Journal of Dental Hygiene supplement on anti-microbial mouth rinses

2007<strong>Journal</strong> <strong>of</strong><strong>Dental</strong> <strong>Hygiene</strong>Special Supplementto Access magazine<strong>Journal</strong><strong>of</strong><strong>Dental</strong><strong>Hygiene</strong>T HE A MERICAN D ENTAL H YGIENISTS’ A SSOCIATIONIncorporating Antimicrobial Mouthrinsesinto Oral <strong>Hygiene</strong>: Strategies for ManagingOral Bi<strong>of</strong>ilm and Gingivitis• Changing Perspectives on the Use <strong>of</strong>Antimicrobial Mouthrinses• The Role <strong>of</strong> <strong>Dental</strong> Plaque Bi<strong>of</strong>ilmin Oral Health• Safety and Efficacy <strong>of</strong> AntimicrobialMouthrinses in Clinical Practice• Strategies for Incorporating AntimicrobialMouthrinses into Daily Oral Care• Antimicrobial Mouthrinses in Contemporary<strong>Dental</strong> <strong>Hygiene</strong> Practice: The Take HomeMessageThis special issue <strong>of</strong> the <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> as a<strong>supplement</strong> to Access was made possible through aneducational grant from Johnson & Johnson HealthcareProducts Division <strong>of</strong> McNEIL-PPC, Inc.

about the authorsGuest Editor■ MICHELE LEONARDI DARBY, RDH, MS, is the graduate program directorin dental hygiene at Old Dominion University in Norfolk, Virginia. Shelectures internationally, is the author <strong>of</strong> over 50 articles, has published 3books, and has served on several editorial advisory boards, currentlyserving as associate editor <strong>of</strong> the International <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong>and as an editorial review board member <strong>of</strong> the <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong>and Dimensions <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong>. In 1981, she was a member <strong>of</strong> the firstdelegation <strong>of</strong> dental hygienists to visit the People’s Republic <strong>of</strong> China. Shehas received many awards, including the Warner Lambert–American<strong>Dental</strong> Hygienists’ Association Award for Excellence in <strong>Dental</strong> <strong>Hygiene</strong> andthe designation <strong>of</strong> Eminent Scholar by Old Dominion University.Authors■ JOANNA ASADOORIAN, RDH, MSc, is an associate pr<strong>of</strong>essor in theSchool <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> at the University <strong>of</strong> Manitoba and worksprivately as a dental hygienist in periodontology. She has published andregularly lectures on her research interests, which include qualityassurance, maintaining competence in health care pr<strong>of</strong>essionals, clinicaldecision making, and oral health care products for home use. Sheserves on the editorial review board for the <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong>.■ LOUIS G. DEPAOLA, DDS, MS, is a pr<strong>of</strong>essor in the Department <strong>of</strong>Diagnostic Sciences and Pathology at the University <strong>of</strong> Maryland <strong>Dental</strong>School and the director <strong>of</strong> dental training for the PA/Mid-Atlantic AIDSEducation and Training Center. He is an international lecturer; hasauthored and coauthored over 130 journal articles, book chapters, andabstracts; and has been awarded over 75 research and service grants,including ones for the study <strong>of</strong> antiplaque chemotherapeutic agents. Heserves as a consultant to many pr<strong>of</strong>essional organizations and from2002 to 2005 served on the American <strong>Dental</strong> Association Council onScientific Affairs. He is a diplomate <strong>of</strong> the American Board <strong>of</strong> OralMedicine and the American College <strong>of</strong> Dentists.■ JOANN R. GURENLIAN, RDH, PhD, is a former chair <strong>of</strong> the Department<strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> at Thomas Jefferson University in Philadelphia andpast president <strong>of</strong> the American <strong>Dental</strong> Hygienists’ Association. Shecontinues to consult and to <strong>of</strong>fer continuing education services in thehealth care field. She has authored over 100 articles, is the coauthor <strong>of</strong>The Medical History: Clinical Implications and Emergency Prevention in<strong>Dental</strong> Settings, and is the recipient <strong>of</strong> numerous awards, including theAmerican <strong>Dental</strong> Hygienists’ Association Distinguished Service Award.She is the vice president <strong>of</strong> the International Federation <strong>of</strong> <strong>Dental</strong>Hygienists and chairs a work group for the National Diabetes EducationProgram.This special issue <strong>of</strong> the <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong><strong>Hygiene</strong> was funded by an unrestrictededucational grant from Johnson & JohnsonHealthcare Products Division <strong>of</strong> McNEIL-PPC, Inc.Continuing Education ProgramTo obtain 2 hours <strong>of</strong> continuing educationcredit, once you have thoroughly reviewed this<strong>supplement</strong>, please complete the exam athttp://www.adha.org/CE_courses/course16/.Open to all licensed U.S. dental hygienists,ADHA’s CE Program <strong>of</strong>fers <strong>Journal</strong> <strong>of</strong><strong>Dental</strong> <strong>Hygiene</strong> readers the opportunity toearn CE credit. Your exam will be graded bythe ADHA staff using questions reviewedand developed in cooperation with theUniversity <strong>of</strong> North Carolina School <strong>of</strong>Dentistry, a recognized provider <strong>of</strong> CEcredit.Credit for this CE program expires one yearfrom the date <strong>of</strong> publication (both print andonline). Duplicate submissions will bedisregarded. Submit your exam only once.Continuing education credits issued forparticipation in this CE activity may notapply toward license renewal in all licensingjurisdictions. It is the responsibility <strong>of</strong> eachparticipant to verify the licensingrequirements <strong>of</strong> his or her licensing orregulatory agency.Any questions? Contact ADHACommunications Division: 312/440-8900.■ ANN ESHENAUR SPOLARICH, RDH, PhD, holds several academicappointments and currently teaches at the Arizona School <strong>of</strong> Dentistryand Oral Health, University <strong>of</strong> Southern California School <strong>of</strong> Dentistry,and University <strong>of</strong> Maryland <strong>Dental</strong> School in addition to practicing dentalhygiene. An international lecturer, she has published over 60 articles and6 chapters in dental hygiene textbooks, has been active in research,serves on several editorial review boards, and is a consultant to theNational Center for <strong>Dental</strong> <strong>Hygiene</strong> Research. She is the current chair <strong>of</strong>the American <strong>Dental</strong> Hygienists’ Association Council on Research. Shehas received several awards, most recently, the University <strong>of</strong>Pennsylvania <strong>Dental</strong> <strong>Hygiene</strong> Alumni Achievement Award in 2002.

Inside<strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong>Message3 Changing Perspectives on the Use <strong>of</strong> Antimicrobial MouthrinsesMichele Leonardi Darby, RDH, MSSupplementIncorporating Antimicrobial Mouthrinses intoOral <strong>Hygiene</strong>: Strategies for ManagingOral Bi<strong>of</strong>ilm and Gingivitis4 The Role <strong>of</strong> <strong>Dental</strong> Plaque Bi<strong>of</strong>ilm in Oral HealthJoAnn R. Gurenlian, RDH, PhD13 Safety and Efficacy <strong>of</strong> Antimicrobial Mouthrinsesin Clinical PracticeLouis G. DePaola, DDS, MSAnn Eshenaur Spolarich, RDH, PhD26 Strategies for Incorporating Antimicrobial Mouthrinsesinto Daily Oral CareJoanna Asadoorian, RDH, MSc32 Antimicrobial Mouthrinses in Contemporary<strong>Dental</strong> <strong>Hygiene</strong> Practice: The Take Home MessageMichele Leonardi Darby, RDH, MSSpecial <strong>supplement</strong> The <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> 1

<strong>Journal</strong><strong>of</strong><strong>Dental</strong><strong>Hygiene</strong>special <strong>supplement</strong>EXECUTIVE DIRECTORAnn Battrell, RDH, BS, MSDHannb@adha.netDIRECTOR OF COMMUNICATIONSJeff Mitchelljeffm@adha.netEDITOR EMERITUSMary Alice Gaston, RDH, MSEDITOR-IN-CHIEFRebecca S. Wilder, RDH, BS, MSrebeccaw@adha.netSTAFF EDITORKatie Bargekatieb@adha.netLAYOUT/DESIGNJean MajeskiPaul R. Palmer■ STATEMENT OF PURPOSEThe <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> is the refereed, scientific publication <strong>of</strong> theAmerican <strong>Dental</strong> Hygienists’ Association. It promotes the publication <strong>of</strong>original research related to the pr<strong>of</strong>ession, the education, and the practice <strong>of</strong>dental hygiene. The journal supports the development and dissemination <strong>of</strong> adental hygiene body <strong>of</strong> knowledge through scientific inquiry in basic, applied,and clinical research.■ EDITORIAL REVIEW BOARDCeleste M. Abraham, DDS, MSCynthia C. Amyot, BSDH, EdDJoanna Asadoorian, RDH, MScCaren M. Barnes, RDH, BS, MSPhyllis L. Beemsterboer, RDH, MS, EdDStephanie Bossenberger, RDH, MSKimberly S. Bray, RDH, MSLorraine Brockmann, RDH, MSPatricia Regener Campbell, RDH, MSDan Caplan, DDS, PhDBarbara H. Connolly, PT, EdD, FAPTAValerie J. Cooke, RDH, MS, EdDMaryAnn Cugini, RDH, MHPSusan J. Daniel, AAS, BS, MSMichele Leonardi Darby, RDH, MSCatherine Davis, RDH, PhD. FIDSAConnie Drisko, RDH, BS, DDSJacquelyn M. Dylla, DPT, PTDeborah E. Fleming, RDH, MSJane L. Forrest, BSDH, MS, EdDJacquelyn L. Fried, RDH, BA, MSMary George, RDH, BSDH, MEdEllen Grimes, RDH, MA, MPA, EdDJoAnn R. Gurenlian, RDH, PhDLinda L. Hanlon, RDH, BS, MEd, PhDKitty Harkleroad, RDH, MSHarold A. Henson, RDH, MEdLaura Jansen Howerton, RDH, MSLisa F. Harper Mallonee,BSDH,MPH,RD/LD■ SUBSCRIPTIONSHeather L. Jared, RDH, BS, MSWendy Kerschbaum, RDH, MA, MPHSalme Lavigne, RDH, BA, MSDHJessica Y. Lee, DDS, MPH, PhDDeborah S. Manne,RDH,RN,MSN,OCNAnn L. McCann, RDH, BS, MSStacy McCauley, RDH, MSGayle McCombs, RDH, MSShannon Mitchell, RDH, MSTricia Moore, RDH, BSDH, MA, EdDChristine Nathe, RDH, MSKathleen J. Newell, RDH, MA, PhDJohanna Odrich, RDH, MS, DrPhPamela Overman, BSDH, MS, EdDVickie Overman, RDH, BS, MEdFotinos S. Panagakos, DMD, PhD, MEdM. Elaine Parker, RDH, MS, PhDCeib Phillips, MPH, PhDMarjorie Reveal, RDH, MS, MBAKip Rowland, RDH, MSJudith Skeleton, RDH, BS, MEd, PhDAnn Eshenaur Spolarich, RDH, PhDSheryl L. Ernest Syme, RDH, MSTerri Tilliss, RDH, BS, MS, MA, PhDNita Wallace, RDH, PhDKaren B. Williams, RDH, PhDCharlotte J. Wyche, RDH, MSPamela Zarkowski, BSDH, MPH, JDThe <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> is published quarterly, online-only, by the American<strong>Dental</strong> Hygienists’ Association, 444 N. Michigan Avenue, Chicago, IL 60611. Copyright2007 by the American <strong>Dental</strong> Hygienists’ Association. Reproduction in whole orpart without written permission is prohibited. Subscription rates for nonmembers areone year, $45; two years, $65; three years, $90; prepaid.■ SUBMISSIONSPlease submit manuscripts for possible publication in the <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong>to Katie Barge at katieb@adha.net.2 The <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> Special <strong>supplement</strong>

IntroductionChanging Perspectives on the Use <strong>of</strong>Antimicrobial MouthrinsesMichele Leonardi Darby, RDH, MSAs oral health care pr<strong>of</strong>essionals,we need to makeevidence-based recommendationsto our patients.Studies from which we derive our recommendationsneed to have beenconducted with scientific rigor andneed to be confirmed with other welldesignedstudies. Given the numerous,long-term, peer-reviewed publishedstudies on antimicrobialmouthrinses with consistent statisticallyand clinically significant outcomes,it is time to change our pr<strong>of</strong>essionalthinking and practices.When considering the oral environment,about 20% is occupied bytooth surfaces, that is, those areas targetedfor toothbrushing and flossing. 1<strong>Dental</strong> plaque bi<strong>of</strong>ilm is not limited totooth surfaces. About 80% <strong>of</strong> theremaining surfaces include the oralmucosa and specialized mucosa <strong>of</strong> thetongue. 1 Saliva, the tongue, and oralmucosa serve as reservoirs <strong>of</strong> pathogenicbacteria able to relocate and colonizeon the teeth and in sulci. Usingan antiseptic mouthrinse produces anantimicrobial effect throughout theentire mouth, including areas easilymissed during toothbrushing andinterdental cleaning. Therefore, it isnot surprising that in May 2007, theAmerican <strong>Dental</strong> Association Councilon Scientific Affairs issued newadvice highlighting the oral healthbenefits <strong>of</strong> ADA-Accepted antimicrobialmouthrinses that help preventand reduce plaque and gingivitis. 2This special Supplement to the<strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> focuses onour changing beliefs about antimicrobialmouthrinses and their value inmaintaining oral health. The paperswithin contain extensive informationabout dental plaque bi<strong>of</strong>ilms, the effectiveness<strong>of</strong> antimicrobial mouthrinses,and how to incorporate these agentsinto patients’oral self-care. Within thisSupplement, dental hygienists will findbest practices regarding antimicrobialmouthrinses so they can confidentlyrecommend their use to patients basedon the evidence. Patients look to dentalhygienists for trustworthy informationthat can make a difference in theiroral and systemic health. In this Supplement,dental hygienists have evidence-basedinformation about antimicrobialmouthrinses from oral healthexperts.Dr. Gurenlian provides a primer ondental plaque bi<strong>of</strong>ilm and the perpetualchallenges facing its management.Drs. DePaola and Spolarich reviewthe safety and efficacy <strong>of</strong> the majormouthrinses on the market and provideclear guidance on which productscan be confidently recommendedto yield predictable clinical healthoutcomes. New bodies <strong>of</strong> researchevidence encourage the replacement<strong>of</strong> old beliefs and practices with moreeffective therapies; but embracingchange is arduous, even with strongevidence to support the change.Joanna Asadoorian tackles the challenge<strong>of</strong> promptly translating evidence-basedinformation into practice,particularly when it meanschange on the part <strong>of</strong> both the practitionerand the patient. From her paper,dental hygienists will better understandresistance to change, the process<strong>of</strong> change, and how to use change theoryto help themselves and patientsincorporate health-promoting behaviorssuch as twice-daily use <strong>of</strong> antimicrobialmouthrinse. Asadoorian’sapproach is also useful in motivatingpatients to adopt other beneficial oralhygiene measures.Clinically relevant and easilyapplied information can be foundwithin these pages. Through this newknowledge, dental hygienists will beequipped to better control plaque andgingivitis in patients who historicallymay have been excluded from antimicrobialmouthrinse recommendations.I encourage you to read this issuefrom cover to cover because theknowledge within will make a differencein the way you practice dentalhygiene. Share the issue with yourcolleagues, and keep an issue in yourreception area for patients to read.Patients will know that you are a valuablesource for oral health care recommendationsthat improve and promotetheir health status.References1. Mager DL, Ximenez-Fyvie LA, HaffajeeAD, Socransky SS. Distribution <strong>of</strong>selected bacterial species on intraoralsurfaces. J Clin Periodontol. 2003;30:644-654.2. ADA affirms benefits <strong>of</strong> ADA-Acceptedantimicrobial mouth rinses and toothpastes,fluoride mouth rinses [newsrelease].Chicago, IL: American <strong>Dental</strong>Association; May 23, 2007. http://ada.org/public/media/releases/0705_release03.asp. Accessed July 27,2007.Special <strong>supplement</strong> The <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> 3

SupplementThe Role <strong>of</strong> <strong>Dental</strong> Plaque Bi<strong>of</strong>ilm in Oral HealthJoAnn R. Gurenlian, RDH, PhDIntroductionIn contrast to an accumulation <strong>of</strong>individual bacteria, a bi<strong>of</strong>ilm is acomplex, communal, 3-dimensionalarrangement <strong>of</strong> bacteria. Bacterialbi<strong>of</strong>ilms are ubiquitous and are potentiallyfound in a variety <strong>of</strong> sites withinthe human body. For example, theycan grow on indwelling catheters,ports, and implants; external surfaces<strong>of</strong> the eye; artificial heart valves;endotracheal tubes; and contaminatedprosthetic joints. A bacterial bi<strong>of</strong>ilm is<strong>of</strong>ten the cause <strong>of</strong> persistent infectionsand has been associated withosteomyelitis, pneumonia in patientswith cystic fibrosis, and prostatitis. 1In areas related to oral health care,bacterial bi<strong>of</strong>ilms are found in dentalunit water lines, on tooth surfaces anddental prosthetic appliances, and onoral mucous membranes. Bi<strong>of</strong>ilm inthe form <strong>of</strong> supragingival and subgingivalplaque is the etiologic agentin dental caries and periodontal diseases(Figure 1). 2-5 The pathogenicity<strong>of</strong> the dental plaque bi<strong>of</strong>ilm isenhanced by the fact that in bi<strong>of</strong>ilmform, the component bacteria haveincreased resistance to antibiotics andother chemotherapeutic agents andare less able to be phagocytized byhost inflammatory cells. Therefore,control <strong>of</strong> the dental plaque bi<strong>of</strong>ilm isa major objective <strong>of</strong> dental pr<strong>of</strong>essionalsand critical to the maintenance<strong>of</strong> optimal oral health. This articlereviews the characteristics <strong>of</strong> dentalbi<strong>of</strong>ilm, its role in the etiology <strong>of</strong>periodontal diseases, and strategiesfor controlling the bi<strong>of</strong>ilm to promotehealth.AbstractOverview. Microbial bi<strong>of</strong>ilms are complex communities <strong>of</strong> bacteria andare common in the human body and in the environment. In recent years,dental plaque has been identified as a bi<strong>of</strong>ilm, and the structure, microbiology,and pathophysiology <strong>of</strong> dental bi<strong>of</strong>ilms have been described. Thenature <strong>of</strong> the bi<strong>of</strong>ilm enhances the component bacteria’s resistance toboth the host’s defense system and antimicrobials. If not removed regularly,the bi<strong>of</strong>ilm undergoes maturation, and the resulting pathogenic bacterialcomplex can lead to dental caries, gingivitis, and periodontitis. In addition,dental bi<strong>of</strong>ilm, especially subgingival plaque in patients with periodontitis,has been associated with various systemic diseases and disorders, includingcardiovascular disease, diabetes mellitus, respiratory disease, andadverse pregnancy outcomes.Clinical Implications. An understanding <strong>of</strong> the nature and pathophysiology<strong>of</strong> the dental bi<strong>of</strong>ilm is important to implementing proper managementstrategies. Although dental bi<strong>of</strong>ilm cannot be eliminated, it can be reducedand controlled through daily oral care. A daily regimen <strong>of</strong> thorough mechanicaloral hygiene procedures, including toothbrushing and interdental cleaning,is key to controlling bi<strong>of</strong>ilm accumulation. Because teeth compriseonly 20% <strong>of</strong> the mouth’s surfaces, for optimal oral health, the use <strong>of</strong> anantimicrobial mouthrinse helps to control bi<strong>of</strong>ilm not reached by brushingand flossing as well as bi<strong>of</strong>ilm bacteria contained in oral mucosal reservoirs.Key words: Antimicrobial mouthrinse, bi<strong>of</strong>ilm, dental plaque, oral health,periodontal diseaseChanging Views <strong>of</strong><strong>Dental</strong> PlaqueOver the past 50 years, the understandingand characterization <strong>of</strong> dentalplaque have undergone significant evolution.Loesche 6 proposed both a nonspecificand a specific plaque hypothesisfor periodontal disease initiationand progression.The nonspecific plaque hypothesisproposed that the entire microbial community<strong>of</strong> plaque that accumulated ontooth surfaces and in the gingivalcrevice contributed to the development<strong>of</strong> periodontal disease. Plaque bacteriaproduced virulence factors and noxiousproducts that initiated inflammation,challenged the host defense system, andresulted in the destruction <strong>of</strong> periodontaltissues. Under this hypothesis, thequantity <strong>of</strong> plaque was considered tobe the critical factor in the development<strong>of</strong> periodontal disease. Thus, increasesin the amount <strong>of</strong> plaque (quantity), asopposed to specific pathogenicmicroorganisms (quality) found in theplaque, were viewed as being primarilyresponsible for inducing diseaseand disease progression. 7,8Studies on the microbial etiology<strong>of</strong> various forms <strong>of</strong> periodontitis sup-4 The <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> Special <strong>supplement</strong>

Figure 1. Scanning electron micrograph <strong>of</strong> bi<strong>of</strong>ilm grown from thesubgingival plaque <strong>of</strong> a healthy subject for 10 days anaerobically onsaliva-coated hydroxyapatite discs. (Grown by Michael Sedlacek, PhD,and Clay Walker, PhD, at the University <strong>of</strong> Florida College <strong>of</strong> DentistryPeriodontal Disease Research Center. Image taken by the University<strong>of</strong> Florida Electron Microscopy Core Facility.)A naeslundii 2(A viscosus)S mitisS oralisS sanguisStreptococcus sp.S gordoniiS intermediusE corrodensC gingivalisC sputigenaC ochraceaC concisusA actino. aV parvulaA odontolyticusS constellatusA actino b.C gracilisP intermediaP nigrescensP microsF nuc vincentiiF nuc nucleatumF nuc polymorphumF periodonticumC showaeC rectusE nodatumS noxiaP gingivalisT forsythensisT denticolaport the specific plaque hypothesis,which proposes that only certainmicroorganisms within the plaquecomplex are pathogenic. Despite thepresence <strong>of</strong> hundreds <strong>of</strong> species <strong>of</strong>microorganisms in periodontal pockets,fewer than 20 are routinely foundin increased proportions at periodontallydiseased sites. These specific virulentbacterial species activate thehost’s immune and inflammatoryresponses that then cause bone and s<strong>of</strong>ttissue destruction. 6,8,9Socransky and colleagues 4,10 recognizedthat early plaque consists predominantly<strong>of</strong> gram-positive organismsand that if the plaque is leftundisturbed it undergoes a process <strong>of</strong>maturation resulting in a more complexand predominantly gram-negativeflora. These investigatorsassigned the organisms <strong>of</strong> the subgingivalmicrobiota into groups, or complexes,based on their association withhealth and various disease severities(Figure 2). 4,10 Color designations wereused to denote the association <strong>of</strong> particularbacterial complexes with periodontalinfections. The blue,yellow, green, and purplecomplexes designate earlycolonizers <strong>of</strong> the subgingivalflora. Orange and red complexesreflect late colonizersassociated with mature subgingivalplaque. Certain bacterialcomplexes are associatedwith health or disease. 10,11For example, the bacteria inthe red complex are morelikely to be associated withclinical indicators <strong>of</strong> periodontaldisease such as periodontalpocketing and clinicalattachment loss.PlaqueRecognized as aBi<strong>of</strong>ilmFigure 2. Microbial complexes in subgingival bi<strong>of</strong>ilm. 4,10 (Modified fromSocransky SS, Haffajee AD, Cugini MA, et al. Microbial complexes insubgingival plaque. J Clin Periodontol 1998;25:134-144. Reprinted withpermission from Blackwell Publishing.)Research over the pastdecade has led to the recognition<strong>of</strong> dental plaque as abi<strong>of</strong>ilm—a highly organizedSpecial <strong>supplement</strong> The <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> 5

accumulation <strong>of</strong> microbial communitiesattached to an environmental surface.Bi<strong>of</strong>ilms are organized to maximizeenergy, spatial arrangements,communication, and continuity <strong>of</strong> thecommunity <strong>of</strong> microorganisms.Bi<strong>of</strong>ilms protect bacteria livingwithin their structures and therebyprovide an advantage over free-floating(planktonic) bacteria. The slimyextracellular matrix produced bybi<strong>of</strong>ilm bacteria encloses the microbialcommunity and protects it fromthe surrounding environment, includingattacks from chemotherapeuticagents. Chemotherapeutic agents havedifficulty penetrating the polysaccharidematrix to reach and affect themicroorganisms. 1,11-13 Thus, the matrixhelps to protect bacteria deep withinthe bi<strong>of</strong>ilm from antibiotics and antiseptics,increasing the likelihood <strong>of</strong>the colonies’ survival. Furthermore,the extracellular matrix keeps the bacteriabanded together, so they are notflushed away by the action <strong>of</strong> salivaand gingival crevicular fluid. Mechanicalmethods, including toothbrushing,interdental cleaning, andpr<strong>of</strong>essional scaling procedures, arerequired to regularly and effectivelydisrupt and remove the plaquebi<strong>of</strong>ilm. Antiseptics, such asmouthrinses, can help to control thebi<strong>of</strong>ilm but must be formulated so asto be able to penetrate the plaquematrix and gain access to the pathogenicbacteria.Bi<strong>of</strong>ilms have a definite architecturalstructure. The bacteria are notuniformly distributed throughout thebi<strong>of</strong>ilm; rather, there are aggregates<strong>of</strong> microcolonies that vary in shapeand size. Channels between thecolonies allow for circulation <strong>of</strong> nutrientsand by-products and provide asystem to eliminate wastes. 14,15Microorganisms on the outer surface<strong>of</strong> bi<strong>of</strong>ilms are not as stronglyattached within the matrix and tendto grow faster than those bacteriadeeper within the bi<strong>of</strong>ilm. Surfacemicroorganisms are more susceptibleto detachment, a characteristic thatfacilitates travel to form new bi<strong>of</strong>ilmcolonies on nearby oral structures andtissues.Bacteria in bi<strong>of</strong>ilm communicatewith each other by a process calledquorum sensing. This dynamic,sophisticated communication systemenables bacteria to monitor eachother’s presence and to modulate theirgene expression in response to thenumber <strong>of</strong> bacteria in a given area <strong>of</strong>the bi<strong>of</strong>ilm. 8 In addition, as a result<strong>of</strong> quorum sensing, portions <strong>of</strong> thebi<strong>of</strong>ilm can become detached in orderto maintain a cell density compatiblewith continued survival.Stages <strong>of</strong> Bi<strong>of</strong>ilmFormationThe growth and development <strong>of</strong>bi<strong>of</strong>ilm are characterized by 4 stages:initial adherence, lag phase, rapidgrowth, and steady state. Bi<strong>of</strong>ilm formationbegins with the adherence <strong>of</strong>bacteria to a tooth surface, followedby a lag phase in which changes ingenetic expression (phenotypic shifts)occur. A period <strong>of</strong> rapid growth thenoccurs, and an exopolysaccharidematrix is produced. During the steadystate, the bi<strong>of</strong>ilm reaches growth equilibrium.Surface detachment andsloughing occur, and new bacteria areacquired.Initial Adherence and Lag PhaseThe first phase <strong>of</strong> supragingivalbi<strong>of</strong>ilm formation is the deposition <strong>of</strong>salivary components, known asacquired pellicle, on tooth surfaces.This pellicle makes the surface receptiveto colonization by specific bacteria.Salivary glands produce a variety<strong>of</strong> proteins and peptides that furthercontribute to bi<strong>of</strong>ilm formation. ForBacteria in bi<strong>of</strong>ilm communicate with each other bya process called quorum sensing. This dynamic,sophisticated communication system enablesbacteria to monitor each other’s presence and tomodulate their gene expression in response to thenumber <strong>of</strong> bacteria in a given area <strong>of</strong> the bi<strong>of</strong>ilm.example, salivary mucins, such asMUC 5 B and MUC 7 , contribute to theformation <strong>of</strong> acquired pellicle, 16,17 andstatherin, a salivary acidic phosphoprotein,and proline-rich proteins promotebacterial adhesion to tooth surfaces.18 Acquired pellicle formationbegins within minutes <strong>of</strong> a pr<strong>of</strong>essionalprophylaxis; within 1 hour,microorganisms attach to the pellicle.Usually, gram-positive cocci are thefirst microorganisms to colonize theteeth. As bacteria shift from planktonicto sessile life, a phenotypicchange in the bacteria occurs requiringsignificant genetic up-regulation(gene signaling that promotes thisshift). As genetic expression shifts,there is a lag in bacterial growth.Rapid GrowthDuring the rapid growth stage,adherent bacteria secrete large amounts<strong>of</strong> water-insoluble extracellular polysaccharidesto form the bi<strong>of</strong>ilm matrix.The growth <strong>of</strong> microcolonies withinthe matrix occurs. With time, additionalvarieties <strong>of</strong> bacteria adhere tothe early colonizers—a process knownas coaggregation—and the bacterialcomplexity <strong>of</strong> the bi<strong>of</strong>ilm increases.These processes involve unique, selectivemolecular interactions leading tostructural stratification within thebi<strong>of</strong>ilm. Coaggregation and subsequentcell division also increase the thickness<strong>of</strong> bi<strong>of</strong>ilm. 19-21Steady State/DetachmentDuring the steady state phase, bacteriain the interior <strong>of</strong> bi<strong>of</strong>ilms slowtheir growth or become static. Bacte-6 The <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> Special <strong>supplement</strong>

ia deep within the bi<strong>of</strong>ilm show signs<strong>of</strong> death with disrupted bacterial cellsand other cells devoid <strong>of</strong> cytoplasm;bacteria near the surface remain intact.During this phase, crystals can beobserved in the interbacterial matrixthat may represent initial calculusmineralization. 22 As noted above, duringthe steady state stage, surfacedetachment and sloughing also occur,with some bacteria traveling to formnew bi<strong>of</strong>ilm colonies.Bi<strong>of</strong>ilm and OralDiseaseFigure 3. Bi<strong>of</strong>ilm lodges in the crevices around the teeth both aboveand below the gingival margin. Accumulation <strong>of</strong> dental plaque bi<strong>of</strong>ilmcan result in dental caries and periodontal disease. (Figure copyright2006 Keith Kasnot, MA, CMI, FAMI.)Bi<strong>of</strong>ilms can cover surfacesthroughout the oral cavity. Microcoloniesexist on oral mucosa, thetongue, biomaterials used for restorationsand dental appliances, and toothsurfaces above and below the gingivalmargin (Figure 3). It is importantfor oral health pr<strong>of</strong>essionals to communicateto their patients that bothdental caries and periodontal diseaseare infectious diseases resulting fromdental plaque bi<strong>of</strong>ilm accumulation.Each <strong>of</strong> these diseases requires specificstrategies for prevention andtreatment.With respect to periodontal disease,dental plaque bi<strong>of</strong>ilm demonstrates asuccession <strong>of</strong> microbial colonizationwith changes in bacterial floraobserved from health to disease.Researchers studied over 13,000plaque samples from 185 patients withconditions ranging from oral health toperiodontal disease. 4,23 As notedabove, based on their findings, a number<strong>of</strong> microbial complexes were identifiedthat were associated with variousstages <strong>of</strong> disease initiation andprogression. Bacterial species containedin the yellow, green, and purplecomplexes appear to colonize the subgingivalsulcus first and predominatein gingival health. In contrast, orangecomplex bacteria are associated withgingivitis and gingival bleeding. Interestingly,bacteria <strong>of</strong> the orange complexmay also be associated with redcomplex microorganisms includingPorphyromonas gingivalis, Tannerellaforsythensis, and Treponema denticola,organisms found in greater numbersin diseased sites and in moreadvanced periodontal disease. 10,24Bacterial communities living in abi<strong>of</strong>ilm possess resourceful survivalstrategies, including a broader habitatfor growth, nutrition, waste elimination,and new colonization; environmentalniches for safety; barriers tothwart antimicrobial drug therapy; protectionfrom the host’s defense systemincluding phagocytosis; and enhancedpathogenicity. 1,8 These strategiesaccount for the ongoing challenge <strong>of</strong>successfully controlling periodontalinfection and disease progression. 25As the bi<strong>of</strong>ilm matures and proliferates,soluble compounds producedby pathogenic bacteria penetrate thesulcular epithelium. These compoundsstimulate host cells to producechemical mediators associated withthe inflammatory process 26 (see Figure4 on page 9).• Interleukin-1 beta (IL-1β),prostaglandins, tumor necrosis factoralpha (TNF-α), and matrixmetalloproteinases are mediatorsthat recruit neutrophils to the areavia chemotaxis and cause increasedpermeability <strong>of</strong> gingivalblood vessels, permitting plasmaproteins to migrate from within theblood vessels into the tissue.• As the gingival inflammatoryprocess continues, additionalmediators are produced, and moreinflammatory cell types such asneutrophils, T cells, and monocytesare recruited to the area.• Proinflammatory cytokines are producedin the tissues as a response tothe chronic inflammatory process,and these proteins may further escalatethe local inflammatoryresponse and affect the initiationand progression <strong>of</strong> systemic inflammationand disease.The result <strong>of</strong> this chronic inflammationis a breakdown <strong>of</strong> gingival collagenand accumulation <strong>of</strong> an inflammatoryinfiltrate, leading to theclinical signs <strong>of</strong> gingivitis. In someindividuals, the inflammatory processwill also lead to the breakdown <strong>of</strong> collagenin the periodontal ligament andresorption <strong>of</strong> the supporting alveolarbone. It is at this point that the lesionprogresses from gingivitis to periodontitis,continuing the same challengefrom proinflammatory mediatorsas with chronic gingivitis. Thus,controlling dental plaque bi<strong>of</strong>ilm isessential to preventing and reversingSpecial <strong>supplement</strong> The <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> 7

gingivitis as well as preventing andmanaging periodontitis.Periodontal Bi<strong>of</strong>ilmInfection and SystemicHealthIn recent years, studies havedemonstrated an association betweenperiodontitis and various systemic diseasesand conditions, including cardiovasculardisease, diabetes mellitus,respiratory disease, adverse pregnancyoutcomes, obesity, pancreatic cancer,and Alzheimer’s disease. 27-57 Whileseveral <strong>of</strong> these associations have notbeen definitively established, biologicalmechanisms explaining some <strong>of</strong>the more extensively studied relationshipsare emerging.The association between periodontaldisease and some systemic diseasesmay relate to the ability <strong>of</strong> subgingivalplaque bacteria and/or their productsto gain access to the systemic circulationthrough the ulceratedepithelium <strong>of</strong> the periodontal pocket.For example, environmental nicheslike a subgingival pocket that containsanaerobic gram-negative microorganismscan potentially seed orange andred complex bacteria and/or theirproducts to distant sites through thecirculatory system. In this way, a dentalbi<strong>of</strong>ilm infection can potentiallycontribute to both oral and systemicinflammation. 25Research on Periodontal MicroorganismsAtheromas. Direct evidence for therole <strong>of</strong> dental bi<strong>of</strong>ilm infection in systemicinflammation comes from findings<strong>of</strong> periodontal microorganisms inhuman carotid atheromas. Studies <strong>of</strong>atheromatous lesions in carotid arteriesrevealed that over 40% <strong>of</strong> atheromascontain antigens from periodontalpathogens including P gingivalis, Tforsythensis, and Prevotella intermedia.28,58 In addition, P gingivalis isknown to induce platelet aggregation,a component <strong>of</strong> atheroma and thrombusformation, 29 and invade endothelialcells in cell cultures. 59 While suchfindings suggest a possible invasion<strong>of</strong> atheromas by oral pathogens aswell as possible contribution to theirdevelopment, it is important to notethat causality has yet to be established.Preterm Birth. Research suggeststhat periodontal pathogens may travelvia the bloodstream from the oral cavityto the placenta initiating pretermIn recent years, studies have demonstrated anassociation between periodontitis and varioussystemic diseases and conditions, includingcardiovascular disease, diabetes mellitus,respiratory disease, adverse pregnancy outcomes,obesity, pancreatic cancer, and Alzheimer’s disease.birth. In an animal model, Han andcoworkers 60 found that periodontalbacteria, including Fusobacteriumnucleatum, entered the bloodstreamfrom ulcerated gingival sulci or periodontalpockets and negatively influencedthe normal birth process.Respiratory Disease. Likewise,bi<strong>of</strong>ilm in the oral cavity may serve asa reservoir <strong>of</strong> infection leading to respiratorydisease. Pseudomonas aeruginosa,Staphylococcus aureus, andenteric bacteria have been shown tocolonize the teeth <strong>of</strong> patients admittedto hospitals and long-term care facilities.These bacteria may be releasedinto saliva and aspirated into the lowerairway causing respiratory infection. 46-49,61Intubation is another vehicle bywhich bacteria from the oral bi<strong>of</strong>ilmcan be directly introduced into the respiratorysystem. Intubation tubes supportbi<strong>of</strong>ilm growth contributing tonosocomial infection such as pneumonia.This is one reason why oralintubation raises the risk <strong>of</strong> nosocomialinfection in intensive and criticalcare hospital populations.Association With ChronicDiseases and ConditionsResearch has also suggested thatthe association between oral inflammationand systemic inflammationmay be key to understanding andmanaging the significant, deleteriouseffects on the multiple organ systemsinvolved in some chronic diseases andconditions (Figure 4). 26Cardiovascular Disease. Cardiovasculardisease is characterized byinflammatory plaque accumulation inblood vessels that can cause thrombosesand lead to myocardial infarction.Atherosclerosis represents achronic inflammatory process thatcauses endothelial dysfunction andinjury to the elastic and muscular arterialtissue. Early atherosclerotic lesionscontain neutrophils, monocytes, andlymphocytes. These leukocytes canaffect the vascular endothelial liningand cause oxidation <strong>of</strong> low-densitylipoproteins. As a result, monocytes,induced to become macrophages, takeup these oxidized lipoproteins andbecome lipid-laden foam cells. As thelesion progresses, the extracellularmatrix <strong>of</strong> the vessel wall is degraded byproteolytic enzymes and becomes susceptibleto rupture. Thromboses canocclude blood flow to the heart andbrain and eventually lead to infarction,heart attack, or stroke. 26Since atherosclerosis is inflammatoryby nature, identifying inflammatorymarkers that correlate with diseasestate is important. One recognized andconsistent marker <strong>of</strong> systemic inflammationand poor cardiovascular prognosisis the acute-phase protein C-reactiveprotein (CRP), the level <strong>of</strong> whichrises with systemic inflammation. 62,63Animal model studies <strong>of</strong> the relationshipbetween cardiovascular diseaseand periodontal disease demonstratethat clinically induced oral infectionwith P gingivalis will increase atheromasize and elevate CRP levels in theblood. 30 Conversely, some studies have8 The <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> Special <strong>supplement</strong>

Figure 4. Subgingival plaque bacteria and/or their products may gain access to distant sites in the bodythrough the circulatory system and may potentially contribute to systemic inflammation; in this way, adental bi<strong>of</strong>ilm infection may potentially contribute to various systemic diseases and conditions.(Illustration owned by McNEIL-PPC, Inc. and provided for educational purposes only. May not bereproduced without the prior written permission <strong>of</strong> McNEIL-PPC, Inc.)shown that treatment <strong>of</strong> periodontitisdecreases CRP blood levels, 64 thoughthis has not been a consistent finding.Diabetes Mellitus. Diabetes mellitusis another chronic systemic diseaseassociated with periodontitis. In fact,periodontitis has been identified as one<strong>of</strong> the major complications <strong>of</strong> diabetes.65 Although diabetes increases thesusceptibility to periodontal disease,38,39,65 periodontitis may alsoincrease the difficulty <strong>of</strong> maintainingsatisfactory glycemic control in peoplewith diabetes as compared withthose with diabetes without periodontitis.40 One biological mechanism proposedto explain the increased incidenceand severity <strong>of</strong> periodontaldisease in individuals with diabetes isthe finding <strong>of</strong> elevated levels <strong>of</strong> inflammatorymediators in the gingivalcrevicular fluid from periodontal pockets<strong>of</strong> patients with diabetes with poorglycemic control as compared withthose with diabetes who are well controlledor those without diabetes. Thosewith poor glycemic control had considerableperiodontal destruction withan equivalent bacterial challenge. 39,66Of note, the proinflammatory cytokineTNF-α plays a significant role in thisprocess. TNF-α has a major role ininsulin resistance, the primary cause <strong>of</strong>type 2 diabetes, and is produced inlarge quantities by fat cells. Periodontitisalso has been associated withincreased levels <strong>of</strong> TNF-α. Elevatedlevels <strong>of</strong> TNF-α may lead to greaterbone loss by killing cells that repairdamaged connective tissue or bone.Elevated TNF-α levels also may exacerbateinsulin resistance and worsenglycemic control. 44,66,67Adverse Pregnancy Outcomes.Studies also demonstrate that periodontaldiseases are associated withthe risk <strong>of</strong> adverse pregnancy outcomes,especially preterm low-birthweightinfants. 50-52 Chronic infection,such as that found with chronic periodontitis,can stimulate the inflammatoryprocess throughout the body. Inthe placenta, this may lead to elevatedamniotic levels <strong>of</strong> prostaglandins,TNF-α, and IL-1 and IL-6, stimulatingpremature rupture <strong>of</strong> membranes,preterm labor, and the birth <strong>of</strong> lowbirth-weightinfants. Intervention studiesare currently under way to investigatea cause and effect relationshipSpecial <strong>supplement</strong> The <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> 9

Table I. Examples <strong>of</strong> Antiseptic Mouthrinses*Active Ingredients Brands Indications Contraindications0.12% Chlorhexidine Peridex ®† (3M ESPE, Gingivitis, Those hypersensitive togluconate (available St Paul, MN) supragingival plaque chlorhexidinegluconate or otherby prescription) PerioGard ®† (Colgate formula ingredients.Oral Pharmaceuticals,Long-term use: can causeInc., Canton, MA)moderate staining, increasedPerioRx ®† (Discuscalculus formation, and possible<strong>Dental</strong>, Culver City, CA)alteration <strong>of</strong> taste perceptionCanton, MA)Various generics †Four essential oils: Listerine ® Antiseptic † Supragingival plaque, Children under 12 yearseucalyptol, menthol, (Johnson & Johnson gingivitis, oral malodormethyl salicylate, Healthcare ProductsthymolDivision <strong>of</strong> McNEIL-PPC,Inc., Skillman, NJ)Various generics †Cetylpyridinium Breath Rx ® (Discus <strong>Dental</strong>, Supragingival plaque, Children under 6 yearschloride Culver City, CA) gingivitis, oral malodorColgate Viadent ® (Colgate-Palmolive, New York, NY)Crest ® Pro-Health Rinse(Procter & Gamble,Cincinnati, OH)* For the mechanisms <strong>of</strong> actions <strong>of</strong> antiseptic mouthrinses, see pages19 and 20.† Has received the ADA Seal <strong>of</strong> Acceptance; note that as the ADA Sealprogram has recently phased out prescription products, chlorhexidinegluconate products no longer carry the ADA Seal.between advanced periodontitis andadverse pregnancy outcomes.Strategies for Managing<strong>Dental</strong> Bi<strong>of</strong>ilm toPromote HealthAlthough dental bi<strong>of</strong>ilm cannot becompletely eliminated, its pathogenicitycan be lessened through effectiveoral hygiene measures. Daily toothbrushing,interdental cleaning, and theuse <strong>of</strong> topical antimicrobial chemotherapeuticsare patient-based strategies toreduce the bacterial bi<strong>of</strong>ilm and to helpprevent periodontal diseases. American<strong>Dental</strong> Association (ADA)–Accepted antimicrobial mouthrinseshave been shown to help prevent andreduce plaque and gingivitis whenadded to a daily oral hygiene regimen<strong>of</strong> mechanical plaque removal. Further,bacteria from the bi<strong>of</strong>ilm on mucosaland tooth surfaces are shed constantlyinto saliva and transferred to otherareas <strong>of</strong> the mouth. Since oral mucosa,which represents about 80% <strong>of</strong> the oralcavity surface, 68 can serve as a reservoirfor pathogenic bacteria that can betransferred to the tooth surface and sulcus,<strong>supplement</strong>ing mechanical plaquecontrol methods with topical antimicrobialsmay also play an importantrole in reducing reservoirs <strong>of</strong>pathogens that are unaffected by brushingand flossing directed at the toothsurface.Using Evidence inPracticeProducts recommended to patientsshould be those that have documentedefficacy and safety (see pages 13 to25). Only 2 nationally branded antisepticmouthrinses and their genericequivalents have received the ADACouncil on Scientific Affairs Seal <strong>of</strong>Acceptance for control <strong>of</strong> supragingivalplaque and gingivitis: Listerine ®(fixed combination <strong>of</strong> essential oils)and Peridex ® (0.12% chlorhexidinegluconate). However, due to recentchanges in the ADA Seal Program,Peridex ® and its generic equivalentsno longer carry the ADA Seal becausechlorhexidine gluconate is a prescriptionproduct (see also page 32 formore information on the ADA SealProgram). The fixed combination <strong>of</strong>essential oils and cetylpyridiniumchloride have also been reviewed by aFood and Drug Administration (FDA)advisory committee and have receiveda Category I recommendation, meaningthey have been found to be safeand effective for the control <strong>of</strong>10 The <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> Special <strong>supplement</strong>

supragingival plaque and gingivitis.Peridex ® and its generic equivalents,which are prescription products, havebeen approved for marketing by theFDA via the New Drug Applicationroute (or for generics, the AbbreviatedNew Drug Application process) (seealso pages 14 and 15). Examples <strong>of</strong>effective antimicrobial mouthrinsescurrently on the market appear inTable I.Conclusion<strong>Dental</strong> bi<strong>of</strong>ilm is a complex, organizedmicrobial community that is theprimary etiologic factor for the mostfrequently occurring oral diseases,dental caries and periodontal diseases.Although the dental bi<strong>of</strong>ilm cannot beeliminated, it can be controlled withcomprehensive mechanical andchemotherapeutic oral hygiene practices.Teaching patients to use dailybrushing, interdental cleaning, andantimicrobial mouthrinses that carrythe ADA Seal <strong>of</strong> Acceptance increasesthe likelihood <strong>of</strong> periodontal diseaseprevention and reduction. Althoughadditional research is needed, there isthe possibility that these cost-effective,preventive strategies may minimizethe effect <strong>of</strong> periodontal diseaseson specific systemic conditions.References1. Costerton JW, Stewart PS, Greenberg EP. Bacterial bi<strong>of</strong>ilms:a common cause <strong>of</strong> persistent infections. Science.1999;284:1318-1322.2. van Houte J. Role <strong>of</strong> micro-organisms in caries etiology. JDent Res. 1994;73:672-681.3. Stenudd C, Nordlund A, Ryberg M, et al. The association <strong>of</strong>bacterial adhesion with dental caries. J Dent Res.2001;80:2005-2010.4. Socransky SS, Haffajee AD, Cugini MA, et al. Microbial complexesin subgingival plaque. J Clin Periodontol. 1998;25:134-144.5. Haffajee AD, Socransky SS. Microbial etiological agents <strong>of</strong>destructive periodontal diseases. Periodontol 2000.1994;5:78-111.6. Loesche WJ. Chemotherapy <strong>of</strong> dental plaque infections. 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Periodontalmicrobiota and carotid intima-media thickness: the oral infectionsand vascular disease epidemiology study (INVEST).Circulation. 2005;111:576-582.32. Tiong AY, Brieger D. Inflammation and coronary artery disease.Am Heart J. 2005;150:11-18.33. Meurman JH, Sanz M, Janket SJ. Oral health, atherosclerosis,and cardiovascular disease. Crit Rev Oral Biol Med.2004;15:403-413.34. Chun YH, Chun KR, Olguin D, Wang HL. Biological foundationfor periodontitis as a potential risk factor for atherosclerosis.J Periodontal Res. 2005;40:87-95.35. Hung HC, Willett W, Merchant A, et al. Oral health and peripheralarterial disease. Circulation. 2003;107:1152-1157.Special <strong>supplement</strong> The <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> 11

36. Wu T, Trevisan M, Genco RJ, et al. Periodontal disease andrisk <strong>of</strong> cerebrovascular disease: the first national health andnutrition examination survey and its follow-up study. ArchIntern Med. 2000;160:2749-2755.37. Joshipura KJ, Hung HC, Rimm EB, et al. Periodontal disease,tooth loss, and incidence <strong>of</strong> ischemic stroke. Stroke.2003;34:47-52.38. Nishimura F, Takahashi K, Kurihara M, et al. Periodontal diseaseas a complication <strong>of</strong> diabetes mellitus. Ann Periodontol.1998;3:20-29.39. Ryan ME, Carnu O, Kamer A. The influence <strong>of</strong> diabetes onthe periodontal tissues. J Am Dent Assoc. 2003;134:34S-40S.40. Taylor GW, Burt BA, Becker MP, et al. Severe periodontitisand risk for poor glycemic control in patients with non-insulindependentdiabetes mellitus. J Periodontol. 1996;67(suppl10):1085-1093.41. Grossi SG, Skrepcinski FB, DeCaro T, et al. 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Arch PediatrAdolesc Med. 2006;160:894-899.58. Chiu B. Multiple infections in carotid atherosclerotic plaques.Am Heart J. 1999;138:S534-S536.59. Dorn BR, Burks JN, Seifert KN, Progulske-Fox A. Invasion <strong>of</strong>endothelial and epithelial cells by strains <strong>of</strong> Porphyromonasgingivalis. FEMS Microbiol Lett. 2000;187:139-144.60. Han YW, Redline RW, Li M, et al. Fusobacterium nucleatuminduces premature and term stillbirths in pregnant mice: implication<strong>of</strong> oral bacteria in preterm birth. Infect Immun.2004;72:2272-2279.61. Scannapieco FA. Periodontal inflammation: from gingivitisto systemic disease? Compend Contin Educ Dent.2004;25(suppl 1):16-25.62. Ridker PM, Hennekens CH, Buring JE, Rifai N. C-reactiveprotein and other markers <strong>of</strong> inflammation in the prediction<strong>of</strong> cardiovascular disease in women. N Engl J Med.2000;342:836-843.63. Liuzzo G, Biasucci LM, Gallimore JR, et al. The prognosticvalue <strong>of</strong> C-reactive protein and serum amyloid A protein insevere unstable angina. N Engl J Med. 1994;331:417-424.64. D’Aiuto F, Parkar M, Andreou G, et al. Periodontitis and systemicinflammation: control <strong>of</strong> the local infection is associatedwith a reduction in serum inflammatory markers. J Dent Res.2004;83:156-160.65. Löe H. Periodontal disease: the sixth complication <strong>of</strong> diabetesmellitus. Diabetes Care. 1993;16:329-334.66. Salvi GE, Yalda B, Collins JG, et al. Inflammatory mediatorresponse as a potential risk marker for periodontal diseasesin insulin-dependent diabetes mellitus patients. J Periodontol.1997;68:127-135.67. Lalla E, Lamster IB, Feit M, et al. Blockade <strong>of</strong> RAGE suppressesperiodontitis-associated bone loss in diabetic mice.J Clin Invest. 2000;105:1117-1124.68. Mager DL, Ximenez-Fyvie LA, Haffajee AD, Socransky SS.Distribution <strong>of</strong> selected bacterial species on intraoral surfaces.J Clin Periodontol. 2003;30:644-654.12 The <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> Special <strong>supplement</strong>

Safety and Efficacy <strong>of</strong> Antimicrobial Mouthrinsesin Clinical PracticeLouis G. DePaola, DDS, MS, and Ann Eshenaur Spolarich, RDH, PhDIntroductionMechanical plaque removal throughtoothbrushing and flossing has beenthe universally accepted “gold standard”for maintaining oral health sincethe early 1960s. However, numerousstudies have shown that most patientsdo not effectively clean interdentallyto remove dental plaque daily. 1-3 By theearly 1980s, chemotherapeutic agentswere marketed as adjuncts to brushingand flossing; however, no definitiveguidelines for the evaluation <strong>of</strong> theirsafety and efficacy were available.Both the American <strong>Dental</strong> Association(ADA) and the Food and Drug Administration(FDA) have established standardsfor assessing the safety and efficacy<strong>of</strong> over-the-counter (OTC) andprescription mouthrinses.ADA Safety andEfficacy Guidelines forMouthrinsesAbstractEfficacy Overview. The use <strong>of</strong> an antimicrobial mouthrinse is an importantadjunct to toothbrushing and interdental cleaning. To varying degrees,chlorhexidine gluconate (CHG), cetylpyridinium chloride (CPC), and essentialoils (EO) interrupt the integrity <strong>of</strong> the bacterial cell membrane, leadingto lysis and death. CHG binds to salivary mucins, tooth structure, dentalplaque, and oral s<strong>of</strong>t tissues and is released slowly into the mouth, whereit inhibits adsorption <strong>of</strong> bacteria onto teeth. CHG is active against a widerange <strong>of</strong> gram-positive and gram-negative microorganisms. CPC binds toteeth and plaque to a lesser degree than CHG and is generally less efficaciousthan CHG. CHG and EO penetrate plaque bi<strong>of</strong>ilm and producechanges in microbial cell surface morphology that alter coaggregation,recolonization, and, thus, survival. CHG, CPC, and EO are active againsta wide variety <strong>of</strong> aerobic and anaerobic bacteria. An overview <strong>of</strong> the Foodand Drug Administration and American <strong>Dental</strong> Association rigorousapproval processes for efficacy and safety is provided.Safety Overview. Long-term use <strong>of</strong> CHG or EO does not adversely affectthe ecology <strong>of</strong> oral microbial flora, including microbial overgrowth, opportunisticinfection, or development <strong>of</strong> microbial resistance. Long-term use<strong>of</strong> CHG, CPC, or EO does not contribute to s<strong>of</strong>t tissue lesions or mucosalaberrations and has no serious adverse effect on salivary flow, taste, toothdeposits, or dental restoration. There is no evidence <strong>of</strong> a causal linkbetween alcohol-containing mouthrinses and the risk <strong>of</strong> oral and pharyngealcancer.Key words: Antimicrobial mouthrinse, efficacy, gingivitis, mechanism <strong>of</strong>action, safetySince 1931, the ADA, through itsvoluntary Seal <strong>of</strong> Acceptance Program,has promoted the use <strong>of</strong> oraland dental products that are both safeand effective. Published guidelinesdeveloped by the ADA list the acceptancecriteria for each type <strong>of</strong> agent,product, or device. In order to obtainthe Seal <strong>of</strong> Acceptance, a companymust provide evidence establishingthat a submitted agent, product, ordevice meets or exceeds the guidelinesfor that particular usage and issafe and effective. Additionally, theproduct must have been approved formarketing in the United States by theFDA. In 1985, the ADA recognizedthe potential benefits <strong>of</strong> some chemotherapeuticformulations, givingimpetus to the development <strong>of</strong> guidelinesfor the evaluation <strong>of</strong> antiplaqueand antigingivitis chemotherapeuticagents for inclusion in the Seal Program,which are still in use today. 4 Inorder to be awarded the Seal, anantiplaque and antigingivitis chemotherapeuticmust 5• Be tested in populations <strong>of</strong> typicalproduct users in a randomized,parallel-group, or crossover clinicaltrial in which the test productis compared with a negative controland, if appropriate, an activecontrol• Be supported by data from atleast two 6-month studies conductedat independent sites, withassessment <strong>of</strong> gingivitis andqualitative and quantitativeassessment <strong>of</strong> plaque performedat baseline, an intermediate point(usually 3 months), and 6months• Document a statistically significantreduction <strong>of</strong> supragingivalplaque and gingivitis as comparedwith a negative control ineach <strong>of</strong> the 2 studies and demonstratea statistically significantreduction <strong>of</strong> gingivitis for themouthrinse group <strong>of</strong> at least 15%for any one study and an averagereduction <strong>of</strong> 20% in the 2studies compared with the controlgroupSpecial <strong>supplement</strong> The <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> 13

Since 1931, the ADA, through itsvoluntary Seal <strong>of</strong> Acceptance Program,has promoted the use <strong>of</strong> oral anddental products that are both safeand effective.• Establish product safety withrespect to s<strong>of</strong>t tissues, teeth, toxicology,and effects on the oralflora (eg, adverse shifts in microbialpopulations, the development<strong>of</strong> microbial resistance, and theemergence <strong>of</strong> opportunisticorganisms)Data from the studies are then presentedto and reviewed by the ADACouncil on Scientific Affairs. If theproduct meets the established standards,it is awarded the ADA Seal <strong>of</strong>Acceptance. 4,5For the pr<strong>of</strong>essional and consumer,the ADA Seal for antimicrobial mouthrinsesindicates that• Product data have successfullyundergone an intensive, nonbiasedsafety and efficacy review• Evidence supports the manufacturer’sclaim for effectivenessagainst supragingival dental plaqueand gingivitis• The product is safe when used asdirectedFDA RegulationThe FDA regulates prescriptiondrugs as well as any OTC productsthat make therapeutic claims, such asthe reduction <strong>of</strong> gingivitis. The FDAhas accepted key elements for gingivitisassessment used by the ADASeal Program as appropriate for itsreview. However, in contrast to theADA, which evaluates products, theFDA evaluates active ingredientswhile recognizing that the way inwhich an ingredient is formulated mayaffect its clinical activity. In 2003, therecommendations <strong>of</strong> the FDA’s <strong>Dental</strong>Plaque Subcommittee <strong>of</strong> the NonprescriptionDrugs Advisory Committeewere published, and theyincluded the conditions under whichOTC products for the reduction orprevention <strong>of</strong> dental plaque and gingivitiswould be recognized as safe,effective, and not misbranded. 6,7 Inaddition to data supporting effectiveness,the following criteria are examinedby the FDA 6 :• Incidence and risk <strong>of</strong> adversereactions and significant sideeffects when used according toadequate directions• Margin <strong>of</strong> safety with normal use• Potential for harm from abuse ormisuse• Potential for inducing adverseside effects (such as irritation,ulceration, inflammation, erosion,damage to teeth/restorations)• Benefit-risk ratioAfter assessing an OTC ingredient,the FDA assigns the ingredient to acategory <strong>of</strong> I, II, or III 6,7 :• Category I: The ingredient isboth safe and effective and is notmisbranded.• Category II: The ingredient isnot generally recognized as safeand effective or is misbranded.• Category III: There are insufficientdata to evaluate safetyand/or effectiveness.The FDA may also approve products,both prescription and OTC,through the New Drug Application(NDA) process. The NDA process isa more lengthy one that also requiresdocumentation <strong>of</strong> both the safety andefficacy <strong>of</strong> the product.Mouthrinses That MeetADA and/or FDAGuidelinesTwo antiseptic mouthrinses (andtheir generic equivalents) have beenawarded the ADA Seal for chemotherapeuticcontrol <strong>of</strong> supragingivalplaque and gingivitis: 0.12% chlorhexidinegluconate (CHG) mouthrinse(Peridex ® ) and essential oils (EO)mouthrinse (Listerine ® ). Because <strong>of</strong> arecent change in the ADA Seal Program,Peridex ® and its generic equivalentsas prescription products nolonger carry the ADA Seal. However,no CPC formulation has yet to obtainthe ADA Seal. (See also page 32 formore information on the ADA SealProgram.)The FDA’s <strong>Dental</strong> Plaque Subcommittee<strong>of</strong> the NonprescriptionDrugs Advisory Committee has classified2 OTC mouthrinse ingredientsas both safe and effective and notKEY POINT:The ADA and FDA have rigorous approval processesThe ADA grants its Seal <strong>of</strong> Acceptance to mouthrinses that havedocumented safety and efficacy through at least 2 longitudinal, controlledclinical trials. The FDA evaluates OTC ingredients making therapeuticclaims. It has adopted key elements for gingivitis assessment from theADA Seal <strong>of</strong> Acceptance criteria and assigns categories (I, II, or III)based on level <strong>of</strong> safety and efficacy. For certain prescriptionmouthrinses, the FDA evaluates safety and efficacy via the New DrugApplication (NDA) process.14 The <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> Special <strong>supplement</strong>

Table I. Effect <strong>of</strong> CHG and EO on Normal Oral FloraMouthrinse Study Description Outcome References0.12% Several studies <strong>of</strong> 6 months’ duration Routine use <strong>of</strong> CHG and EO did 8, 9,12Chlorhexidine or longer; dental plaque harvested at not cause adverse shifts in plaquegluconate (CGH) baseline, midpoint, and end. Minimum ecology, emergence <strong>of</strong> opportunisticand essential inhibitory concentration microbial pathogens, or development <strong>of</strong>oils (EO) samples taken resistant microbial strains0.12% CHGand EO Candida species (C albicans, Both agents effective against test 13C dubliniensis, C krusei, C glabrata, fungal species at commerciallyC tropicalis) grown in vitro and treated available concentrations withwith 0.12% CHG or EOcomparable inhibition betweenCHG and EOEO Randomized, crossover study with 29 Reduction in S mutans: Recover- 14adults to determine whether regular able S mutans counts from theantimicrobial rinse use had theparticipants’ interproximal spacespotential for a selective increase <strong>of</strong> reduced by 75.4% with EO comparedStreptococcus mutans or an overgrowth with control. Total streptococci in inter<strong>of</strong>fungal species. Participants rinsed proximal plaque declined by 69.9%.with EO or placebo for 14 daysEO activity 37.1% greater againstS mutans than against other streptococci.No increase in risk <strong>of</strong> cariesEO In vivo investigations in persons with Rinsing with EO twice daily was as 15,16denture stomatitis caused by an effective as nystatin oral suspensionovergrowth <strong>of</strong> C albicans and other in reducing clinical palatal inflammationfungal species in maxillary prostheses and candidiasismisbranded (Category I): cetylpyridiniumchloride (CPC; examples <strong>of</strong>products include Colgate Viadent ®and Crest ® Pro-Health Rinse) andEO. 6,7 CHG was reviewed and foundto be safe and effective by the FDAby means <strong>of</strong> an NDA and is availablein the United States only by prescription.Although many commercial mouthrinsemanufacturers claim antiplaqueand antigingivitis properties, most lackthe efficacy data required to earn theADA Seal. Stannous fluoride hasreceived Category I recommendationby the FDA’s advisory committee, andtriclosan has received NDA approvalby the FDA. However, these agents arenot found in mouthrinse formulationsin the United States. This article discussesthe safety and efficacy data <strong>of</strong>mouthrinses that have been approvedby the FDA, recommended as CategoryI by the advisory committee, orawarded the ADA Seal.AntimicrobialMouthrinse SafetyTwo essential criteria for any productare safety and efficacy (see also pages 19to 22, Efficacy <strong>of</strong> Mouthrinses). Themost effective product would be uselessif it were not safe; conversely, thesafest product would be inconsequentialif it did not work. Issues related tosafety in mouthrinses include the following:• Are there any adverse effects onthe oral microbial flora?• Are there any oral s<strong>of</strong>t tissueaberrations?• Does routine use adversely affectdental restorative materials?• Are there any contraindicationsfor the use <strong>of</strong> these products?Each <strong>of</strong> these concerns merits carefulconsideration.Special <strong>supplement</strong> The <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> 15

Evidence confirms that daily, long-term use<strong>of</strong> CHG or EO does not adversely affectoral microbial flora, including no microbialovergrowth, opportunistic infection, ordevelopment <strong>of</strong> microbial resistance.Do Mouthrinses Have AdverseEffects on Oral Microbiota?Some dental pr<strong>of</strong>essionals may fearthat antiseptic mouthrinses pose a riskin killing or inhibiting normal flora withsubsequent repopulation with opportunisticand/or more pathogenic orresistant organisms. The microbial shiftwould manifest as an overgrowth <strong>of</strong>opportunistic organisms, such as Candida.Fortunately, studies document noadverse effects on supragingival dentalplaque micr<strong>of</strong>lora after 6 months <strong>of</strong>continued use with either CHG or EO. 8-12Table I describes the findings <strong>of</strong> severalstudies <strong>of</strong> the impact <strong>of</strong> EO andCHG on normal oral flora. Evidenceconfirms that daily, long-term use (6months or longer) <strong>of</strong> CHG or EO doesnot adversely affect oral microbial flora,including no microbial overgrowth,opportunistic infection, or development<strong>of</strong> microbial resistance.Do Mouthrinses Cause OralMucosal or Other S<strong>of</strong>t TissueAberrations?Concerns about potential adverseeffects on oral mucosa and other s<strong>of</strong>ttissue include the following:KEY POINT:No link between ACMs and OPC• Does alcohol cause adverseeffects such as an increased risk<strong>of</strong> oral and pharyngeal cancer(OPC)?• Are the active ingredients foundin CHG, CPC, and EO safe forlong-term use on the oral mucosa?• Do mouthrinses affect salivaryflow?• Are there adverse effects on tasteor tooth deposits?Several studies have addressedthese issues and are discussed below.Does alcohol cause adverseeffects such as an increased risk <strong>of</strong>OPC? Many mouthrinses containpharmaceutical-grade alcohol to solubilizeactive ingredients, make thembiologically active, or dissolve flavoringagents. Typical alcohol levelsin mouthrinses include the following:• CHG: generally 12.6% alcohol• CPC: 6% to 18% alcohol (traditional)and alcohol free, withhigh-bioavailability CPC, 0.07% 17• EO: 26.9% alcohol (original“gold” product) and 21.6% alcohol(flavored products)According to the FDA, National Cancer Institute, and ADA, there is noevidence <strong>of</strong> a causal relationship between ACMs and OPC. 6,28 Mostmouthrinses accepted by the ADA as safe and effective contain alcohol.The ADA Seal documents a product’s safety and efficacy, and the ADArecommends that patients continue to use antiseptic mouthrinses asadvised by their dental hygienist and dentist. 28,34Oral care pr<strong>of</strong>essionals may be reluctantto recommend an alcohol-containingmouthrinse (ACM) because<strong>of</strong> perceived risk for developingOPC. It is well known that tobaccousage and excessive alcoholic beverageconsumption cause a substantialportion <strong>of</strong> the OPC. 18-20 Sincemost mouthrinses contain alcohol, doACMs increase cancer risk as well?A number <strong>of</strong> studies have examineda cause-effect relationship betweenACMs and OPC with varyingresults. 19,21-27 A critical review <strong>of</strong>investigations that suggested a causeeffectrelationship revealed a number<strong>of</strong> deficiencies and study designflaws that necessitate rethinking theACM-cancer link 28,29 :• Lack <strong>of</strong> a dose-response based onfrequency and/or duration <strong>of</strong> mouthwashuse• Inconsistent findings among studies• Lack <strong>of</strong> a scientific or biologicalbasis to explain inconsistent findingsbetween males and females• Absence <strong>of</strong> correction for alcoholicbeverage ingestion and tobacco use• Inclusion <strong>of</strong> pharyngeal cancer,an improper classification as mouthrinsesonly contact the oral cavity• Inclusion <strong>of</strong> other head and neckcarcinomas, lymphomas, and sarcomasas oral cancer, an improperclassification as mouthrinses onlycontact the oral cavityA widely referenced study by theNational Cancer Institute erroneouslyconcluded that OPC risks were elevated60% among female and 40%among male users <strong>of</strong> mouthwash(with >25% alcohol). 27 This epidemiologicretrospective investigationconsisted <strong>of</strong> interviews with 866patients with OPC, diagnosed January1984 through March 1985, and1249 controls from the general populationwithout OPC sampled from4 areas <strong>of</strong> the United States. Reanalysis<strong>of</strong> this report by independentreviewers concluded that manypatients in the OPC group (6.6% <strong>of</strong>men and 12.6% <strong>of</strong> women) hadtumors <strong>of</strong> nonmucosal histology thatcould not have been contacted by an16 The <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> Special <strong>supplement</strong>

Table II. Effects <strong>of</strong> EO on Salivary FlowStudy Description Outcome ReferencesEffect <strong>of</strong> EO versus placebo Under exaggerated conditions 54on the salivary flow rate and (3 rinses/day instead <strong>of</strong> theoral mucosa <strong>of</strong> 19 volunteers recommended 2), no lesionswith documented xerostomia attributable to EO observedwho used 3 rinses daily for in the majority <strong>of</strong> patients.14 days followed by a cross- No statistically significantover after a 7-day washout differences detected betweenperiod. Pre- and postrinse pre- and postrinse salivarysalivary flow rates were flow rates for either the EOmeasured and oral s<strong>of</strong>t or control grouptissues examined forevidence <strong>of</strong> irritation andinflammationEffect on salivary flow or No significant effect on 55symptoms <strong>of</strong> dry mouth salivary flow or dry mouth<strong>of</strong> an EO mouthrinse and between the 2 groupsa non–alcohol-containingmouthrinseACM. Reanalysis <strong>of</strong> the data showedno relationship between ACMs andOPC. 6,30,31 Additional investigatorscontinue to report that there is no evidencethat ACM use increases OPCrisk. 28,32,33Data comparisons <strong>of</strong> topical alcoholexposure <strong>of</strong> the oral mucosa fromACMs and alcoholic beverage consumptionmay be invalid. Two or even3 topical administrations <strong>of</strong> a 25%ACM, each lasting 30 seconds, seemunlikely to produce the same effect aslong-term, habitual alcoholic beverageconsumption. Pharmaceuticalalcohol is not a carcinogen. 6,28 However,chemicals and additives foundin alcoholic beverages can cause cancer;for example, urethane, a knowncarcinogen, is commonly found inalcoholic beverages. 6,19,28 Commercialmouthrinses contain pharmaceuticalgradedenatured alcohol (pureethanol), which is free from contaminatingcarcinogens.Taking the following precautionsshould limit any potential problemswith ACMs:• Advise patients to consult withtheir abuse sponsor (counselor)before using an ACM.• EO is indicated for use in individualsover the age <strong>of</strong> 12 years.The effectiveness and safety <strong>of</strong>CHG have not been establishedin individuals under 18 years. 35,36• Use <strong>of</strong> an ACM in persons takingdisulfiram (Antabuse ® ) andmetronidazole (Flagyl ® ) is contraindicated,because in combinationthey may induce nausea,vomiting, and other unpleasantside effects. 37,38Do the active ingredients <strong>of</strong> CHG,CPC, and EO adversely affect theoral mucosa? Evidence supports thatlong-term use <strong>of</strong> CHG, CPC, or EOdoes not contribute to s<strong>of</strong>t tissuelesions or mucosal aberrations. Longtermclinical trials (at least 6 months’duration) produced substantial evidencedocumenting the safety <strong>of</strong> theactive ingredients <strong>of</strong> CHG, CPC, andEO mouthrinses on the oral mucosaand periodontium. 39-52 Complete orals<strong>of</strong>t tissue examinations were performedat each data collection period(baseline, 3 months, and 6 months) inthese studies. Findings revealed nodifferences in the incidence or severity<strong>of</strong> adverse events between theCHG, CPC, or EO groups and control/placebogroups. With EO, usersreport an initial tingling/burning sensationthat lessens rapidly with timeand is considerably reduced by theaddition <strong>of</strong> flavoring such as citrus. 29,42A burning sensation and occasionalmild desquamation have also beenreported with CPC use. 53Do mouthrinses affect salivaryflow? Xerostomia is a common sideeffect <strong>of</strong> many systemic diseases,radiation/chemotherapy, and numerousOTC and prescription medications.A misconception is that the use<strong>of</strong> an ACM desiccates the oralmucosa, leading to xerostomia. However,studies have shown that rinsingwith an EO mouthrinse does notinduce mucosal drying or aberration.54,55 Table II summarizes thesestudy findings.Are there adverse effects on tasteand tooth deposits? Some patientsmay experience a bitter taste with EOuse. 56 Taste alteration, as well asA misconception is that the use <strong>of</strong> anACM desiccates the oral mucosa, leading toxerostomia. However, studies have shownthat rinsing with an EO mouthrinse does notinduce mucosal drying or aberration.Special <strong>supplement</strong> The <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> 17

Table III. Effects <strong>of</strong> Antimicrobial Mouthrinses on <strong>Dental</strong> MaterialsMouthrinse Study Description Outcome ReferencesSeven mouthrinses In vitro study <strong>of</strong> resin specimens placed No statistical difference 61(5 alcohol-containing in 1 <strong>of</strong> 7 mouthrinses and vibrated for among the testedmouthrinses [ACMs], 30 seconds or 1 minute twice daily (to solutions. ACMs caused1 alcohol free, simulate actual use exposure times) no increased reduction inand 1 plain water) for 180 days composite resin hardnessEssential oils In vitro study measured effect <strong>of</strong> EO No differences in SBS 62(EO) on resin bond strength on human found between the EOteeth embedded in dental stone.and control groups at allTooth surfaces etched and rinsed for dilutions. EO had no30 seconds with distilled water or effect on resin bondvarious EO dilutions. Each tooth was strengththen dried, a film <strong>of</strong> adhesive resinapplied followed by composite resin,and shear bond strength (SBS) recordedEO Direct effect <strong>of</strong> EO use on dental No significant differences 63materials. Specimens <strong>of</strong> amalgam, between the EO andglass ionomer, and composite subjected control groups detectedto EO or distilled water for a continuous in vitro or in vivo. EO use10-day period. For each material, com- had no adverse effect onpressive strength and water fluidrestorative materialsabsorption were compared; surface testedporosity was evaluated with scanningelectron micrographs (SEM). Also, 10subjects wore appliances with implantedstudy materials and rinsed twice dailyfor 30 seconds with EO or placebo.After 10 days, dental materialsexamined by SEMincreased supragingival calculus formationand brown staining <strong>of</strong> theteeth and tongue, is associated withuse <strong>of</strong> CHG and CPC. 42,46,56-60 CHGstains teeth, esthetic restorations, andimplant abutments, and this stainingcan be problematic in a society thatdesires cosmetic dentistry and whiterand brighter teeth. 36,56KEY POINT:CHG, CPC, and EO cause no serious adverse effects in agenerally healthy population when used according todirectionsThis includes effects on salivary flow, taste, tooth deposits, and dentalrestorations. Some users may experience minor taste alteration, staining,and supragingival calculus formation with some CHG and CPCformulations.Does Routine Use <strong>of</strong> MouthrinsesAdversely Affect <strong>Dental</strong>Restorative Materials?A number <strong>of</strong> studies have addressedthe concern raised about theeffect <strong>of</strong> antimicrobial mouthrinseson dental materials. Other than thepotential for staining with CHG andCPC, there are no documentedadverse effects on dental materials.Table III summarizes the findings <strong>of</strong>these studies.18 The <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> Special <strong>supplement</strong>

Efficacy <strong>of</strong> MouthrinsesHow Antimicrobial MouthrinsesWorkAntiseptics are chemical agentsused to eliminate oral microorganismsin a variety <strong>of</strong> ways:Different antimicrobial mouthrinses havedemonstrated efficacy against bacteria, fungi,viruses, and spores. Some products produce awide spectrum <strong>of</strong> activity, while others areeffective against selected microorganisms only.• By producing cell death• By inhibiting microbial reproduction• By inhibiting cellular metabolismMost antiseptic agents are bactericidal,although some are bacteriostatic.The effectiveness <strong>of</strong> these agentsvaries widely and is dependent uponproduct formulation, concentration <strong>of</strong>the active agent, dose, substantivity,compliance, and interactions with otherchemicals present in the oral cavity atthe time <strong>of</strong> use. Different antimicrobialmouthrinses have demonstratedefficacy against bacteria, fungi, viruses,and spores. Some products produce awide spectrum <strong>of</strong> activity, while othersare effective against selected microorganismsonly. 56 Notably, most studies,including longitudinal trials, testing theefficacy <strong>of</strong> CHG used the commercialproduct Peridex ® , and Listerine ® wasthe EO commercial product used forall studies cited in this paper. CPCcommercial preparations used inresearch studies vary by product concentrationand brand.Mechanism <strong>of</strong> action <strong>of</strong> CHG.CHG (0.12%) is a bactericidal bisbiguanideantiseptic, with demonstratedefficacy against the followingorganisms:• A wide range <strong>of</strong> gram-positiveand gram-negative organisms 64• Aerobes and anaerobes, many <strong>of</strong>which are associated with plaqueand gingivitis, including Fusobacteriumand Prevotella intermedia65• Herpes simplex virus 1 and 2,human immunodeficiency virus1, cytomegalovirus, influenza A,parainfluenza, and hepatitisB. 12,66,67 CHG is not approved forthe prevention and treatment <strong>of</strong>viral infections• Seven species <strong>of</strong> Candida andother yeasts 13,68,69 (<strong>of</strong>ten used aloneor in combination with other antifungalmedications to reduceopportunistic infections in at-riskpopulations, such as those undergoingtreatment for leukemia orbone marrow transplantation 70,71 )Exposure to CHG causes rupturing<strong>of</strong> the bacterial cell membrane,which allows for leakage <strong>of</strong> the cytoplasmiccontents, resulting in celldeath. 72,73 CHG binds to salivarymucins, reducing pellicle formationand inhibiting colonization <strong>of</strong> plaquebacteria. 64,74 It also binds to bacteria,which inhibits their adsorption ontothe teeth. 64 CHG has been shown topenetrate the dental plaque bi<strong>of</strong>ilm,which enables CHG to access andkill pathogens embedded within thebi<strong>of</strong>ilm. 72CHG binds tightly to tooth structure,dental plaque, and oral s<strong>of</strong>t tissues.It is released slowly into themouth, which allows antimicrobialeffects to be sustained for up to 12hours, thus its high degree <strong>of</strong> substantivity.64,75 A 30-minute interval isoptimal between toothbrushing andrinsing with CHG to avoid an interactionbetween the positively chargeddetergents found in dentifrices (eg,sodium lauryl sulfate) and thecationic CHG rinse. This interaction,and possible inactivation <strong>of</strong> CHG,can also occur with the anionic fluorideion found in stannous fluorideand in some toothpastes andmouthrinses. 73,76Mechanism <strong>of</strong> action <strong>of</strong> CPC.CPC, a quaternary ammonium compound,demonstrates bactericidalactivity. Its mechanism <strong>of</strong> action issimilar to CHG in that it ruptures thebacterial cell wall membrane, resultingin leakage <strong>of</strong> the intracellular contentsand eventual cell death. CPC isalso thought to alter bacterial metab-73, 77olism and inhibit cell growth.CPC binds to tooth structure anddental plaque bi<strong>of</strong>ilm; however, thedegree <strong>of</strong> binding is not as strong aswith CHG. Further, CPC is rapidlyreleased from binding sites, whichexplains why it is generally less efficaciousthan CHG. 73 Like CHG, thiscationic rinse may adversely interactwith other charged ions found in dentifricesand mouthrinses, possibly limitingits biological activity.Published data regarding the efficacy<strong>of</strong> CPC-containing mouthrinsesare limited. In the United States, CPCis available in 2 concentrations:0.05% found in cosmetic mouthrinses(Cepacol ® and Scope ® ) and0.07% found in therapeutic mouthrinses(BreathRx ® and Crest ® Pro-Health Rinse). It has been suggestedthat the unique vehicle found in Crest ®Pro-Health Rinse is purported toincrease the product’s oral bioavailabilitywhen compared with otherCPC-containing mouthrinses. 78In vitro studies have documentedthat CPC can be effective against thefollowing organisms:• Actinomyces viscosus, Porphyromonasgingivalis, Campylobacterrectus, Streptococcus sanguis,Eikenella corrodens, Salmonellatyphimurium, Fusobacteriumnucleatum, Haemophilus actinomycetemcomitans,Lactobacilluscasei, and P intermedia 78• Several species <strong>of</strong> Candida 68,69,79-81CPC, like CHG, has been suggestedas a possible agent for the preventionSpecial <strong>supplement</strong> The <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> 19

and treatment <strong>of</strong> fungal infections.However, CPC mouthrinses mayadversely affect systemic azole drugtreatment <strong>of</strong> oropharyngeal candidiasisin immunocompromised persons. Thisnegative outcome may be attributed toeither a cross-resistance to the azoledrugs against CPC-resistant organismsor drug antagonism between CPC andazole antifungal medications whenthey are used in combination. 82 Two <strong>of</strong>5 fluconazole-resistant C albicansstrains have also exhibited reducedsusceptibility to CPC. 82Mechanism <strong>of</strong> action <strong>of</strong> EO. EOantiseptic mouthrinse is a bactericidalcombination <strong>of</strong> phenolic essentialoils, including eucalyptol, menthol,methyl salicylate, and thymol.Phenolic compounds exert theirantimicrobial effects by the followingmechanisms 77, 83-87 :• Cause protein denaturation• Alter the cell membrane, resultingin leakage <strong>of</strong> the intracellular contentsand eventual cell death• Alter bacterial enzyme activity• Exhibit anti-inflammatory propertiesby inhibiting prostaglandinsynthetase, an enzymeinvolved in the formation <strong>of</strong>prostaglandins, which are primaryinflammatory mediators.Note that the anti-inflammatoryeffect <strong>of</strong> phenolic compoundsoccurs at concentrations lowerthan those needed for antibacterialactivity• Cause perforation <strong>of</strong> the cellmembrane and rapid efflux <strong>of</strong>intracellular contents (especiallythymol)• Alter neutrophil function by suppressingthe formation <strong>of</strong> andscavenging existing free radicalsgenerated in neutrophils and byaltering neutrophil chemotaxis(especially thymol)A 30-second exposure time to EOproduces morphologic cell surfacealterations in a variety <strong>of</strong> oralpathogens that suggest the loss <strong>of</strong> cellmembrane integrity. 88 Cell surfacechanges may also alter bacterial coaggregationand recolonization thatcould potentially affect the growthand metabolism <strong>of</strong> these organisms.Microscopic evidence <strong>of</strong> cell surfaceroughening was obtained for the followingmicroorganisms:• C albicans• F nucleatum• A viscosus• Actinobacillus actinomycetemcomitans• S sanguisCell surface changes that resultfrom a short exposure time to EOmay adversely affect bacterial andfungal survival. 88 Exposure to levels<strong>of</strong> EO sublethal to microorganismsalso reduces bacterial coaggregationwith gram-positive pioneer species,an essential step in plaque maturationand the development <strong>of</strong> thecomplex pathogenic flora found ingingival disease. Decreased bacterialcoaggregation reduces the rate <strong>of</strong>plaque maturation, which in turnmay result in a decreased plaquemass, as is observed clinically withEO use. 89 EO also has been shownto extract endotoxins from gramnegativebacteria. 90 Endotoxins playan important role in pathogenesis;thus, reduction in endotoxin levelshould manifest as a decrease in gingivalinflammation.Unlike other OTC mouthrinses,EO has been shown to penetrate thedental plaque bi<strong>of</strong>ilm and is activeagainst bacteria embedded within thebi<strong>of</strong>ilm. 72,91-93 EO kills a wide variety<strong>of</strong> aerobic and anaerobic bacteriaassociated with plaque bi<strong>of</strong>ilm andgingivitis, including the following 94• A actinomycetemcomitans• A viscosus• S mutans• S sanguis• Bacteroides speciesEfficacy against gram-positive andgram-negative organisms occurs evenat concentrations that are less than fullstrength. 94,95 A single 30-second rinsereaches and exerts an antibacterialeffect interproximally, an importantconsideration given that gingival diseasestarts between the teeth and thatindividuals <strong>of</strong>ten cannot access interproximalareas with mechanicalplaque removal techniques such astoothbrushing and flossing. Totalrecovered bacteria from proximaltooth surfaces was 43.8% lower followinga single 30-second rinse <strong>of</strong> EOcompared with a control (P=.001). 96Rinsing twice daily with EO as anadjunct to brushing for 11 daysreduced total recoverable streptococciin interproximal plaque by 69.9%(P

Table IV. Effects <strong>of</strong> CHG on Supragingival Plaque and GingivitisTrial Concentration Plaque GingivitisLength No. <strong>of</strong> <strong>of</strong> CHG Decrease DecreaseInvestigator (months) Subjects (%) (%) (%)Löe et al, 1976 49 24 120 0.20 45 27Lang et al, 1982 50 6 158 0.10 16.2 66.60.20 19.4 80.4Segreto et al, 1986 102 3 600 0.12 36 370.20 28 28Grossman et al, 1986 48 6 430 0.12 61 39Grossman et al, 1989 47 6 481 0.12 49 31Brightman et al, 1991 103 3 34 0.12 64.9 60.0Overholser et al, 1990 42 6 124 0.12 50.3 30.5Eaton et al, 1997 104 3 121 0.12 28 25Charles et al, 2004 46 6 108 0.12 21.6 18.2Table V. Effects <strong>of</strong> CPC on Supragingival Plaque and GingivitisTrial Concentration Plaque GingivitisLength No. <strong>of</strong> <strong>of</strong> CHG Decrease DecreaseInvestigator (months) Subjects (%) (%) (%)Allen et al, 1998 105 6 111 0.05 28.2 24.0Mankodi et al, 2005 51 6 139 0.07 15.8 15.4Stookey et al, 2005 52 * 6 366 0.075 17 230.10 19 20* The mouthrinse formulations in this study were experimental.CHG. Results regarding the efficacy<strong>of</strong> CPC varied and were dependentupon product formulation. 101 Efficacystudies <strong>of</strong> CHG, CPC, and EO aresummarized in Tables IV, V, and VI,respectively.The following observations can bemade from these study results:• CHG generally reduces moreplaque than either CPC or EO, apredictable outcome given itsgreater substantivity; the longeran antimicrobial agent stays incontact with plaque bacteria, thegreater its effect.• CHG and EO are comparable inreducing gingivitis. 39-41,43-45,48-50,102-104• In head-to-head comparisonstudies that evaluated both CHGand EO in the same participants,antiplaque effects were greaterfor CHG, but antigingivitiseffects were similar for bothagents. 42,46,47• Both CHG and EO demonstrategreater reductions in supragingivalplaque and gingivitis as comparedwith CPC (see Tables IV-VI).Perhaps one EO study best summarizesthe effectiveness <strong>of</strong> mouthrinsesas an aid to reducing supragingivalplaque and controlling gingivitis. In alarge, randomized, controlled clinicaltrial involving 237 participants, thosewho added twice-daily rinsing withEO to their homecare routine <strong>of</strong> regularbrushing and flossing demonstrateda 51.9% greater reduction inplaque and a 21.0% greater reductionSpecial <strong>supplement</strong> The <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> 21

Table VI. Effects <strong>of</strong> EO (Listerine ® ) on Supragingival Plaque and GingivitisTrial Plaque GingivitisLength No. <strong>of</strong> Rinsing Decrease DecreaseInvestigator (months) Subjects Supervision (%) (%)Lamster et al, 1983 40 6 145 Supervised 22 28Gordon et al, 1985 39 9 85 Supervised 19.5 23.9DePaola et al, 1989 41 6 107 Supervised 34 34Overholser et al, 1990 42 6 124 Supervised 36.1 35.9Charles et al, 2001 43 6 316 Unsupervised 56.1 22.9Bauroth et al, 2003 44 6 326 Unsupervised 21 12Sharma et al, 2004 45 6 237 Unsupervised 51.9 21.0Charles et al, 2004 46 6 108 Unsupervised 18.8 14.0in gingivitis, as compared with thosewho brushed and flossed only. 45 Thisstudy demonstrates the benefit <strong>of</strong>adding an EO mouthrinse to regularmechanical plaque removal andshows that mouthrinses are able toreach bacteria in areas that are difficultto access and where mechanicalmethods <strong>of</strong>ten leave residual plaquebehind.Approved Mouthrinses Are EfficaciousThroughout the EntireMouthConclusionAntimicrobial mouthrinses that areapproved by the FDA and carry theADA Seal <strong>of</strong> Acceptance are safe andeffective for the reduction <strong>of</strong> supragingivalplaque and gingivitis. Productsthat have not been evaluated in longtermclinical trials have no scientificevidence documenting safety or efficacyand should be used with caution.Antimicrobial mouthrinses with establishedsafety and efficacy are animportant and effective addition tomechanical plaque control methods toestablish a healthy mouth. Mostpatients will benefit by adding anADA-Accepted antimicrobial mouthrinseto their self-care daily regimen<strong>of</strong> brushing and interdental cleaning.Using an antiseptic mouthrinse producesan antimicrobial effect throughoutthe entire mouth, including areaseasily missed during toothbrushing andinterdental cleaning. Studies havedemonstrated that antiseptics kill bacteriain saliva and on the s<strong>of</strong>t tissues <strong>of</strong>the mouth, including the tongue andoral mucosa, which are reservoirs <strong>of</strong>pathogenic bacteria that are able totransfer and colonize onto the teeth. 98,105-108These collective research findings,with consideration given to the respectiveadverse events pr<strong>of</strong>iles <strong>of</strong> antisepticagents, reinforce the value <strong>of</strong> usingCHG, CPC, and EO in addition tomechanical plaque control for longtermmaintenance <strong>of</strong> gingival health.Using an antiseptic mouthrinseproduces an antimicrobial effectthroughout the entire mouth,including areas easily missed duringtoothbrushing and interdental cleaning.22 The <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> Special <strong>supplement</strong>

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84. Walker CB. Microbiological effects <strong>of</strong> mouthrinses containingantimicrobials. J Clin Periodontol. 1988;15:499-505.85. Shapiro S, Meier A, Guggenheim B. The antimicrobialactivity <strong>of</strong> essential oils and essential oil componentstowards oral bacteria. Oral Microbiol Immunol.1994;9:202-208.86. Kuehl FA Jr, Humes JL, Egar RW, et al. Role <strong>of</strong>prostaglandin endoperoxide PGG2 in inflammatoryprocesses. Nature. 1977;265:170-172.87. Azuma Y, Ozaza N, Ueda Y, Takagi N. Pharmacologicalstudies on the anti-inflammatory action <strong>of</strong> phenolic compounds.J Dent Res. 1986;65:53-56.88. Kubert D, Rubin M, Barnett ML, Vincent JW. Antisepticmouthrinse-induced microbial cell surface alterations. AmJ Dent. 1993;6:277-279.89. Fine DH, Furgang D, Lieb R, et al. Effects <strong>of</strong> sublethalexposure to an antiseptic mouthrinse on representativeplaque bacteria. J Clin Periodontol. 1996;23:444-451.90. Fine DH, Letizia J, Mandel ID. The effect <strong>of</strong> rinsing withListerine antiseptic on the properties <strong>of</strong> developing dentalplaque. J Clin Periodontol. 1985;12:660-666.91. Pan P, Barnett ML, Coelho J, et al. Determination <strong>of</strong> thein situ bactericidal activity <strong>of</strong> an essential oil mouthrinseusing a vital stain method. J Clin Periodontol. 2000;27:256-261.92. Fine DH, Furgang D, Barnett ML. Comparative antimicrobialactivities <strong>of</strong> antiseptic mouthrinses against isogenicplanktonic and bi<strong>of</strong>ilm forms <strong>of</strong> Actinobacillus actinomycetemcomitans.J Clin Periodontol. 2001;28:697-700.93. Ouhayoun JP. Penetrating the plaque bi<strong>of</strong>ilm: impact <strong>of</strong>essential oil mouthrinse. J Clin Periodontol. 2003;30(suppl5):10-12.94. Ross NM, Charles CH, Dills SS. Long-term effects <strong>of</strong> Listerineantiseptic on dental plaque and gingivitis. J ClinDent. 1989;1:92-95.95. Whitaker EJ, Pham K, Feik D, et al. Effect <strong>of</strong> an essentialoil-containing antiseptic mouthrinse on induction <strong>of</strong> plateletaggregation by oral bacteria in vitro. J Clin Periodontol.2000;27:370-373.96. Charles CH, Pan PC, Sturdivant L, Vincent JW. In vivoantimicrobial activity <strong>of</strong> an essential oil-containingmouthrinse on interproximal plaque bacteria. J Clin Dent.2000;11:94-97.97. Pitts G, Brogdon C, Hu L, et al. Mechanism <strong>of</strong> action <strong>of</strong> an antiseptic,anti-odor mouthwash. J Dent Res. 1983;62:738-742.98. DePaola LG, Minah GE, Overholser CD, et al. Effect <strong>of</strong> anantiseptic mouthrinse on salivary microbiotia. Am J Dent.1996;9:93-95.99. Furgang K, Sinatra K, Schreiner H, et al. In vitro antimicrobialactivity <strong>of</strong> an essential oil mouthrinse. J Dent Res.2002;81(special issue A). Abstract 2854.100. Dennison DK, Meredith GM, Shillitoe EJ, Caffesse RG.The antiviral spectrum <strong>of</strong> Listerine antiseptic. Oral SurgOral Med Oral Pathol Oral Radiol Endod. 1995;79:442-448.101. Gunsolley JC. A meta-analysis <strong>of</strong> six-month studies <strong>of</strong>antiplaque and antigingivitis agents. J Am Dent Assoc.2006;137:1649-1657.102. Segreto VA, Collins EM, Beiswanger BB, et al. A comparison<strong>of</strong> mouthrinses containing two concentrations <strong>of</strong>chlorhexidine. J Periodontal Res. 1986;21(suppl):23-32.103. Brightman LJ, Terezhalmy GT, Greenwell H, et al. Theeffects <strong>of</strong> a 0.12% chlorhexidine gluconate mouthrinse onorthodontic patients aged 11 through 17 with establishedgingivitis. Am J Orthod Dent<strong>of</strong>acial Orthop. 1991;100:324-329.104. Eaton KA, Rimini FM, Zak E, et al. The effects <strong>of</strong> a 0.12%chlorhexidine–digluconate-containing mouthrinse versusa placebo on plaque and gingival inflammation over a 3-month period. A multicentre study carried out in generaldental practices. J Clin Periodontol. 1997;24:189-197.105. Allen DR, Davies R, Bradshaw B, et al. Efficacy <strong>of</strong> amouthrinse containing 0.05% cetylpyridinium chloride forthe control <strong>of</strong> plaque and gingivitis: a 6-month clinicalstudy in adults. Compend Contin Educ Dent. 1998;19(2suppl):20-26.106. Dahlen G. Effect <strong>of</strong> antimicrobial mouthrinses on salivarymicr<strong>of</strong>lora in healthy subjects. Scand J Dent Res.1984;92:38-42.107. Jenkins S, Addy M, Wade W, Newcombe RG. The magnitudeand duration <strong>of</strong> the effects <strong>of</strong> some mouthrinseproducts on salivary bacterial counts. J Clin Periodontol.1994;21:397-401.108. Pitts G, Pianotti R, Feary TW, et al. The in vivo effects <strong>of</strong>an antiseptic mouthwash on odor-producing microorganisms.J Dent Res. 1981;60:1891-1896.109. Fine DH, Furgang D, Sinatra K, et al. In vivo antimicrobialeffectiveness <strong>of</strong> an essential oil-containing mouth rinse12 h after a single use and 14 days’ use. J Clin Periodontol.2005;32:335-340.Special <strong>supplement</strong> The <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> 25

Strategies for Incorporating Antimicrobial Mouthrinsesinto Daily Oral CareJoanna Asadoorian, RDH, MScIntroductionAbstractOverview. A cost-effective way <strong>of</strong> improving patient outcomes is adoptingpreventive practices known to be effective. As “front-line” providers <strong>of</strong> dentalhealth services and information, dental hygienists are an important catalystfor the implementation <strong>of</strong> evidence-based preventive practices—such as the twice-daily use <strong>of</strong> antimicrobial mouthrinses—in the self-careroutines <strong>of</strong> patients. However, encouraging patients to adopt new behaviorscan present a challenge: providers may be uncomfortable with recommendingnew behaviors and patients may be resistant to learning newskills. As expert clinicians, educators, and counselors, dental hygienists arein an excellent position to help patients make changes and learn newbehaviors.Clinical Implications. This article discusses practical methods for promotingchange. Targeting interventions to individual patient values, stage <strong>of</strong>readiness to change, and skill set encourages patient incorporation <strong>of</strong> newbehaviors. Time should be allotted for supervised practice <strong>of</strong> new skills, andpatients should be supported in planning for effective and lasting behaviorchange. Through effective communication, skills teaching, and use <strong>of</strong> follow-up,dental hygienists can help patients adopt healthy behaviors.Key words: Antimicrobial mouthrinse, compliance, dental hygiene, oralhealth, patient educationThe merits <strong>of</strong> oral hygiene to healthhave long been valued by oral healthcare providers. However, publicawareness <strong>of</strong> the importance <strong>of</strong> oralhealth and the links between oral andsystemic health and disease hasincreased in recent years, particularlysince the publication <strong>of</strong> Oral Health inAmerica: A Report <strong>of</strong> the SurgeonGeneral in 2000 and the subsequentrelease and implementation <strong>of</strong> theNational Call to Action to PromoteOral Health, a public-private partnershipunder the leadership <strong>of</strong> the Office<strong>of</strong> the Surgeon General. 1,2 <strong>Dental</strong>hygienists now have an importantwindow <strong>of</strong> opportunity to counselpatients on behaviors that promoteoral health. Health care providers,including dental hygienists, can act ascatalysts for change by teachingpatients about oral health, modelinghealth behaviors, and helping patientsadopt healthy behaviors. 3It has been noted that “the mostcost-effective opportunity to improvepatient outcomes over the next quartercentury will likely come not fromdiscovering new therapies but fromdiscovering how to deliver therapiesthat are known to be effective.” 4 Theaim <strong>of</strong> this article is to enable dentalhygienists to put evidence-basedinformation about antimicrobialmouthrinses into practice by effectivelycommunicating research findingswith patients and promotingincorporation <strong>of</strong> healthy behaviorsinto their self-care regimens. Thisreview will focus on practical methodsfor promoting positive change andsuggest ways to involve patients inoptimizing their oral health. By promotingoptimal oral care, dentalhygienists can make a significant differencein the health and well-being <strong>of</strong>their patients.Initiating BehavioralChangeWhile encouraging patients toadopt new, healthful behaviors issomething dental hygienists frequentlydo, they may find it difficultto recommend new behaviors, such asuse <strong>of</strong> antimicrobial mouthrinses. Barriersto change are varied and include:• Habit: <strong>Dental</strong> hygienists may recommendtraditional oral hygienemethods most <strong>of</strong>ten (such asbrushing and flossing), despiteresearch demonstrating the effectiveness<strong>of</strong> other oral hygiene aidsand techniques. 5• Lack <strong>of</strong> confidence 6 : <strong>Dental</strong>hygienists may lack the confidenceto use motivational interviewingtechniques (please seePractical Strategies for Change)• Lowered expectations: Hygienistsmay feel that patients are unlikelyto change their behaviors despitecounseling. Patients that dentalhygienists have the lowest expectation<strong>of</strong>—those with high plaquelevels—may receive less genuineverbal interaction and not receivethe more intensive instructionthey need. 7 These more challengingpatients may be ideal candidatesfor dental hygienists tobegin targeting for incorporatingantimicrobial oral rinsing intodaily home care.• Not enough time: Lack <strong>of</strong> interestand resistance from the patient26 The <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> Special <strong>supplement</strong>

Practical Strategies for ChangeThe patient is the center <strong>of</strong> any successful change effort.Promoting change starts with listening to the patient andproviding suggestions and skills teaching that are alignedwith the patient’s values. <strong>Dental</strong> hygienists need to be comfortablewith actively questioning and interviewing patientsto elicit the patient’s beliefs and values about oral hygiene,health, and disease and be prepared for responses that donot conform with ideals. 28 Effective questioning minimizespatient defensiveness, allowing patients to consider change.The following are strategies that can promote effective dialogueand support adoption <strong>of</strong> healthy behaviors.• Ask patient about current oral health practicesBegin with determining the patient’s current level <strong>of</strong> selfcare.Example: “What do you do each day to take care<strong>of</strong> your teeth and gums?” You may want to ask thepatient questions that elicit felt needs, such as, “If youcould change anything about your oral health, whatwould you change?” Avoid a confrontational approach,and be sure to support healthy activities the patient isalready performing.• Assess patient readiness to changeDetermine the patient’s readiness to incorporate newself-care behaviors. 23 The initial question may be “Wouldyou be willing to try using an antimicrobial mouthrinsetwice daily?” If the patient responds positively, move topractical support. If the patient responds with disinterest,determine any obstacles to change. “Have you triedthem in the past? Did you find one you liked? Why not?Why don’t you think it would be helpful?” Be sure tomaintain a nonconfrontational attitude. It may help towrite down patient objections, and continue to listen toobjections until the patient is finished. Active listeningmay diffuse patient resistance. If the patient is unwillingto consider change, providing interventions over multiplevisits can encourage the patient to rethink his or herdecision. Always work within the patient’s stage <strong>of</strong> readinessto change.• Supervise new skills / behaviorsIf the patient is ready to attempt new behaviors, supervisedpractice will enhance patient self-efficacy. 3 Encouragethe patient to practice using mouthrinse, and showthe patient what to look for on the label. This will increasethe patient’s comfort level and success with the newbehavior. Remind the patient that if a product was shownvia research to be effective with twice daily use, using theproduct once daily may not yield the desired outcomes.• Structure a plan for successful adoption <strong>of</strong> the newbehaviorIf the patient is ready to change, it is also important to helpwith the plan for success. Unlike other negative behaviorssuch as overeating or smoking, patients do not derivepositive satisfaction when neglecting oral self-care. Theprimary obstacle is apathy. Work with the patient todevelop a brief change plan that incorporates environmentalsupport. Encourage the patient to be specific.These planning steps maximize the likelihood <strong>of</strong> successfulchange. Example: “I’m glad you’re ready to makea positive change. I’ve seen many patients significantlyimprove the health <strong>of</strong> their gums by adding an antimicrobialmouthrinse to their daily routine. Do you have anantimicrobial mouthrinse? Do you know where to look t<strong>of</strong>ind out if your rinse is ADA-Accepted? When do youplan to use your rinse? Will your use <strong>of</strong> the rinse matchthe manufacturer’s recommendations for daily care?”• Anticipate obstaclesStressful life experiences can disrupt the formation <strong>of</strong>positive habits. 18 Encourage the patient to incorporateexternal memory triggers (eg, notes to self) to allow himor her to maintain or resume positive oral health practicesduring disruptive or stressful periods. If the patientdoes not discuss obstacles, you may want to engage inself-disclosure or share examples from your experiencewith other patients. Example: “It can be hard sometimesto remember new healthy habits when we’re busy, sick,traveling, or stressed out. I’m a dental hygienist, andsome days I’m so busy I barely have time to brush myteeth. What are some ways that help you remember todo things when life is stressful? What are some obstaclesthat may keep you from using an antimicrobialmouthrinse twice daily?”• Follow up with the patientAsk the patient about whether he or she has successfullyincorporated the behavior and any obstacles thatwere encountered: “Were you able to find a productyou really liked? Could you easily access the product?Was it hard to be consistent? What was your biggestchallenge?” Praise any progress toward the desiredbehavior, and revise the patient’s action plan accordingly:“Even though you weren’t able to use the rinseevery day twice daily, I’m glad that you were able touse it before bed most nights. You have made a greatstart! Do you think you can use it more <strong>of</strong>ten? When doyou think you can incorporate a second rinse into yourday?” Specific follow-up demonstrates care for thepatient and is appreciated. Follow-up is also central tomaintaining change. 26,27While it takes time to change behaviors, the above interventionsare brief and can be incorporated into a preventive,therapeutic, or periodontal maintenance visit. Throughuse <strong>of</strong> effective questioning and encouraging patients toshare their health values and behaviors, dental hygienistscan <strong>of</strong>fer targeted advice and be perceived as caring andsupportive while fulfilling their responsibility to educatepatients. Nonconfrontational questioning minimizes patientdefensiveness and ensures they will be as receptive aspossible to receiving information on their oral health.Repeated interventions can assist patients as they adoptpositive behaviors that will improve oral health and quality<strong>of</strong> life.Special <strong>supplement</strong> The <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> 27

and poor financial incentives fororal hygiene instruction may contributeto limiting the time spenton education. 8,9For all <strong>of</strong> these reasons, dentalhygienists may tend to continue torecommend the traditional therapies<strong>of</strong> brushing and flossing alone. However,compliance with daily flossinghas been reported to be generally low,ranging from only 10% to 30%, 5 sopatients may benefit from informationabout new and adjunctive methods forthorough plaque removal.But changing dental hygienistbehavior is difficult due to the complexity<strong>of</strong> the process, and differentbarriers likely respond to differentapproaches to change. 10,11 Simpleexposure to new knowledge may beinsufficient to overcome most barriersto change practices, 11,12 but dissemination<strong>of</strong> information can be more effectivein changing behavior when combinedwith other methods such asinteractive educational activities,enabling tools, and reminders. 13 Inaddition, comparing one’s currentpractice behaviors to sources <strong>of</strong> evidence,such as guidelines and externalfeedback, has been shown to motivatechange. 12,14 Reading journal articlesthat summarize the evidence base in asubject area, like the ones published inthis journal <strong>supplement</strong>, and comparingthe findings to one’s current practicemay stimulate a need that encouragespractitioners to change theirpr<strong>of</strong>essional behaviors.Recently, two pr<strong>of</strong>essional dentalorganizations have <strong>of</strong>ficially acknowledgedevidence about the adjunctiveuse <strong>of</strong> daily antimicrobial rinsing. TheAmerican <strong>Dental</strong> Association (ADA)released a statement in support <strong>of</strong> theuse <strong>of</strong> ADA–Accepted antimicrobialmouthrinses in addition to traditionalbrushing and interdental cleaning. 15The Canadian <strong>Dental</strong> Hygienists’Association (CDHA) published a positionstatement supporting the incorporation<strong>of</strong> antimicrobial rinsing inpatient home care routines. 16 Both <strong>of</strong>these documents provide support forthe dental hygienist as he or she recommendsthat patients incorporate oralrinsing into their daily routine.EncouragingCompliance / AdherenceOnce a dental hygienist decides toassist patients in improving their oralhealth status through the implementation<strong>of</strong> an evidence-based product, (eg,an antimicrobial mouthrinse), the dentalhygienist must motivate the patientto change his or her daily oral care routine.Research confirms what dentalhygienists know intuitively, thatAdherence versus Compliancepatients are reluctant to change theirhome care routines and, overall, maynot display interest in oral hygieneinstruction. 9,17Despite the value people place onoral health, patients are increasinglyDespite the value people place on oral health,patients are increasingly strained withmeeting the demands <strong>of</strong> daily life.Stressful life events have also been shown tointerfere with self-care.strained with meeting the demands <strong>of</strong>daily life. 18 Stressful life events havealso been shown to interfere with selfcare.18 In a study examining the impact<strong>of</strong> oral hygiene education, patientswith poor oral hygiene subsequent toinstructions and education reportedhaving difficulty taking care <strong>of</strong> theirteeth and had more factors that interferedwith self-care than the more successfulstudy participants. 19 Moreover,because incorporating complex behaviors—suchas traditional oral self-carebehaviors—may be met with lesscompliance than simpler strategies, 19oral rinsing interventions may produceimproved adherence (see Adherenceversus Compliance below).Further complicating the issue <strong>of</strong>compliance, research evidence demonstratesthat even persons with highplaque levels believe they are doing agood job with their oral home care. 19The fact that patients have an inabilityto evaluate their oral hygiene effectivenessand monitor their oral healthstatus has been raised as a weaknessCompliance is a common term used in oral health care literature to describea patient’s willingness to follow a practitioner’s instructions. 20,28 The term hasbeen criticized because it implies that the patient assumes a passive role andacquiesces to pr<strong>of</strong>essional recommendations he or she may not understandor agree with. 17,20,28 Some authors use the term adherence instead <strong>of</strong>compliance, as it implies that the patient takes a more active role in decisionmaking and thereby improves behavior change. 20undermining dental hygiene instruction.8 Finally, compliance in behaviorspreventing conditions perceived to benon–life threatening, such as periodontaldisease and dental caries, mayhave a lower priority for patients. 18,20<strong>Dental</strong> hygienists can encouragepatients to adopt healthy behaviors,such as the twice-daily use <strong>of</strong> anADA-Accepted antimicrobial mouthrinse,by a variety <strong>of</strong> methods. <strong>Dental</strong>hygienists can listen to patientfeelings and values and emphasizethe value and relevance <strong>of</strong> oralhygiene care before providing oralhygiene education. 21 This allowspatients to link improved healthbehaviors to these values, enhancing28 The <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> Special <strong>supplement</strong>

20, 22-23Table I. Transtheoretical Stages <strong>of</strong> Change and Suggested InterventionsStage Characteristics Suggested InterventionPrecontemplation Patient is unaware <strong>of</strong> the Verify patient’s state <strong>of</strong> readinessneed for behavior changeor resistant to changeRaise patient awareness“I won’t change” “Are you aware <strong>of</strong> the health benefits <strong>of</strong> using anantimicrobial mouthrinse twice daily?”Contemplation Patient has considered Verify patient’s state <strong>of</strong> readinesschanging behavior but isnot currently taking action Compliment patient on thinking about making a change“I might change” “Sounds like you’ve been thinking about making changesin your oral self-care. That’s great! What would you sayis holding you back from taking that step?”Preparation Patient is ready to take Verify patient’s state <strong>of</strong> readinesspositive actionProvide actionable information“I will change”I’m glad you’re ready to make a healthy change. If youwanted to use mouthrinse tonight, what steps would youneed to take? (eg, suggest purchasing a mouthrinse knownto reduce plaque and gingivitis)Action Patient is making initial Verify patient’s state <strong>of</strong> readinesssteps toward behaviorchangeSupport change“I am making a change” “I’m glad you decided to give mouthrinse a try. Have youthought about ways to make it easier to continue yournew habit?” (eg, suggest placing it on the counters inall the bathrooms, placing a reminder note on thebathroom mirror, or including it in an oral care kit at work)Maintenance Patient has incorporated Verify patient’s state <strong>of</strong> readinessbehavior change successfully,although some relapseSupport behavior maintenance, explore potentialmay have occurredobstacles, make contingency plans“I have been making “That’s wonderful to hear you’re using mouthrinse! I canchanges”see the improvement in your plaque and gingival bleedingscores. It takes time to change lifetime habits. We will keepmonitoring your oral health status at each dental hygienevisit. Let me show you how to monitor yourself at home.”their readiness to make positivechanges. 21In addition, change efforts shouldbe tailored to the patient’s expressedreadiness to change. According to theTranstheoretical Model <strong>of</strong> Change,patients are in one <strong>of</strong> several stages<strong>of</strong> readiness to incorporate new20, 22-23behaviors, and interventionsshould be targeted accordingly. TableI shows stages <strong>of</strong> change and appropriateinterventions based on thepatient’s stages <strong>of</strong> readiness.In addition to matching educationalinterventions to patient readiness forchange, it is important to tailor informationto each individual patient.Through the skillful use <strong>of</strong> listening,questioning, imparting knowledge,and teaching skills, the dental hygienistcan influence the key dimensions <strong>of</strong>patient behavior including acquiringknowledge, changing attitudes, heighteningperceived needs, and improvingmotivation. 19,24 While the actual interventionsrecommended may be thesame across a variety <strong>of</strong> patients—forSpecial <strong>supplement</strong> The <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> 29

Table II. <strong>Dental</strong> Hygienist Actions for Supporting Patient Behavior ChangeGeneral for All PatientsIndividualized to Specific PatientTarget high-risk patientsClarify patient valuesDetermine the patient’s state <strong>of</strong> readiness for changeInquire about current behaviorsTailor approach—ensure relevanceConvince patient <strong>of</strong> effectiveness <strong>of</strong> interventionHighlight the pleasurable sensations and socialbenefits <strong>of</strong> oral hygiene and healthMaintain a positive environmentDisplay warmth and genuinenessProvide ongoing remindersBe prepared for relapseProvide sufficient contact timeEnsure mastery <strong>of</strong> one skill at a timeProvide meaningful praiseInclude intraoral demonstrationsInclude supervised practiceEncourage a partnership incorporating two-waycommunicationEnsure patient can self-monitor improvements (eg,decreased redness, swelling, and bleeding)Provide patient specific written educational materials to<strong>supplement</strong> interventionsAssist patient in managing when home care will occur,incorporating contingency plansKey elements to maximize that patients maintaintheir new behaviors include the use <strong>of</strong>positive feedback, patient reminders(such as phone calls and postcards),and adapting dental hygiene instructionsto the needs <strong>of</strong> the patientexample, twice daily use <strong>of</strong> an antimicrobialrinse—the individual tailoring<strong>of</strong> educational sessions to these behavioraldimensions are critical for motivatingchange. 19,25 As new products areintroduced to the market, the dentalhygienists’ role becomes crucial inhelping patients understand the personalhealth care implications <strong>of</strong> theresearch literature. 25The provision <strong>of</strong> information aboutsafe and effective antimicrobialmouthrinses is important, but informationalone will not change patientbehavior. 8,9 The teaching <strong>of</strong> new skillsis a necessary component <strong>of</strong> an effectiveintervention. Skills acquisition isfacilitated by introducing skills one ata time, allowing time for supervisedpractice. This approach increases thechance for successful transfer <strong>of</strong>knowledge from the <strong>of</strong>fice to thehome setting. 7 Using quantitativehygiene assessment tools such asplaque and gingivitis scores can helppatients see the relevance <strong>of</strong> instructionto their oral health. 7Table II summarizes important features<strong>of</strong> successful dental hygieneinterventions designed to motivatepatients into changing their home carebehaviors. These factors combinedwith the patient’s belief that he or shehas control over his or her oralhygiene and health will increase thelikelihood for positive behaviorchange. 3The fact that research-supported,oral health–promoting behaviors(such as the twice-daily use <strong>of</strong> a safeand effective antimicrobial mouthrinse)need to be carried out overone’s lifetime contributes to the challenge.17 Studies consistently showthat modest gains achieved initiallyin changing patient behavior diminishwith time and minimize initialgains. 19 Key elements to maximizethat patients maintain their newbehaviors include the use <strong>of</strong> positivefeedback, patient reminders (such asphone calls and postcards), andadapting dental hygiene instructionsto the needs <strong>of</strong> the patient. 20 In aseries <strong>of</strong> 3 studies evaluating themaintenance <strong>of</strong> self-care behaviorprograms, adherence was improvedwhen reminders were used, seeminglyfor as long as the reminderswere provided. 26 Therefore, maintenance<strong>of</strong> behavioral change is anongoing and deliberate process. 27ConclusionsAs preventive oral health experts,dental hygienists must continually evaluatemethods <strong>of</strong> enhancing oral healthand recommend those techniques andproducts with evidence-based effectivenessto their patients. This articlehas examined strategies for promotingbehavioral change in the context <strong>of</strong>adoption <strong>of</strong> twice-daily use <strong>of</strong> antimicrobialmouthrinses, which have beenshown to effectively reduce plaque andpromote oral health when used as part<strong>of</strong> a daily self-care regimen. These principlescan also be applied when teachingpatients about other health careproducts and behaviors.30 The <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> Special <strong>supplement</strong>

References1. US Department <strong>of</strong> Health and Human Services. Oral Healthin America: A Report <strong>of</strong> the Surgeon General. Rockville,MD: US Department <strong>of</strong> Health and Human Services,National Institute <strong>of</strong> <strong>Dental</strong> and Crani<strong>of</strong>acial Research,National Institutes <strong>of</strong> Health; 2000. http://www2.nidcr.nih.gov/sgr/sgrohweb/welcome.htm.2. US Department <strong>of</strong> Health and Human Services. NationalCall to Action to Promote Oral Health. Rockville, MD: USDepartment <strong>of</strong> Health and Human Services, Public HealthService, National Institutes <strong>of</strong> Health, National Institute <strong>of</strong><strong>Dental</strong> and Crani<strong>of</strong>acial Research; 2003. NIH PublicationNo. 03-5303. http://www.surgeongeneral.gov/topics/oralhealth/nationalcalltoaction.htm.3. Koelen MA, Lindstrom B. 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The resistance to changingguidelines—what are the challenges and how to meet them.Best Pract Res Clin Anaesthesiol. 2006;20:379-395.11. Bain KT. Barriers and strategies to influencing physicianbehavior. Am J Med Qual. 2007;22, 5-7.12. Bloom BS. Effects <strong>of</strong> continuing medical education on improvingphysician clinical care and patient health: A review <strong>of</strong>systematic reviews. Int J Technol Assess Health Care. 2005;21:380-385.13. Gray J. Changing physician prescribing behaviour. Can JClin Pharmacol. 2006;13:e81-e84.14. Mead P. Clinical guidelines: promoting clinical effectivenessor a pr<strong>of</strong>essional minefield? J Adv Nurs. 2000;31:110-116.15. ADA affirms benefits <strong>of</strong> ADA-Accepted antimicrobial mouthrinses and toothpastes, fluoride mouth rinses [newsrelease].Chicago, IL: American <strong>Dental</strong> Association; May 23,2007. http://ada.org/public/media/releases/0705_release03.asp. Accessed July 27, 2007.16. Asadoorian J. Oral rinsing: Canadian <strong>Dental</strong> Hygienists AssociationPosition Statement. CDHA position paper on commerciallyavailable over-the-counter oral rinsing products.CJDH. 2006;40:168-183.17. Blinkhorn AS. Factors affecting the compliance <strong>of</strong> patients withpreventive dental regimens. Int Dent J.1993;43,294-298.18. Ower P. The role <strong>of</strong> self-administered plaque control in themanagement <strong>of</strong> periodontal diseases: 2. Motivation, techniquesand assessment. Dent Update. 2003;30:110-116.19. Weinstein P, Milgrom P, Melnick S, et al. How effective isoral hygiene instruction? Results after 6 and 24 weeks. JPublic Health Dent. 1989;49:32-38.20. Silverman S, Wilder R. Antimicrobial mouthrinse as part <strong>of</strong> acomprehensive oral care regimen: safety and compliancefactors. J Am <strong>Dental</strong> Assoc. 2006;137(11 suppl ):22S-26S.21. Horowitz LG, Dillenberg J, Rattray J. Self-care motivation: amodel for primary preventive oral health behavior change. JSch Health. 1987;57:114-11822. Prochaska JO, Norcross JC, DiClemente CC. Changing forGood: The Revolutionary Program That Explains the SixStages <strong>of</strong> Change and Teaches You How to Free YourselfFrom Bad Habits. New York: William Morrow; 1994.23. Astroth, DB, Cross-Poline GN, Stach DJ, et al. The transtheoreticalmodel: an approach to behavioral change. J DentHyg. 2002;76:286-295.24. Uitenbroek DG, Schaub RMH, Tromp JA, Kant JH. <strong>Dental</strong>hygienists’ influence on the patients’ knowledge, motivation,self-care, and perception <strong>of</strong> change. Community Dent OralEpidemiol. 1989;17:87-90.25. Gluch-Scranton J. Motivational strategies in dental hygienecare. Semin Dent Hyg. 1991;3:1-4, 6-8.26. McCaul KD, Glasgow RE, O’Neill HK. The problem <strong>of</strong> creatinghabits: establishing health-protective dental behaviors.Health Psychol. 1992;11:101-110.27. Cifuentes M, Fernald DH, Green LA, et al. Prescription forhealth: changing primary care practice to foster healthybehaviors. Ann Fam Med. 2005;3:S4-S12.28. Chu R, Craig B. Understanding the determinants <strong>of</strong> preventiveoral health behaviours. Probe. 1996; 30:12-18.Special <strong>supplement</strong> The <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> 31

ConclusionAntimicrobial Mouthrinses in Contemporary <strong>Dental</strong><strong>Hygiene</strong> Practice: The Take Home MessageMichele Leonardi Darby, RDH, MSIntroductionThe primary indication for antimicrobialmouthrinse use is to achieve areduction in supragingival plaque andgingivitis. Evidence shows that anAmerican <strong>Dental</strong> Association (ADA)–Accepted antimicrobial mouthrinsecan result in a greater reduction inplaque and gingivitis than brushingand flossing alone. 1 Therefore, eventhe most diligent brusher and flossercan benefit from the addition <strong>of</strong> anADA-Accepted antimicrobial mouthrinseto the daily homecare regimen.Antimicrobial mouthrinses reducethe bacterial count and inhibit thepathogenic bacterial activity in dentalbi<strong>of</strong>ilm that can cause gingivitis, aprecursor to periodontitis. Brushingand flossing alone may not always beenough to control the pathogenicity<strong>of</strong> dental bi<strong>of</strong>ilm. Untreated, gingivitiscan advance to periodontitis andtooth loss and may be associated withother chronic diseases and conditionssuch as diabetes mellitus, cardiovasculardisease, obesity, and pre-termbirth. Most patients will improve theiroral health by adding an ADA-Accepted antimicrobial mouthrinse totheir self-care daily regimen <strong>of</strong> brushingand interdental cleaning. Therefore,the incorporation <strong>of</strong> an ADA-Accepted mouthrinse into the dailyregimen <strong>of</strong> brushing and cleaninginterdentally is important to achieveoptimal oral health outcomes.The ADA Seal <strong>of</strong>Acceptance ProgramMore than 100 companies voluntarilyparticipate in the ADA Seal <strong>of</strong>Acceptance Program and more than400 oral care products marketeddirectly to consumers carry the ADASeal (Figure 1). 2 Oral health care pr<strong>of</strong>essionalsand consumers can visithttp://www.ada.org/ada/seal/adaseal_consumer_shopping.pdf to identifyproducts that have earned the ADASeal <strong>of</strong> Acceptance to guide their recommendationsand purchases <strong>of</strong> overthe-counter(OTC) products. GivenMore than 100 companies voluntarilyparticipate in the ADA Seal <strong>of</strong>Acceptance Program and more than400 oral care products marketed directly toconsumers carry the ADA Seal.Figure 1. The American<strong>Dental</strong> Association Seal<strong>of</strong> Acceptance. (Courtesy<strong>of</strong> the American<strong>Dental</strong> Association.)the importance <strong>of</strong> oral and systemichealth, and product safety and efficacy,this list is likely to expand andshould be reviewed regularly.The safety and efficacy data for thetwice-daily use <strong>of</strong> an antiplaque andantigingivitis antimicrobial mouthrinseis unequivocal. Products thathave been found effective againstplaque and gingivitis and that haveearned the ADA Seal are those thatcontain 0.12% chlorhexidine gluconate(CHG) or a fixed combination<strong>of</strong> essential oils (EO). Listerine ® — afixed combination <strong>of</strong> EO—and itsgeneric equivalents carry the ADASeal; however, because <strong>of</strong> recentchanges in the ADA Seal program,prescription products such as Peridex ®(0.12% CHG), even if they have pre-32 The <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> Special <strong>supplement</strong>

viously earned the ADA Seal, are nolonger included in the ADA Seal program,as the granting <strong>of</strong> the ADA Sealfor prescription product has beenphased out.Evidence-BasedLiteratureIn addition to the ADA Seal, wellprepared,published systematicreviews and meta-analyses that synthesizea large number <strong>of</strong> rigorousstudies on a focused topic and thatarrive at clear conclusions can beextremely valuable in guiding clinicaldecisions regarding products,devices, treatments, and interventions.Many such studies and reviews inaddition to original research papersare cited throughout this <strong>supplement</strong>,and these references can provide furtherbackground and information onthe benefits <strong>of</strong> using an antimicrobialmouthrinse as part <strong>of</strong> a daily regimen.One good example cited withinthese pages is a recent meta-analysis<strong>of</strong> 6-month studies <strong>of</strong> antiplaque andantigingivitis agents. 3 Moreover, systematicreviews on a variety <strong>of</strong> dentalsubject areas are also available fromthe Cochrane Library including theCochrane Database <strong>of</strong> SystematicReviews at www.cochrane.org. Thissite is an essential resource for busydental hygienists who strive to maintainan evidence-based practice.In general, possessing a basicknowledge <strong>of</strong> what constitutes appropriateresearch methods and the abilityto read the pr<strong>of</strong>essional literatureincreases the dental hygienist’s competenceas a critical consumer <strong>of</strong>research, enabling the dental hygienistto translate important research findingsinto practice in a timely manner.ConclusionsIn conclusion, most patients willimprove their oral health by adding anADA-Accepted antimicrobialmouthrinse to their self-care daily regimen<strong>of</strong> toothbrushing and interdentalcleaning. Within the context <strong>of</strong> clinicalpractice and current research evidence,dental hygienists should recommendthat patients practice a three-step dailyoral hygiene regimen <strong>of</strong> brushing,interdental cleaning, and rinsing withan ADA-Accepted antimicrobialmouthrinse to help prevent and reduceplaque and gingivitis and speak withtheir dental hygienist or dentist foradditional guidance. Understandingthe process <strong>of</strong> change and matchingpr<strong>of</strong>essional oral care recommendationsto patient’s specific needs, goals,values, and levels <strong>of</strong> readiness tochange may lead to patient adherenceand attainment <strong>of</strong> desired clinical outcomesover the long term. Regardless<strong>of</strong> the level <strong>of</strong> adherence to pr<strong>of</strong>essionalrecommendations, patients needregular instruction and encouragementfrom a dental hygienist they trust.References1. Sharma N, Charles CH, Lynch MC, etal. Adjunctive benefit <strong>of</strong> an essentialoil-containing mouthrinse in reducingplaque and gingivitis in patients whobrush and floss regularly: a six-monthstudy. J Am Dent Assoc. 2004;135:496-504.2. About the ADA Seal <strong>of</strong> Acceptance.American <strong>Dental</strong> Association Website. http://www.ada.org/ada/seal/index.asp. Accessed July 30, 2007.3. Gunsolley JC. A meta-analysis <strong>of</strong> sixmonthstudies <strong>of</strong> antiplaque andantigingivitis agents. J Am Dent Assoc.2006;137:1649-1657.Special <strong>supplement</strong> The <strong>Journal</strong> <strong>of</strong> <strong>Dental</strong> <strong>Hygiene</strong> 33

©McNEIL-PPC, Inc. 2007Rinse twice a day and call me in the morning.Taking care <strong>of</strong> your mouth may be important to your overall health. Rinsing with LISTERINE ® Antisepticmay help. It kills germs that cause gingivitis. That’s important because, if left untreated, gingivitis couldprogress to advanced gum disease, which emerging science associates with heart disease, diabetes andother health problems. To learn more, visit www.listerine.com, or ask your dentist, dental hygienistor physician about the mouth-body connection.*DO IT FORDO IT FORThe Seal on the product means: *If brushing and flossing aren’t enough, use as directed as part <strong>of</strong> your regular oral care routine to help prevent and reduce plaque and gingivitis.“The ADA Council on Scientific Affairs’ Acceptance <strong>of</strong> Listerine is based on its finding that the product is effective in helping to prevent or reduce gingivitis and plaque above thegumline, when used as directed.”