Adjunctive support for plaque control
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Aims and objectives
In consideration of Working Group 2’s consensus at the 11th European Workshop in Periodontology on the circumstances in which the use of an adjunctive chemical agent for plaque control may support mechanical efforts,1 the aim of this article is to explore the current evidence regarding recommending a third step in their oral care routine to certain patients (i.e. for whom mechanical cleaning is insufficient).
On completing this CPD session, the reader will:
•Understand why some patients may benefit from the use of an adjunctive chemical agent for plaque control to support their mechanical efforts
•Understand expert opinion in relation to brushing, interdental cleaning and mouthwash use for patients with periodontal disease
•Understand the World Dental Federation’s (FDI) view on prevention and management of periodontal diseases in terms of an at-home oral health preventive regimen
•Understand the efficacy of some of the more commonly available chemotherapeutic ingredients in mouthwash
•Understand the dental team’s role in advising patients about mouthwash use.
Adjunctive support for plaque control
This article explores the current evidence regarding recommending mouthwash as an adjunct for patients for whom mechanical cleaning is insufficient to control plaque.
In 2005, Barnett wrote: ‘While it theoretically is possible to maintain a level of oral hygiene sufficient to control gingivitis using mechanical methods alone, data indicate that the vast majority of people are unable to accomplish this on an ongoing basis.2
The results gathered for the Adult Dental Health Survey 2009 appear to support this idea. It found that 66% of dentate adults had visible plaque on at least one tooth, despite 75% of respondents claiming to brush their teeth at least twice a day, and 25% of those also cleaning interdentally.3
This suggests that there is an, as yet, unmet need in terms of preventive oral health care.
Supporting this concept, in 2015, Working Group 2 of the 11th European Workshop in Periodontology reached a consensus that, for patients with periodontitis, the universal recommendation to brush twice daily for at least two minutes with a fluoridated toothpaste is likely to be insufficient.1
Chapple and colleagues (2015) wrote: ‘While mechanical plaque removal remains the bedrock of successful periodontal disease management, in high-risk patients it appears that the critical threshold for plaque accumulation to trigger periodontitis is low, and such patients may benefit from adjunctive agents for primary prevention of periodontitis.’1
They continued: ‘Expert opinion is that for periodontitis patients 2 min. [of brushing] is likely to be insufficient, especially when considering the need for additional use of inter-dental cleaning devices. In patients with gingivitis once daily inter-dental cleaning is recommended and the adjunctive use of chemical plaque control agents offers advantages in this group.’1
More recently, looking at periodontal disease as a whole, the FDI’s White Paper on Prevention and Management of Periodontal Diseases for Oral Health and General Health (2018) asserts that toothbrushing with a fluoride toothpaste achieves insufficient results, stating: ‘The additional use of flosses and/or interdental brushes is essential for removal of interdental plaque. In addition, according to the Guidelines for Effective Prevention of Periodontal Diseases produced by the EFP (2015), some specific mouth rinses offer benefit in the management and prevention of gingivitis, as do certain chemical agents in dentifrices as an adjunct to mechanical plaque removal.’4
Boyle and colleagues (2015) investigated mouthwash use and the prevention of plaque, gingivitis and caries. To that end, they explored the efficacy of chemotherapeutic ingredients including chlorhexidine, essential oils, cetylpyridinium and triclosan, concluding that each supports the use of mouthwash in preventing dental plaque to varying degrees.5
They found that over a period of less than three months, mouthwashes containing chlorhexidine were the most effective of the formulae considered, resulting in a reduction of dental plaque. When used for six months or longer, essential oil-containing mouthwash equalled or exceeded the effect of chlorhexidine in controlling plaque as an adjunct to mechanical cleaning. They further found that cetylpyridinium or triclosan may be effective, but less so than mouthwash containing chlorhexidine or essential oils.5
Adding a note on possible side effects, Boyle and colleagues (2015) reported that chlorhexidine may stain teeth or affect taste, making it, ‘[…] generally unacceptable for long-term use.’5
With this in mind, it would seem prudent to consider essential oils in further detail as a possible adjunct to mechanical cleaning for long-term use. In 2016, Araujo and colleagues’ meta-analysis demonstrated the clinically-relevant benefits of an essential oil-containing mouthrinse in site-specific areas of the mouth, when used as an adjunct to mechanical cleaning over a six-month period.6
Responder curves* plotted by the authors demonstrated that a mean average of 36.9% subjects using mechanical methods with essential oil-containing mouthrinses (MMEO) experienced at least 50% plaque-free sites after six months compared to just 5.5% of patients using mechanical methods alone (MM).6 A further responder curve for percent reduction in whole-mouth mean plaque index (PI) indicated that 83% of MMEO participants achieved a 20% reduction in PI from baseline in the six months of the study, compared to only 25% of MM subjects.6
Reasons to rinse
Explaining the motives behind their meta-analysis, Araujo and colleagues (2015) wrote that there were two reasons for using an antimicrobial mouthwash: 6
1. As an adjunct to mechanical methods to help control and inhibit plaque accumulation, which can assist in the prevention of gingivitis and dental decay
2. An an effective means of delivering antimicrobial agents to mucosal sites, facilitating the elimination of plaque bacteria otherwise capable of resettling on tooth surfaces above and below the gum line.
Looking at it from a practical perspective, Fernandez y Mostajo and colleagues (2017) wrote: ‘Currently, there is a wide range of over the counter mouthwashes products available, containing various active ingredients with […] specific indications. It is the role of the dental teams to advice [sic] the use of mouthwashes when indicated, which is justified when its efficacy has been proven by studies based on clinical evidence.’7
In terms of communicating the significance of using mouthwash to patients, Wilson and colleagues (2014) suggested: ‘It is important to recognise and remind patients that, currently, no mouthwash is a substitute for routine oral hygiene measures, which should be based on the twice-daily use of a toothbrush and fluoride-containing toothpaste, together with some form of interdental cleaning.’8
* Responder curves plot the proportion of participants within each treatment group achieving at least the given percentage of healthy sites, for all possible percentages of healthy sites (0-100%).6
Chapple ILC et al. Primary prevention of periodontitis: managing gingivitis. Clin Periodontol 2015; 42 (Suppl. 16): S71-S76
Barnett ML. The rationale for the daily use of an antimicrobial mouthrinse. JADA 2006; 137: 16S-21S
The Adult Dental Health Survey 2009. The Health and Social Care Information Centre 2011
White Paper on Prevention and Management of Periodontal Diseases for Oral Health and General Health. FDI World Dental Federation 2018
Boyle P et al. Mouthwash use and the prevention of plaque, gingivitis and caries. Head and Neck Oral Diseases 2014; 20 (Supp1): 1-68
Araujo MWB et al. Meta-analysis of the effect of an essential oil-containing mouthrinse on gingivitis and plaque. JADA 2015; 146(8): 610-622
Fernandez y Mostajo M et al. Effect of mouthwashes on the composition and metabolic activity of oral biofilms grown in vitro. Clin Oral Invest 2017; 21: 1221-1230
Wilson N et al. Question from practice: How to select the right mouthwash. The Pharmaceutical Journal 2014; 292(7795): 119