The Role of Antimicrobial Mouth Rinses in Infection Prevention
The Role of Antimicrobial Mouth Rinses in Infection Prevention
The Role of Antimicrobial Mouth Rinses in Infection Prevention
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Mary Govoni, CDA, RDA, RDH, MBA<br />
<strong>The</strong> <strong>Role</strong> <strong>of</strong> <strong>Antimicrobial</strong><br />
<strong>Mouth</strong> <strong>R<strong>in</strong>ses</strong> <strong>in</strong> <strong>Infection</strong><br />
<strong>Prevention</strong><br />
Educational Objectives<br />
Upon completion <strong>of</strong> read<strong>in</strong>g these article, the cl<strong>in</strong>ician will be able to:<br />
1. Differentiate between the various types <strong>of</strong> mouth r<strong>in</strong>ses marketed as “antimicrobial” or<br />
“therapeutic”<br />
2. Identify the active <strong>in</strong>gredients <strong>in</strong> antimicrobial mouth r<strong>in</strong>ses and their mechanism <strong>of</strong><br />
action<br />
3. Determ<strong>in</strong>e whether utiliz<strong>in</strong>g a pre-procedural mouth r<strong>in</strong>se for all or some patients is<br />
valuable to patients and dental team members.
Introduction<br />
<strong>Mouth</strong> r<strong>in</strong>ses have been studied extensively for their potential benefits to patients for disease<br />
prevention, as well as the benefit to dental health pr<strong>of</strong>essionals for their potential to reduce<br />
exposure to oral microorganisms dur<strong>in</strong>g dental procedures.<br />
<strong>The</strong> studies have focused on three key areas. <strong>The</strong> first is the role <strong>of</strong> antimicrobial r<strong>in</strong>ses <strong>in</strong><br />
treatment and prevention <strong>of</strong> periodontal disease by kill<strong>in</strong>g or <strong>in</strong>hibit<strong>in</strong>g the growth <strong>of</strong> bacteria that<br />
cause g<strong>in</strong>givitis and periodontitis. Second is their role <strong>in</strong> the prevention <strong>of</strong> bacteremia, by<br />
reduc<strong>in</strong>g the number <strong>of</strong> microorganisms <strong>in</strong> the oral cavity which might be <strong>in</strong>troduced <strong>in</strong>to the<br />
bloodstream dur<strong>in</strong>g dental procedures. <strong>The</strong> third is <strong>in</strong>fection prevention and safety for the dental<br />
team and patients by reduc<strong>in</strong>g the number <strong>of</strong> microorganisms <strong>in</strong> saliva that may become<br />
airborne dur<strong>in</strong>g dental procedures.<br />
In addition, the types <strong>of</strong> antimicrobial agents <strong>in</strong> the mouthr<strong>in</strong>ses have also been studied and<br />
compared for their effectiveness <strong>in</strong> reduc<strong>in</strong>g microorganisms, as well as potential side effects <strong>of</strong><br />
us<strong>in</strong>g the r<strong>in</strong>ses. This course will exam<strong>in</strong>e the uses <strong>of</strong> antimicrobial mouth r<strong>in</strong>ses prior to dental<br />
procedures and the potential benefits to both patients and dental health pr<strong>of</strong>essionals. In order<br />
to understand the value <strong>of</strong> antimicrobial mouthr<strong>in</strong>ses, it is important to understand the types <strong>of</strong><br />
r<strong>in</strong>ses available and their mechanism <strong>of</strong> action.<br />
Types <strong>of</strong> <strong>Mouth</strong> <strong>R<strong>in</strong>ses</strong><br />
<strong>Mouth</strong> r<strong>in</strong>ses are available <strong>in</strong> over-the-counter (OTC) formulations as well as <strong>in</strong> prescription-only<br />
formulations. Oral r<strong>in</strong>ses can be categorized by their <strong>in</strong>gredients or mode <strong>of</strong> action. For<br />
example, many OTC mouth r<strong>in</strong>ses are meant to be cosmetic – to freshen breath, or whiten<br />
teeth. <strong>The</strong>y conta<strong>in</strong> active <strong>in</strong>gredients, such as flavor<strong>in</strong>g oils and/or hydrogen peroxide, which is<br />
a whiten<strong>in</strong>g agent. Other OTC r<strong>in</strong>ses are categorized as therapeutic, mean<strong>in</strong>g that they conta<strong>in</strong><br />
an <strong>in</strong>gredient that is meant to protect aga<strong>in</strong>st disease, such as caries or g<strong>in</strong>givitis. <strong>The</strong>se r<strong>in</strong>ses<br />
may conta<strong>in</strong> fluoride or other <strong>in</strong>gredients, such as chlorhexad<strong>in</strong>e (CHX) or cetylpyrid<strong>in</strong>ium<br />
chloride (CPC), or essential oils, which we will discuss later. Many <strong>of</strong> the OTC oral r<strong>in</strong>ses are a<br />
comb<strong>in</strong>ation <strong>of</strong> both cosmetic and therapeutic characteristics, while the prescription r<strong>in</strong>ses<br />
typically conta<strong>in</strong> one key active <strong>in</strong>gredient, such as fluoride or CHX. Table 1 compares the<br />
characteristics <strong>of</strong> cosmetic and therapeutic oral r<strong>in</strong>ses.<br />
<strong>The</strong>rapeutic oral r<strong>in</strong>ses are regulated by the Food and Drug Adm<strong>in</strong>istration (FDA), whether they<br />
are OTC or prescription-only. In order to make a claim that a product has therapeutic value, it<br />
must go through rigorous test<strong>in</strong>g by the FDA to prove its safety and efficacy. <strong>The</strong> FDA has taken<br />
action aga<strong>in</strong>st some manufacturers <strong>of</strong> mouth r<strong>in</strong>ses for unsubstantiated claims <strong>of</strong> effectiveness<br />
<strong>in</strong> prevent<strong>in</strong>g plaque formation and antimicrobial activity. <strong>The</strong>se r<strong>in</strong>ses are approved as<br />
antimicrobial “drugs”, s<strong>in</strong>ce they act chemically to kill bacteria. In addition to FDA approval, OTC<br />
therapeutic oral r<strong>in</strong>ses may also receive the Seal <strong>of</strong> Acceptance from the American Dental<br />
Association (ADA), which is a voluntary acceptance or approval for products that have met<br />
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certa<strong>in</strong> safety and efficacy requirements. Additional <strong>in</strong>formation regard<strong>in</strong>g the FDA approval<br />
process is available at: http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/<br />
DeviceApprovalsandClearances/default.htm. And <strong>in</strong>formation regard<strong>in</strong>g the ADA Seal program<br />
is available at: http://www.ada.org/sealprogramproducts.aspx.<br />
It should be noted that the FDA has also approved a r<strong>in</strong>se that forms a physical barrier on teeth<br />
– a surfactant – that prevents the attachment <strong>of</strong> plaque bacteria on tooth surfaces, mak<strong>in</strong>g it<br />
easier to remove. This type <strong>of</strong> r<strong>in</strong>se, which conta<strong>in</strong>s Delmop<strong>in</strong>ol, is approved by the FDA as a<br />
medical device, s<strong>in</strong>ce its action is physical rather than chemical. It is available as an OTC r<strong>in</strong>se.<br />
While the studies show positive results with this type <strong>of</strong> r<strong>in</strong>se,, its action is not one that would<br />
lend itself to use as a pre-procedural mouthr<strong>in</strong>se, s<strong>in</strong>ce it does not kill microorganisms.<br />
S<strong>in</strong>ce many therapeutic mouthr<strong>in</strong>ses claim to kill or <strong>in</strong>hibit the growth <strong>of</strong> microorganisms that<br />
cause periodontal disease, some may be further categorized as antimicrobial oral r<strong>in</strong>ses. <strong>The</strong>se<br />
types <strong>of</strong> r<strong>in</strong>ses typically conta<strong>in</strong> one <strong>of</strong> three active <strong>in</strong>gredients: chlorhexad<strong>in</strong>e gluconate (CHX),<br />
cetylpyrid<strong>in</strong>ium chloride (CPC) or essential oils – conta<strong>in</strong><strong>in</strong>g r<strong>in</strong>ses. <strong>The</strong> essential oil r<strong>in</strong>ses,<br />
sometimes referred to as phenolics, may conta<strong>in</strong> <strong>in</strong>gredients such as thymol, menthol,<br />
eucalyptol, or eugenol; alone or <strong>in</strong> comb<strong>in</strong>ation. <strong>The</strong>se antimicrobial oral r<strong>in</strong>ses have been<br />
studied extensively for safety and efficacy with regard to treatment and prevention <strong>of</strong> periodontal<br />
disease, their potential for reduc<strong>in</strong>g bacteremia dur<strong>in</strong>g dental procedures and for their potential<br />
for reduc<strong>in</strong>g the number <strong>of</strong> microorganisms <strong>in</strong> the splash, splatter or aerosol <strong>of</strong> saliva dur<strong>in</strong>g<br />
dental procedures. <strong>The</strong> research strongly supports the <strong>in</strong>corporation <strong>of</strong> antimicrobial mouth<br />
r<strong>in</strong>ses <strong>in</strong>to the oral hygiene protocol for patients who have g<strong>in</strong>givitis and periodontitis., In<br />
addition, these r<strong>in</strong>se agents are <strong>of</strong>ten used as irrigat<strong>in</strong>g solutions dur<strong>in</strong>g dental hygiene<br />
procedures, such as ultrasonic scal<strong>in</strong>g. Table 2 lists common brands <strong>of</strong> therapeutic r<strong>in</strong>ses and<br />
their active <strong>in</strong>gredients.<br />
Comparison <strong>of</strong> Active Ingredients <strong>in</strong> <strong>The</strong>rapeutic Oral <strong>R<strong>in</strong>ses</strong><br />
Chlorhexad<strong>in</strong>e gluconate (CHX) is an antiseptic – a cationic bis-biguanide that is used for<br />
numerous applications. In dentistry it is used as a dental unit waterl<strong>in</strong>e dis<strong>in</strong>fectant, as a gelat<strong>in</strong>like<br />
chip for placement <strong>in</strong>to periodontal pockets at high concentration <strong>of</strong> 36% and as a mouth<br />
r<strong>in</strong>se at lower concentration <strong>of</strong> 0.12% <strong>in</strong> the United States. <strong>The</strong> CHX oral r<strong>in</strong>se is a prescriptiononly<br />
product that has been widely prescribed for periodontal patients for a number <strong>of</strong> years and<br />
its effectiveness is well documented.<br />
It is effective on both gram-positive and gram-negative bacteria, which is particularly beneficial<br />
<strong>in</strong> prevention <strong>of</strong> plaque formation, which is normally composed <strong>of</strong> gram-positive bacteria and is<br />
a key factor <strong>in</strong> the development <strong>of</strong> g<strong>in</strong>givitis and its progression to periodontitis, <strong>in</strong> which grampositive<br />
bacteria and gram-negative bacteria are present. Chlorhexad<strong>in</strong>e gluconate works by<br />
adsorption <strong>in</strong>to the pellicle on tooth enamel, to the hydroxyapatite <strong>of</strong> the enamel, to plaque<br />
bacteria and mucous membranes, which provides a long-last<strong>in</strong>g bacteriostatic and bactericidal<br />
effect, <strong>in</strong>hibit<strong>in</strong>g bacterial colonization <strong>of</strong> plaque. CHX r<strong>in</strong>ses come <strong>in</strong> both alcohol and alcoholwww.ColgateOralHealthNetwork.com<br />
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free formulas. Alcohol is not an active <strong>in</strong>gredient <strong>in</strong> the r<strong>in</strong>se, but is a solubilizer or delivery<br />
vehicle for the other <strong>in</strong>gredients. Some patients are sensitive to the burn<strong>in</strong>g sensation <strong>of</strong><br />
alcohol-conta<strong>in</strong><strong>in</strong>g mouth r<strong>in</strong>ses, especially if they experience xerostomia. In addition, patients<br />
who have issues with alcohol abuse are not candidates for use <strong>of</strong> alcohol-conta<strong>in</strong><strong>in</strong>g mouth<br />
r<strong>in</strong>ses. Long term use <strong>of</strong> CHX oral r<strong>in</strong>ses has been shown to cause brownish discoloration <strong>of</strong><br />
the teeth and some restorations, as well as some sta<strong>in</strong><strong>in</strong>g <strong>of</strong> the tongue and g<strong>in</strong>giva. It should<br />
be noted, however, that heavy sta<strong>in</strong><strong>in</strong>g on teeth has been shown to be associated with<br />
unremoved plaque, which can be decreased with improved oral hygiene. It can also cause a<br />
change <strong>in</strong> taste perception for some patients.<br />
Cetylpyrid<strong>in</strong>ium chloride (CPC) is also an antiseptic – a cationic quaternary ammonium<br />
compound which is used <strong>in</strong> products such as toothpaste, nasal sprays, and more recently <strong>in</strong><br />
mouth r<strong>in</strong>ses <strong>in</strong> a .45% to 10% concentration. CPC r<strong>in</strong>ses are more recent additions to the<br />
antimicrobial therapeutic r<strong>in</strong>se category and have also been extensively studied for their<br />
effectiveness, which is said to be comparable to CHX r<strong>in</strong>ses. In addition to the concentration <strong>of</strong><br />
the CPC <strong>in</strong> a therapeutic r<strong>in</strong>se, it is important that the other <strong>in</strong>gredients <strong>in</strong> the r<strong>in</strong>se, such as<br />
solubilizers (sometimes alcohol), preservatives and stabilizers do not have a negative effect on<br />
the bioavailability <strong>of</strong> the CPC. Higher bioavailability is will <strong>in</strong>crease the effectiveness <strong>of</strong> the r<strong>in</strong>se.<br />
CPC r<strong>in</strong>ses have been shown to prevent the formation <strong>of</strong> plaque and reduce g<strong>in</strong>givitis, a<br />
precursor to periodontitis, by penetrat<strong>in</strong>g the cell walls <strong>of</strong> bacteria, which causes leakage and<br />
eventually death <strong>of</strong> the bacteria. Like CHX, CPC is a long-act<strong>in</strong>g agent, shown to be bioactive <strong>in</strong><br />
the mouth for up to 12 hours after us<strong>in</strong>g the r<strong>in</strong>se due to its ability to adhere to the teeth. CPC<br />
mouth r<strong>in</strong>ses are also available <strong>in</strong> both alcohol and alcohol-free formulas. A dist<strong>in</strong>ct advantage<br />
<strong>of</strong> CPC mouthr<strong>in</strong>ses is that they are OTC products, mak<strong>in</strong>g them more readily available to<br />
patients.<br />
Essential Oils formulations are OTC r<strong>in</strong>ses. <strong>The</strong> essential oil formulation that has been<br />
approved by the FDA as a therapeutic oral r<strong>in</strong>se is that <strong>of</strong> Lister<strong>in</strong>e®, with a composition <strong>of</strong><br />
eucalyptol, menthol, methyl salicylate, and thymol which are delivered <strong>in</strong> an alcohol base.<br />
<strong>R<strong>in</strong>ses</strong> with essential oils as their active <strong>in</strong>gredients are able to disrupt cell membranes and also<br />
<strong>in</strong>hibit the enzyme activity <strong>of</strong> cells, which makes the products bacteriostatic or bactericidal.<br />
Because alcohol is the delivery vehicle for this formulation, patients may experience burn<strong>in</strong>g<br />
and it is not the most appropriate choice for patients with xerostomia or who are alcohol<br />
abusers. Essential oils r<strong>in</strong>ses have not been proven to have the adhesive properties <strong>of</strong> CHX and<br />
CPC products, therefore they have more limited bioavailability.<br />
<strong>Mouth</strong>r<strong>in</strong>ses and <strong>Prevention</strong> <strong>of</strong> Bacteremia<br />
<strong>Antimicrobial</strong> mouth r<strong>in</strong>ses used by the patient before a dental procedure can decrease the<br />
number <strong>of</strong> microorganisms <strong>in</strong>troduced <strong>in</strong>to the patient's bloodstream dur<strong>in</strong>g <strong>in</strong>vasive dental<br />
procedures. <strong>The</strong> scientific evidence is not clear, however, that reduc<strong>in</strong>g the number <strong>of</strong><br />
microorganisms through mouth r<strong>in</strong>s<strong>in</strong>g directly reduces the <strong>in</strong>cidence <strong>of</strong> bacteremia. In its 1997<br />
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guidel<strong>in</strong>es for antibiotic prophylaxis, the American Heart Association (AHA) recommended the<br />
use <strong>of</strong> pre-procedural mouth r<strong>in</strong>ses for patients at risk for bacteremia dur<strong>in</strong>g dental procedures.<br />
In its most current guidel<strong>in</strong>es, the AHA does not mention pre-procedural mouth r<strong>in</strong>s<strong>in</strong>g. In<br />
addition, the American Academy <strong>of</strong> Orthopaedic Surgeons (AAOS) also states <strong>in</strong> their 2012<br />
guidel<strong>in</strong>es on <strong>Prevention</strong> <strong>of</strong> Orthopaedic Implant <strong>Infection</strong> <strong>in</strong> Patients Undergo<strong>in</strong>g Dental<br />
Procedures that the evidence is <strong>in</strong>conclusive to support the use <strong>of</strong> topical antimicrobials (mouth<br />
r<strong>in</strong>ses) to prevent orthopaedic implant <strong>in</strong>fections. Further study is needed to determ<strong>in</strong>e the<br />
effectiveness <strong>of</strong> pre-procedural mouth r<strong>in</strong>s<strong>in</strong>g for reduc<strong>in</strong>g dental procedure-<strong>in</strong>duced bacteremia<br />
and the <strong>in</strong>cidence <strong>of</strong> bacteremia <strong>in</strong> patients who have underly<strong>in</strong>g risks.<br />
<strong>Mouth</strong> <strong>R<strong>in</strong>ses</strong> for Environmental <strong>Infection</strong> Control<br />
<strong>The</strong> third issue related to pre-procedural mouth r<strong>in</strong>s<strong>in</strong>g is that <strong>of</strong> reduc<strong>in</strong>g the number <strong>of</strong> bacteria<br />
<strong>in</strong> the saliva dur<strong>in</strong>g dental procedures that <strong>in</strong>volve the creation <strong>of</strong> aerosols, spatter and spray.<br />
<strong>The</strong>se procedures <strong>in</strong>clude the use <strong>of</strong> a high and slow speed handpieces, air/water syr<strong>in</strong>ges and<br />
ultrasonic scalers. <strong>The</strong> most effective way to reduce the aerosol and spatter contam<strong>in</strong>ation is to<br />
use a dental dam. But a dental dam would <strong>in</strong>terfere with hygiene procedures, such as ultrasonic<br />
scal<strong>in</strong>g and polish<strong>in</strong>g. And the use <strong>of</strong> dental dam for restorative procedures may take additional<br />
time and <strong>in</strong>strumentation that many practices choose not to adapt <strong>in</strong>to their protocols. In this<br />
case, a pre-procedural antibacterial mouth r<strong>in</strong>se is a simple way to decrease the potential for<br />
aerosol contam<strong>in</strong>ation <strong>in</strong> the treatment rooms.<br />
While the Centers for Disease Control and <strong>Prevention</strong> (CDC) does not specifically recommend<br />
pre-procedural mouthr<strong>in</strong>ses as an <strong>in</strong>fection prevention protocol, there is evidence that us<strong>in</strong>g an<br />
antimicrobial mouthr<strong>in</strong>se prior to procedures can reduce the potential for is contam<strong>in</strong>ation <strong>of</strong><br />
equipment and environmental surfaces. Accord<strong>in</strong>g to the CDC, the spray from dental<br />
procedures typically conta<strong>in</strong>s large-particle spatter or spray <strong>of</strong> water, saliva, blood,<br />
microorganisms and other debris (tooth, restorative material, calculus). <strong>The</strong> spatter has been<br />
shown to travel only short distances from the patient’s mouth, which would potentially<br />
contam<strong>in</strong>ate equipment (e.g. bracket tray), operatory surfaces (counter tops or other work<br />
surfaces) and the dental team members and patients. Aerosol, on the other hand is composed<br />
<strong>of</strong> much smaller particles and can rema<strong>in</strong> airborne for long periods <strong>of</strong> time and can pose an<br />
<strong>in</strong>halation risk for dental team members. It is important to note, however, that there is no<br />
evidence <strong>of</strong> transmission <strong>of</strong> bloodborne pathogens, such as hepatitis B or C or HIV/AIDS<br />
through exposure to aerosol or spatter <strong>in</strong> dentistry. <strong>The</strong> use <strong>of</strong> pre-procedural mouthr<strong>in</strong>ses is an<br />
additional safeguard that could be employed by dental practices for protection aga<strong>in</strong>st other<br />
types <strong>of</strong> microorganisms, such as the <strong>in</strong>fluenza virus. But dental teams should utilize dental<br />
dams and high volume evacuation as their first l<strong>in</strong>e <strong>of</strong> defense aga<strong>in</strong>st spatter and<br />
aerosolization <strong>of</strong> saliva and blood dur<strong>in</strong>g dental procedures. It is also important to note that the<br />
use <strong>of</strong> pre-procedural mouthr<strong>in</strong>ses does not preclude the need for environmental clean<strong>in</strong>g and<br />
dis<strong>in</strong>fection <strong>of</strong> equipment and surfaces follow<strong>in</strong>g treatment. Although the mouthr<strong>in</strong>se may<br />
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decrease the number <strong>of</strong> microorganisms, it does not reduce the spatter, unless high-volume<br />
suction or dental dam is used.<br />
S<strong>in</strong>ce hygiene procedures are the least likely to have high volume evacuation utilized, and the<br />
use <strong>of</strong> dental dam is not appropriate, pre-procedural mouthr<strong>in</strong>ses make the most sense for use<br />
prior to hygiene procedures. Not only can the mouthr<strong>in</strong>se reduce microorganisms, but it<br />
provides an excellent opportunity for the hygienist to <strong>in</strong>troduce the concept <strong>of</strong> utiliz<strong>in</strong>g an<br />
antimicrobial mouthr<strong>in</strong>se as part <strong>of</strong> rout<strong>in</strong>g oral health care for the patients. <strong>The</strong> hygienist has an<br />
opportunity to educate the patients about the benefits <strong>of</strong> antimicrobial r<strong>in</strong>ses <strong>in</strong> controll<strong>in</strong>g<br />
plaque formation and treat<strong>in</strong>g periodontal disease. <strong>The</strong> education process can also <strong>in</strong>clude<br />
<strong>in</strong>formation about the most appropriate antimicrobial r<strong>in</strong>se for each patient, such as alcohol-free<br />
formulas, and the long last<strong>in</strong>g effects <strong>of</strong> CPC and CHX mouthr<strong>in</strong>ses. Hav<strong>in</strong>g the patient utilize<br />
the antimicrobial mouthr<strong>in</strong>se prior to a procedure is a strong endorsement <strong>of</strong> the belief <strong>in</strong> the<br />
therapeutic value <strong>of</strong> us<strong>in</strong>g the r<strong>in</strong>se and opens the door for additional dialogue with the patient<br />
about their oral health and the need to control oral microorganisms that can cause disease. It<br />
also provides the opportunity for the hygienist to differentiate between cosmetic and therapeutic<br />
mouthr<strong>in</strong>ses, the research that supports the use <strong>of</strong> therapeutic mouthr<strong>in</strong>ses and the benefits to<br />
the patient.<br />
Implementation <strong>of</strong> a Pre-Procedural <strong>Mouth</strong>r<strong>in</strong>se Protocol:<br />
If a practice implements a pre-procedural mouthr<strong>in</strong>se protocol, the first step is to decide if the<br />
protocol will apply to all procedures or just to hygiene procedures. Although the data <strong>in</strong>dicates<br />
that the most benefit is ga<strong>in</strong>ed when no dental dam or high volume evacuation is utilized, the<br />
patient and the team can certa<strong>in</strong>ly benefit from the r<strong>in</strong>se be<strong>in</strong>g used for all hygiene, restorative<br />
and surgical procedures. Aga<strong>in</strong>, this makes a positive statement to patients regard<strong>in</strong>g the<br />
benefit <strong>of</strong> antimicrobial mouthr<strong>in</strong>ses. <strong>The</strong> next step is evaluat<strong>in</strong>g products and determ<strong>in</strong><strong>in</strong>g<br />
which product or products are most appropriate to use. As mentioned earlier, the three types <strong>of</strong><br />
products that are classified by the FDA and therapeutic, antimicrobial r<strong>in</strong>ses are those that<br />
conta<strong>in</strong> CPP, CHX and Essential Oils. If a practice wishes to select a product that will work will<br />
all types <strong>of</strong> patients, <strong>in</strong>clud<strong>in</strong>g those with xerostomia and who have alcohol abuse issues, than<br />
an alcohol-free product is the most appropriate. <strong>The</strong>re are alcohol-free formulations <strong>of</strong> most<br />
FDA approved antimicrobial mouthr<strong>in</strong>ses. Table 3 lists commonly recommended or prescribed<br />
products with alcohol-free formulas. Another consideration is the potential for sta<strong>in</strong><strong>in</strong>g <strong>of</strong> the<br />
teeth which is a common occurrence with CHX and CPC r<strong>in</strong>ses, although CPC r<strong>in</strong>ses have<br />
been shown to cause less severe sta<strong>in</strong><strong>in</strong>g. If a patient has anterior composite restorations,<br />
especially older restorations, there may be some sta<strong>in</strong><strong>in</strong>g that occurs when the r<strong>in</strong>se is utilized.<br />
For a hygiene procedure, however, the sta<strong>in</strong> will be easily removed if the teeth are polished.<br />
Other considerations may be the flavor, cost and availability. CPC and essential oil mouthr<strong>in</strong>ses<br />
are available as OTC products, whereas CHX r<strong>in</strong>ses are prescription-only. If the hygienist or<br />
other dental team member wants to re<strong>in</strong>force the use <strong>of</strong> the antimicrobial r<strong>in</strong>se for the patient on<br />
a daily basis at home, this may be a consideration for some patients and possibly for the<br />
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practice, s<strong>in</strong>ce the OTC products may be less expensive to utilize <strong>in</strong> the <strong>of</strong>fice than prescription<br />
products.<br />
Once the type and brand <strong>of</strong> mouthr<strong>in</strong>se has been selected, the team should develop a protocol<br />
for <strong>in</strong>troduc<strong>in</strong>g the mouth r<strong>in</strong>s<strong>in</strong>g procedure <strong>in</strong>to the practice. <strong>The</strong> team should decide whether<br />
to utilize the mouthr<strong>in</strong>se for all operative and hygiene procedures or only for hygiene<br />
procedures. <strong>The</strong> patients should be <strong>in</strong>formed and educated about the benefits <strong>of</strong> utiliz<strong>in</strong>g the<br />
mouth r<strong>in</strong>se and given <strong>in</strong>formation about the product used. This <strong>in</strong>formation is readily available<br />
from the product manufacturer.<br />
It may also be beneficial to provide samples if it is an OTC r<strong>in</strong>se, or to have prescription-only<br />
products available to dispense to patients. OTC products could be sold <strong>in</strong> the practice as well,<br />
which can make it convenient for patients and potentially <strong>in</strong>crease their compliance with us<strong>in</strong>g<br />
the r<strong>in</strong>ses at home. If a practice chooses not to dispense prescription-only r<strong>in</strong>ses, it is<br />
recommended to have prescrib<strong>in</strong>g <strong>in</strong>formation readily available <strong>in</strong> the practice management<br />
s<strong>of</strong>tware or pre-pr<strong>in</strong>ted prescriptions to give to the patients.<br />
<strong>The</strong> pre-procedural r<strong>in</strong>se is adm<strong>in</strong>istered to the patient soon after they are seated and the<br />
appropriate explanations are given. <strong>The</strong> patient is given a disposable cup with the appropriate<br />
amount <strong>of</strong> r<strong>in</strong>se, <strong>in</strong>structed to swish for the time recommended on the product, and can then spit<br />
it out <strong>in</strong> the s<strong>in</strong>k <strong>in</strong> the operatory or it can be evacuated with the suction.<br />
Conclusions:<br />
<strong>The</strong> therapeutic value <strong>of</strong> antimicrobial mouthr<strong>in</strong>ses has been well documented by current<br />
research for the control <strong>of</strong> plaque formation and <strong>in</strong> treat<strong>in</strong>g g<strong>in</strong>givitis and periodontitis. While<br />
there is no compell<strong>in</strong>g evidence that suggests that utiliz<strong>in</strong>g pre-procedural mouthr<strong>in</strong>ses is<br />
effective <strong>in</strong> controll<strong>in</strong>g the <strong>in</strong>troduction <strong>of</strong> microorganisms <strong>in</strong>to the bloodstream dur<strong>in</strong>g dental<br />
procedures and potentially prevent<strong>in</strong>g bacteremia, there is also no compell<strong>in</strong>g evidence that<br />
suggests that this practice is harmful to patients, if the appropriate r<strong>in</strong>se is used. <strong>The</strong> evidence<br />
is also not conclusive that the use <strong>of</strong> a pre-procedural mouthr<strong>in</strong>se can prevent the transmission<br />
<strong>of</strong> an <strong>in</strong>fectious disease by decreas<strong>in</strong>g the number <strong>of</strong> microorganisms <strong>in</strong> the spatter and aerosol<br />
produced dur<strong>in</strong>g dental procedures. But decreas<strong>in</strong>g the number if microorganisms that can<br />
potentially contam<strong>in</strong>ate equipment and surfaces <strong>in</strong> a treatment room through spatter, and <strong>in</strong> the<br />
aerosol produced, can help provide a safer environment for both the patients and the dental<br />
team members. <strong>The</strong> true value <strong>of</strong> us<strong>in</strong>g a pre-procedural antimicrobial mouthr<strong>in</strong>se may be <strong>in</strong> the<br />
example that it provides for patients and the re<strong>in</strong>forcement that they may receive about the<br />
usefulness <strong>of</strong> these r<strong>in</strong>ses <strong>in</strong> their every-day home care. If the dental team believes <strong>in</strong> the<br />
therapeutic value <strong>of</strong> the r<strong>in</strong>ses they can, by their example, re<strong>in</strong>force this concept with their<br />
patients on a regular basis.<br />
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Table 1<br />
Type <strong>of</strong> R<strong>in</strong>se<br />
Cosmetic<br />
<strong>The</strong>rapeutic<br />
Characteristics<br />
over the counter (OTC)<br />
controls bad breath – temporarily<br />
refreshes the mouth<br />
helps to remove food and debris before or after<br />
brush<strong>in</strong>g<br />
over the counter (OTC) or prescription<br />
controls bad breath – temporarily<br />
refreshes the mouth<br />
helps to remove food and debris before or after<br />
brush<strong>in</strong>g<br />
regulated by the FDA<br />
conta<strong>in</strong> an added <strong>in</strong>gredient that helps to protect<br />
aga<strong>in</strong>st some oral disease (e.g.caries or periodontal<br />
disease)<br />
may have voluntary Seal <strong>of</strong> Acceptance from ADA<br />
Table 2<br />
Oral R<strong>in</strong>se Manufacturer Active Ingredient How Sold<br />
Peridex 3M ESPE CHX Prescription<br />
Periogard Colgate CHX Prescription<br />
Paroex Sunstar Butler CHX Prescription<br />
Oris Dentsply CHX Prescription<br />
Crest Pro Health Procter & Gamble CPC OTC<br />
Colgate Total Advanced<br />
Pro-Shield<br />
Colgate CPC OTC<br />
Lister<strong>in</strong>e Johnson & Johnson Essential Oil OTC<br />
Table 3<br />
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Preventive antibiotics prior to a dental procedure are advised for patients with:<br />
1.artificial heart valves<br />
2.a history <strong>of</strong> <strong>in</strong>fective endocarditis<br />
3.certa<strong>in</strong> specific, serious congenital (present from birth) heart conditions, <strong>in</strong>clud<strong>in</strong>g<br />
I.unrepaired or <strong>in</strong>completely repaired cyanotic congenital heart disease, <strong>in</strong>clud<strong>in</strong>g those with palliative<br />
shunts and conduits<br />
II.a completely repaired congenital heart defect with prosthetic material or device, whether placed by<br />
surgery or by catheter <strong>in</strong>tervention, dur<strong>in</strong>g the first six months after the procedure<br />
III.any repaired congenital heart defect with residual defect at the site or adjacent to the site <strong>of</strong> a<br />
prosthetic patch or a prosthetic device<br />
4.a cardiac transplant that develops a problem <strong>in</strong> a heart valve.<br />
American Heart Association 2007<br />
Table 4<br />
Brand Name<br />
Colgate Total Advanced Pro-Shield<br />
Crest Pro Health R<strong>in</strong>se<br />
GUM CHX R<strong>in</strong>se<br />
Paroex<br />
Periogard Alcohol Free<br />
Formula<br />
CPC<br />
CPC<br />
CHX<br />
CHX<br />
CHX<br />
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References<br />
1. Elworthy AJ, Edgar R, Moran J, et al. A 6-month home-usage trial <strong>of</strong> 0.1% and 0.2% delmop<strong>in</strong>ol<br />
mouthwashes(II). Effects on the plaque micr<strong>of</strong>lora. Journal <strong>of</strong> Cl<strong>in</strong>ical Periodontology. 1995: 2(7):<br />
527-532.<br />
2. Claydon N, Hunter L, Moran J, et al. A 6-month home-use trial <strong>of</strong> <strong>of</strong> 0.1% and 0.2% delmop<strong>in</strong>ol<br />
mouthwashes(I). Effects on plaque, g<strong>in</strong>givitis, suprag<strong>in</strong>gival calculus and tooth sta<strong>in</strong><strong>in</strong>g. Journal <strong>of</strong><br />
Cl<strong>in</strong>ical Periodontology. 1996;23:220-228.<br />
3. Ste<strong>in</strong>berg D, Beeman D, Bowen WH. Interactions <strong>of</strong> delmop<strong>in</strong>al with constituents <strong>of</strong> experimental<br />
pellicle. Journal <strong>of</strong> Dental Research. 1992;71(11):1791-1802.<br />
4. Overholser CD, Meiller TF, DePaola LG, et al. Comparitive effects <strong>of</strong> 2 chemotherapeutic mouthr<strong>in</strong>ses<br />
on the developmet <strong>of</strong> suprag<strong>in</strong>gival dental plaque and g<strong>in</strong>givitis. Journal <strong>of</strong> Cl<strong>in</strong>ical Periodontology.<br />
1990;17(8):575-579.<br />
5. DePaola LG, Overholser CD, Meiller TF, et al. Chemotherapeutic <strong>in</strong>hibition <strong>of</strong> suprag<strong>in</strong>gival dental<br />
plaque and g<strong>in</strong>givitis development. Journal <strong>of</strong> Cl<strong>in</strong>ical Periodontology. 1989;16(5):311-315.<br />
6. Ciancio SG. Antiseptics and antiobiotics ad chemotherapeutic agents for periodontitis management.<br />
Compendium <strong>of</strong> Cont<strong>in</strong>u<strong>in</strong>g Education <strong>in</strong> Dentistry. 2000 Jan;21(1):59-62.<br />
7. Loe H, Schiott CR. <strong>The</strong> effect <strong>of</strong> mouthr<strong>in</strong>ses and topical application <strong>of</strong> chlorhexid<strong>in</strong>e on the<br />
development <strong>of</strong> dental plaque and g<strong>in</strong>givitis <strong>in</strong> man. Journal <strong>of</strong> Periodontal Research 1970;5:79-83.<br />
8. A 6-month cl<strong>in</strong>ical trial to study the effectos <strong>of</strong> a cetylpyrid<strong>in</strong>ium chloride mouthrise on g<strong>in</strong>givitis and<br />
plaque. American Journal <strong>of</strong> Dentistry. 2005;18((Spec No.9):9-A-14A.<br />
9. He S, Wei, Y, Fan X, Hu D, Sreenivasan PK, A cl<strong>in</strong>ical study to assess the 12-hour antimicrobial<br />
effects <strong>of</strong> cetylpyrid<strong>in</strong>ium chloride mouthwasher on suprag<strong>in</strong>gival plaque. Journal <strong>of</strong> Cl<strong>in</strong>ical Dentistry<br />
2011;22(special issue): 195-199.<br />
10. Veksler AE, Kayrouz GA, Newman MG. Reduction <strong>of</strong> salivary bacteria by pre-procedural r<strong>in</strong>ses with<br />
chlorhexid<strong>in</strong>e 0.12%. J Periodontol 1991;62:649-651<br />
11. Logothetis DD, Mart<strong>in</strong>ez-Welles JM. Reduc<strong>in</strong>g bacterial aerosol contam<strong>in</strong>ation with a chlorhexid<strong>in</strong>e<br />
gluconate pre-r<strong>in</strong>se. J Am Dent Assoc 1995;126:1634-1639.<br />
12. Harrel SK, Mol<strong>in</strong>ari J. Aerosols and splatter <strong>in</strong> dentistry: A brief review <strong>of</strong> the literature and <strong>in</strong>fection<br />
control implications. JADA 2004;135:429-437.<br />
13. Addy M, Mahdavi SA, Loyn T., Dietary sta<strong>in</strong><strong>in</strong>g <strong>in</strong> vitro by mouthr<strong>in</strong>ses as a comparative measure <strong>of</strong><br />
antiseptic activity and predictor <strong>of</strong> sta<strong>in</strong><strong>in</strong>g <strong>in</strong> vivo. Journal <strong>of</strong> Dentistry 1995;23:95-99.<br />
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Author Bio<br />
Mary Govoni br<strong>in</strong>gs over 40 years <strong>of</strong> experience <strong>in</strong> dentistry to the team. She is a Certified<br />
Dental Assistant, a Registered Dental Assistant (MI) and a Registered Dental Hygienist, with<br />
experience <strong>in</strong> general and specialty practices both cl<strong>in</strong>ically and as an adm<strong>in</strong>istrator. Mary is a<br />
former dental assist<strong>in</strong>g educator and was a partner <strong>in</strong> a successful dental staff<strong>in</strong>g service.<br />
For the past 20 years, Mary has focused on speak<strong>in</strong>g and consult<strong>in</strong>g with dental teams on<br />
<strong>in</strong>fection prevention, OSHA and HIPAA compliance, ergonomics, chairside efficiency and team<br />
communication and development. Mary has published numerous articles <strong>in</strong> pr<strong>of</strong>essional<br />
journals, such as RDH Magaz<strong>in</strong>e, Dental Economics, <strong>The</strong> Dental Assistant, Dental Products<br />
Reports, and is featured monthly <strong>in</strong> Dental Economics. She is a life member and Past President<br />
<strong>of</strong> the American Dental Assistants Association, and serves on the ADAA Editorial Board as well<br />
as the Corporate Council for Dimensions <strong>of</strong> Dental Hygiene. Mary is also a consultant to the<br />
American Dental Association Council on Dental Practice (ADA) and a featured speaker on the<br />
Cont<strong>in</strong>u<strong>in</strong>g Education and Lifelong Learn<strong>in</strong>g Sem<strong>in</strong>ar Series.<br />
Author Contact Information<br />
Mary Govoni<br />
2435 Seville Drive<br />
Okemos, MI 48864<br />
517-214-8223 <strong>of</strong>fice<br />
866-628-4149 fax<br />
mary@marygovoni.com<br />
www.marygovoni.com<br />
@Mary Govoni<br />
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