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Should patients rinse after brushing?

This article will examine the evidence to support whether (and when) it is best simply to spit out toothpaste without rinsing, and when rinsing is appropriate, including why the prevention of caries versus periodontal disease requires a different approach.

Public Health England’s (PHE) toolkit, published in 2014, states: ‘[…] 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. ’1

It is important to note, however, that this guidance is pertinent when it comes to the prevention of caries rather than periodontal disease. As the toolkit 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. ’1

The advice that, to prevent caries in all adults, patients should spit out after brushing and not rinse, to maintain fluoride concentration levels, is based upon Grade III evidence, which is evidence from well-designed trials without randomisation, single group pre-post, cohort, time series of matched case-control studies.

Adult patients giving concern to their dentist (for example, those with obvious current active caries, who wear orthodontic appliances or suffer from xerostomia), should additionally use a fluoride mouth rinse daily (0.05% NaF-) at a different time to brushing. This advice has been assessed as Grade I evidence (i.e. strong evidence from at least one systematic review of multiple well-designed randomised control trial/s).

PHE’s 2014 toolkit further states: ‘To control gum disease the physical removal of plaque is the important element of toothbrushing as it reduces the inflammatory response of the gingivae and its sequelae. Some toothpastes contain ingredients which also reduce plaque, gingivitis and bleeding gums.’1 Supporting evidence Adding to the Toolkit’s recommendations, Pitts and colleagues (2012) examined the evidence base in relation to rinsing after tooth brushing and made practical recommendations. They wrote that: ‘Post-tooth brushing rinsing behaviours have the potential to either reduce or enhance the effectiveness of fluoride toothpaste and show wide variation in the general population. ’2

Having given due consideration to the evidence available at the time, 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.

Pitts and colleagues (2012) further asserted that: ‘To maintain the anticaries benefit of a standard fluoride toothpaste, a mouth rinse should […] contain at least 100 ppm fluoride if it is to be used at any time, including soon after brushing. A non-fluoride mouth rinse should preferably be applied at different times of the day to a standard fluoride toothpaste so as to avoid the ‘wash-out phenomenon’ that impacts on the benefit of the fluoride toothpaste. ’2

In 2016, Nelson and Labella also considered the use of mouthrinse and when best to administer it, 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. ’3

Moreover, in relation to periodontal disease, the 2015 Working Group 2 of the 11th European Workshop in Periodontology on the primary prevention of periodontitis suggested that: ‘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

Ultimately, it seems important to consider whether the advice in the PHE toolkit should hold for patients looking to control plaque levels and maintain good oral health, rather than focusing specifically on prevention of caries, for which a fluoride mouthwash may be best used between brushings rather than following with it immediately. 5

 

References

  1. Delivering better oral health: an evidence-based toolkit for prevention. Public Health England, 2014
  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
  3. Nelson G, Labella R. Response to a letter by James M. Oral health: an evidence-based approach. BDJ 2016; 221(3): 100
  4. Chapple ILC et al. Primary prevention of periodontitis: managing gingivitis. Clin Periodontol 2015; 42 (Suppl. 16): S71–S76
  5. Duckworth RM et al. Effect of rinsing with mouthwashes after brushing with a fluoridated toothpaste on salivary fluoride concentration. Caries Research 2009; 43: 391-396