adults.(16)
Caries Risk Assessment
Recommendations for fluoride and antimicrobials for caries prevention should be based on caries risk assessment. This article reviews a validated method for assessing caries risk, CAMBRA, and provides an overview of treatment planning options for patients with low, moderate, and high risk.(17-21)
1. Moran JM. Home use oral hygiene products: mouthrinses. Periodontology 2000. 2008; 48:42-53.
2. Gunsolley JC. A meta-analysis of 6-month studies of antiplaque and antigingivitis studies. J Amer Dent Assoc 2006;137:1649-1657.
3. Haps S, Slot DE, Berchier CE, Van der Weijden GA. The effect of cetylpyridinium chloride-containing mouth rinses as adjuncts to toothbrushing on plaque and parameters of gingival inflammation: a systematic review. Int J Dent Hyg. 2008 Nov;6(4):290-303.
4. Zero DT. Dentifrices, mouthwashes, and remineralization/caries arrestment strategies. BMC Oral Health. 2006; 6(Suppl 1):S9. Published online 2006 June 15. DOI:10.1186/1472-6831-6-S1-S9.
5. Grusovin MG, Coulthard P, Worthington HV, George P, Esposito M. Interventions for replacing missing teeth: maintaining and recovering soft tissue health around dental implants. Cochrane Database of Systematic Reviews 2010, Issue 8. Art. No.: CD003069. DOI: 10.1002/14651858.CD003069.pub4.
6. Fedorowicz Z, Aljufairi H, Nasser M, Outhouse TL, Pedrazzi V. Mouthrinses for the treatment of halitosis. CochraneDatabase of Systematic Reviews 2008, Issue 4. Art. No.: CD006701. DOI: 10.1002/14651858.CD006701.pub2.
7. Scully C and Greenman J. Halitosis (breath odor). Periodontology 2000, Vol. 48, 2008, 66–75.
8. Walsh T, Worthington HV, Glenny AM, Appelbe P, Marinho VCC, Shi X. Fluoride toothpastes of different concentrations for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD007868. DOI: 10.1002/14651858.CD007868.pub2.
9. Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD002278. DOI:10.1002/14651858.CD002278.
10. Davies, RM. Toothpaste in the control of plaque/gingivitis and periodontitis. Periodont 2000. 2008;48:23-30.
11. Davies RM. The clinical efficacy of triclosan/copolymer and other common therapeutic approaches to periodontal health. Clin Microbiol Infect 2007;13(Supp 4):25-29.
12. Gunsolley JC. A meta-analysis of 6-month studies of antiplaque and antigingivitis studies. J Amer Dent Assoc 2006;137:1649-1657.
13. Rethman M. et al Nonfluoride caries-preventive agents Executive summary of evidence-based clinical recommendations. JADA 142(9): Sept. 2011.
14. Slots DE et al. The effect of chlorhexidine varnish on root caries: a systematic review. Caries Res. 2011;45(2):162-73. Epub 2011 Apr 27.
15. Tan HP et al. A Randomized Trial on Root Caries Prevention in Elders. J Dent Res 2010 89: 1086
16. Featherstone JD, White JM, Hoover CI, Rapozo-Hilo M, Weintraub JA, Wilson RS, Zhan L, Gansky SA. A randomized clinical trial of anticaries therapies targeted according to risk assessment (caries management by risk assessment). Caries Res. 2012;46(2):118-29. Epub 2012 Apr 3.
17. Dome’jean, S, White, JM, Featherstone, JDB. Validation of the CDA CAMBRA caries risk assessment – A six-year retrospective study. CDA Journal, October 2011
20. Marinho VCC, et al. Fluoride gels for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2002, Issue 1. Art. No.: CD002280. DOI: 10.1002/14651858.CD002280.
21. Francisco J, Ramos-Gomez FJ, Crall J, Gansky S, Slayton R, Geatherstone J. Caries risk assessment appropriate for the age 1 visit (infants and toddlers). J Calif Dent Assoc 2007;35(10):687-702.