Introduction
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
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)
References
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19. .American Dental Association http://www.ada.org/.
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