When to use mouthwash - presenting two evidence-based consensuses

At the end of 2021, two thought-provoking events were organised by Johnson & Johnson Ltd.:

1. The National Advisory Panel (NAP)

2. The Hygienist Advisory Panel (HAP)

First to be held was the NAP, during which the key opinion leaders (KOLs) provided insight into how Johnson & Johnson Ltd. can best support primary care dental professionals in maintaining and improving the oral health of their patients, as well as building on the company’s continuing supportive partnership. The overarching aim of the event was to seek the KOLs’ views in relation to supporting and maintaining oral health in patients between appointments, specifically looking at mechanical cleaning, any limitations, and possible adjunctive support in the form of a chemotherapeutic mouthwash.

Ultimately, they agreed on an evidence-based consensus on mouthwash use (detailed at the end). A few weeks later, the inaugural HAP was held; as a natural progression from the NAP, and to deliver balance and perspective, it was critical to engage with this group, which, for many, represent the driving force of dental plaque management in the primary care setting. Working on the front line, dental hygienists and therapists are key to providing education and oral health instruction to patients and supporting them through behaviour and habit change between appointments for improved outcomes.

Therefore, like their counterparts at the NAP, the aim was to seek participants’ views in terms of maintaining oral health in patients between appointments, with a particular focus on mechanical cleaning and, potentially, the use of a chemotherapeutic mouthwash to offer adjunctive support. To assist these efforts, three presentations offered valuable insight into periodontal disease and caries. These included the science, evidence base and recommendations that support primary care practitioners’ decision-making in the pursuit of prevention, which then led to discussions amongst the two groups as to what guidance might be needed moving forward to tailor recommendations to the individual.

The global impact of periodontal health

Chairperson for both events, Prof. Iain Chapple, gave the first presentation of the day, looking at the global impact of periodontal health. With periodontitis being the most common human inflammatory disease, affecting 45 to 50% of the population,¹ the importance of early diagnosis and preventive care in an effort to stop gingivitis progressing to periodontitis was highlighted.

Interestingly, since it has been established that caries and periodontal disease have common risk factors such as socio-economic status, diet, smoking, obesity and diabetes, this means you cannot address one without the other, despite the fact that they have different patho-biological mechanisms. The session closed with a simple message, that if you can control plaque levels, there will be a benefit in terms of both caries and periodontal disease reductions.

Tackling a ubiquitous disease

Next up was Prof. Anthony Roberts, who offered a fresh perspective on periodontal health and disease, stating that periodontitis is a ubiquitous disease.² With the prevalence of this disease fully established by data revealed in the first two presentations of the day, there was a natural progression to discuss that a patient having persistent gingivitis matters because it means that they may progress to periodontitis,³ and therefore early intervention is important. Additionally worthy of note is the idea that health care materials shared with patients can be equally relevant to periodontal disease and caries prevention, and that a consistent approach is needed to ensure confusion does not follow.

Also on the agenda was the issue of patient engagement and the need for better daily plaque control and, for patients willing to engage, the use of adjunctive chemotherapeutics to support mechanical cleaning may be recommended for some patients in specific circumstances.⁴

Caries – a multi-risk condition

Prof. Chris Deery then took to the floor to speak about the current situation in relation to caries, which, like periodontal disease, is biofilm driven, requiring plaque control to halt the maturation of plaque for caries (which takes two to three days).⁵ Preventive care requires tooth brushing twice a day with a fluoridated toothpaste, with the public using a number of means to try to achieve good outcomes, such as powered toothbrushes, mouthwash or dental floss.⁶

How to meet the needs of children, teenagers and adults were covered, such as children's and teenagers' motivation for brushing being cosmetic. Together with their preference for powered brushes, this may mean they would use them more than they would manual brushes.⁷ Then, in a section focused on prevention and management of caries and periodontal disease, behaviour modification was discussed, mooting the idea that with the use of sealants, fluoride and improved diet, caries would be eliminated.

The consensus statements

Following each presentation, there was a group discussion and a review of the evidence. Ultimately, both groups had concluded there was need for simple recommendations to help primary care dental professionals support their patients’ plaque management efforts to best effect and therefore created consensus statements relevant to their work.

From the National Advisory Panel

‘Healthy gums don’t bleed. Effective toothbrushing and interdental cleaning is essential for keeping gums healthy. Mouthwashes containing fluoride (> 100 ppm F) that are clinically proven to reduce plaque offer additional benefit.’

Children over the age of 7 and adults:

'After brushing with a fluoride toothpaste, spit don't rinse with water and if gingival bleeding is present, use a daily fluoride containing mouthwash that is clinically proven to reduce plaque.’

From the Hygienist Advisory Panel

‘Healthy gums don’t bleed when brushed. Twice daily brushing along the gum line and cleaning in between the teeth is essential to support a healthy mouth. Fluoride mouthwashes clinically proven to reduce germs (plaque) offer additional benefit.’

Below the age of 7:

‘Spit don’t rinse.’

Over the age of 7:

‘For better gum health, after brushing spit and then rinse with a fluoride mouthwash that is clinically proven to reduce germs (plaque).’

Johnson & Johnson Ltd. looks forward to continuing to work in partnership with dental professionals following the insights gained from both the National Advisory Panel and the Hygienist Advisory Panel.

NAP key opinion leaders:

• Dr Nigel Carter, Chief Executive of the Oral Health Foundation
• Professor Iain Chapple, Director of Research within the Institute of Clinical Sciences, College of Medical and Dental Sciences, The University of Birmingham
• Professor Chris Deery, Dean of the School of Clinical Dentistry, University of Sheffield
• Professor Mike Milward, Professor of Periodontology at the University of Birmingham
• Professor Anthony Roberts, Professor / Consultant in Restorative Dentistry at Cork University Dental School and Hospital
• Miranda Steeples, President-Elect of the British Society of Dental Hygiene and Therapy
• Professor Nicola West, Professor in Restorative Dentistry, Bristol Dental School
• Professor Helen Whelton, Head of the College of Medicine and Health at University College Cork and Chief Academic Officer to the HSE South/South-West Hospital Group in Ireland.

The dental hygienists and therapists at the HAP:

• Hawa Azhar, multi-awardwinning dental hygienist and therapist based in Essex
• Laura Bailey, dental therapist, practising in Richmond
• Claire Berry, multi-award-winning hygienist based in Leeds
• Faye Donald, chair of the BSDHT North East Regional Group and a multi-award-winning hygienist
• Alison Edisbury, dental hygienist and therapist in private dental practice and Chair of BSDHT North West Regional Group
• Sarah Macdonald, award-winning orthodontic therapist in London
• Charlotte Manahan, dental hygienist and therapist currently practising in London
• Anna Middleton, award-winning dental hygienist in Chelsea and Knightsbridge and founder of London Hygienist
• Amber Ojak, award-winning dental therapist based in Edinburgh
• Anna Peterson, London-based dental hygienist and therapist
• Maya Samuel, dental therapist practising in London
• Benjamin Tighe, Tutor Dental Therapist at The Eastman and a dental therapist in private practice