Revisiting Spit Don’t Rinse
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Aims and objectives
The aim of this article is to revisit the issue of when to rinse after brushing, including differentiating between the needs of patients at-risk of caries or periodontal disease, the potential effect on fluoride levels of rinsing with water, and why and when a mouthrinse might be appropriate to recommend to patients.
On completing this CPD session, the reader will:
• Understand the prevalence of rinsing after toothbrushing, and why it is so common
• Understand the need for oral hygiene procedures to complement one other
• Understand the recommendations in ‘Delivering better oral health: an evidence-based toolkit for prevention’ in relation to the prevention of caries, spitting and rinsing
• Understand when and how a patient might benefit from the use of a mouthwash as an adjunct to mechanical cleaning
• Understand that behavioural change may be required on the part of the dental team to achieve the best possible outcomes for patients.
Revisiting spit or rinse
Reflecting on the evidence presented in Public Health England’s ‘Delivering better oral health: an evidence-based toolkit for prevention’, this article revisits the issue of rinsing after brushing.
It has been suggested that fluoride toothpaste is the most commonly used topical fluoride modality for the prevention and control of caries.1 It has further been proposed that rinsing with water or a mouthwash is commonly practised, perhaps as a hangover from times when tooth cleaning products contained ingredients such as animal body parts, snail shells and even urine.1,2
This rinsing, however, may be counter-intuitive in modern times since, as Pitts and colleagues (2012) wrote: ‘Ideally oral hygiene procedures should complement each other, yet the method of rinsing and the product used for rinsing (for example, water, fluoride mouth rinse or antimicrobial mouth rinse) could potentially either reduce or enhance the effectiveness of fluoride toothpaste.’1
Adding to this view, Parnell and O’Mullane (2013) stated: ‘The intra-oral retention or substantivity of active ingredients in toothpastes is important for their effectiveness, and this is influenced by product-related and user-related factors. Product-related factors include the formulation and the compatibility of active and other agents in the toothpaste and the concentration of the active ingredient. User-related factors include biological aspects such as salivary flow and salivary clearance, and behavioural aspects, such as frequency and duration of brushing, amount of toothpaste used and post-brushing rinsing behaviour.’2
‘Delivering better oral health: an evidence-based toolkit for prevention’ offers guidance on the effect of rinsing after brushing in relation to the prevention and control of caries. The latest edition of the Toolkit, published in 2017, states: ‘To control caries it is the fluoride in toothpaste which is the important element of toothbrushing, as fluoride serves to prevent, control and arrest caries. Higher concentration of fluoride in toothpaste leads to better caries control.’3
It therefore follows that, ‘[…] rinsing with water, mouthwashes or mouth rinses (including fluoride rinses) immediately after toothbrushing will wash away the concentrated fluoride in the remaining toothpaste, thus diluting it and reducing its preventive effects. For this reason rinsing after toothbrushing should be discouraged.’3
The idea that adult patients should not rinse after brushing with a fluoridated toothpaste and, rather, just spit out the excess in the mouth, to maintain fluoride levels, is based on Grade III evidence.3 Evidence at this level is derived from from well-designed trials without randomisation, single group pre-post, cohort, time series, matched case-control studies.
For those patients whom dentists are concerned about in terms of caries susceptibility (i.e. those with obvious current active caries, who wear orthodontic appliances or suffer from xerostomia), the Toolkit suggests the use of a fluoride mouthwash daily (0.05% NaF) at a different time to brushing. This is based on Grade I evidence, which is strong evidence from at least one systematic review of multiple well-designed randomised control trial(s).3
The role of mouthwash
In 2015, Working Group 2 of the 11th European Workshop in Periodontology on the primary prevention of periodontitis considered the issue of rinsing with a mouthwash. They wrote: ‘When used as an adjunctive therapy to conventional manual tooth brushing with a fluoridated dentifrice, the use of chemical anti-plaque agents in mouth rinses or incorporated into the fluoridated dentifrice, alone or in combination, offers clear and significant improvements in managing gingival inflammation and preventing plaque accumulation.’4
In line with this view and the Toolkit, in 2016 Nelson and Labella offered an evidence-based overview on when to use a mouthwash to achieve the best possible outcomes, writing: ‘For the wider population who simply want to control plaque and maintain good oral health, the evidence suggests that rinsing with mouthwash after brushing is effective. This has the additional practical benefit of fitting mouthwash use into most people’s daily routine. Indeed, as caries is a multi-factorial disease, plaque control is one way to help reduce caries risk. In addition, as demonstrated in the scientific literature, using fluoride-containing mouthwash, rather than rinsing with water after brushing, can help maintain or boost the levels of fluoride exposure, at least during morning and evening oral hygiene routines.’5
Having analysed the guidelines available at the time of writing – and remaining in line with the Toolkit’s recommendations – Pitts and colleagues’ (2012) consensus statements included:
• Rinsing with water after brushing with fluoride toothpaste can reduce the benefit of fluoride toothpaste
• There is a theoretical benefit in keeping the intra-oral levels of fluoride elevated by replacing a post-brushing water rinse with a fluoride rinse
• Non-fluoride rinses should preferably be used before brushing or at a different time to brushing with fluoride toothpaste
• Mouth rinses containing fluoride can be used after brushing with fluoride toothpaste.1
Recognising the need to raise awareness of the truth behind the widely-disseminated spit don’t rinse message, Parnell and O’Mullane (2013) added: ‘Behaviour change may also be required on the part of the dental team as inconsistencies towards caries prevention, and specifically use of fluoride, have been noted among general dental practitioners in the UK. From a public health perspective, it is likely that investing in strategies to promote twice daily use of fluoride toothpaste has the potential to yield greater oral health benefits than focusing on changing post-brushing rinsing methods. The fact that low-frequency toothbrushing tends to be accompanied by smoking, unhealthy eating patterns and low levels of physical activity suggests that it may be useful to integrate oral disease prevention into general health promotion programmes using a ‘common risk factor approach'. It is important to understand the determinants of user-related factors such as frequency of brushing and rinsing behaviours to better target oral health care messages.’2
Pitts N et al. Post-brushing rinsing for the control of dental caries: exploration of the available evidence to establish what advice we should give our patients. BDJ 2012; 212(7): 315-320
Parnell C, O’Mullane D. After-brush rinsing protocols, frequency of toothpaste use: fluoride and other active ingredients. In: van Loveren C (ed). Toothpastes. Monogr Oral Sci. Basel, Karger, 2013; 23: 140-153
Delivering better oral health: an evidence-based toolkit for prevention. Public Health England, 2017
Chapple ILC et al. Primary prevention of periodontitis: managing gingivitis. Clin Periodontol 2015; 42 (Suppl. 16): S71–S76
Nelson G, Labella R. Response to a letter by James M. Oral health: an evidence-based approach. BDJ 2016; 221(3): 100