Mouthwash and periodontal disease

This article explores the multi-factorial causes of periodontal disease and offers evidence as to why brushing, interdental cleaning and rinsing with an appropriate mouthwash may be the most effective way forward for some patients.


In 2017, Chapple and colleagues reached a consensus regarding the current understanding of periodontal disease. In their report on group 2’s findings from the joint EFP/ORCA workshop on the boundaries between caries and periodontal diseases, they stated: ‘Periodontal diseases and dental caries are complex diseases with multiple and diverse exposures that impact upon risk of disease initiation (risk factors) or progression of existing disease (prognostic factors).’1


They continued: ‘Exposures include those that are inherited (e.g. genetic variants), those that are acquired, such as social, educational and economic factors, and the local environment (e.g. biofilm load or composition), other diseases (e.g. sub-optimally controlled diabetes) and lifestyle (e.g. smoking, consumption of sugars, carbohydrate intake) factors. These may arise in different combinations in different individuals, and at an individual patient level may also have differentially weighted effects.’1


Despite the multi-factorial nature of periodontal disease, experts agree that plaque is a major initiator of the condition and oral plaque biofilm disruption is currently the most effective way to treat and prevent gingivitis and periodontitis.2,3


In line with this, according to Chapple and colleagues (2015): ‘[…] the most important risk factor for periodontitis is the accumulation of a plaque biofilm at and below the gingival margin, within which dysbiosis develops and is associated with an inappropriate and destructive host inflammatory immune response. Plaque removal and/or control is therefore fundamentally important in the prevention of periodontal diseases.’4


The mechanical cleaning challenge


According to the Adult Dental Health Survey 2009, only 17% of dentate adults in England, Wales and Northern Ireland had very healthy periodontal tissues (i.e. no bleeding, no calculus, no periodontal pocketing of 4mm or more, and in the case of adults aged 55 or above, no loss of periodontal attachment of 4mm or more anywhere in their mouth).5

Data from the same survey reveals that 75% of survey participants claimed to brush their teeth at least twice a day and a quarter of those further reported that they clean interdentally daily.5


These figures suggest there remains an unmet need when it comes to tackling periodontal disease.


Barnett recognised this disparity, writing, ‘While it theoretically is possible to maintain a level of oral hygiene sufficient to control gingivitis using mechanical methods alone, data indicate that the vast majority of people are unable to accomplish this on an ongoing basis.6


While tooth brushing in general is recommended in terms of reducing plaque, where improvements are needed to achieve better plaque control, it may be prudent to recommend a patient uses an electric toothbrush in preference to a manual one. This is because controlled studies have demonstrated that an electric toothbrush produces significantly better reductions in plaque bacteria when compared to a manual brush.4


Added to this, interdental cleaning is considered, ‘[…] essential in order to maintain interproximal gingival health, in particular for secondary prevention […]’.4


The FDI’s White Paper on Prevention and Management of Periodontal Diseases for Oral Health and General Health (2018) adds to this ideology, stating, ‘The additional use of flosses and/or interdental brushes is essential for removal of interdental plaque.’7


The White Paper further suggests: ‘…according to the Guidelines for Effective Prevention of Periodontal Diseases produced by the EFP (2015), some specific mouth rinses offer benefit in the management and prevention of gingivitis, as do certain chemical agents in dentifrices as an adjunct to mechanical plaque removal.’7


The same year as the Guidelines for Effective Prevention of Periodontal Diseases were published, Chapple and colleagues (2015) wrote: ‘For the treatment of gingivitis and where improvements in plaque control are required, adjunctive use of antiplaque chemical agents may be considered.’4


Also, in 2015, Araujo and colleagues circulated the results of their meta-analysis on the effect of an essential oil mouthwash on gingivitis and plaque compared to mechanical methods alone. They demonstratedthe clinically relevant benefits of an essential oil-containing mouthrinse in site-specific areas of the mouth, when used as an adjunct to mechanical cleaning over a six-month period.8


One year later, Haas and colleagues (2016) explored the effect of essential oil mouthwash on plaque by means of a meta-analysis of the effect of essential oil mouthwash on plaque compared to a placebo or cetylpyridium chloride. They concluded: ‘Mouthwashes containing essential oils should be considered the first choice for daily use as adjuvants to self-performed mechanical plaque control.9


Prevention at the point of gingivitis


In 2015, Working Group 2 of the 11th European Workshop in Periodontology added to the body of evidence, suggesting that the universal recommendation to brush twice daily for at least two minutes with a fluoridated toothpaste is likely to be insufficient for patients with periodontitis.4


Whilst this statement refers to periodontitis, gingivitis is also a challenge that needs to be considered in terms of helping patients to adopt an effective at-home oral care regimen, since it has been demonstrated that gingivitis and periodontitis are a continuum of the same inflammatory disease.3


However, it is important to note that gingivitis will not always progress to periodontitis.3 Instead, it is thought that: ‘The weight of the evidence indicates that the prevention of gingival inflammation prevents periodontitis.’3


Thus, as stated by Chapple and colleagues (2015): ‘[…] while not all patients with gingivitis will progress to periodontitis, management of gingivitis is both a primary prevention strategy for periodontitis and a secondary prevention strategy for recurrent periodontitis.4


Tackling a complex disease


Offering a final point, following their review of the effectiveness of antiseptic mouthrinses for oral health, Farook and Said (2018) wrote: ‘As a primary etiological factor, control in plaque is mandatory for primary prevention of gingivitis. Plaque is essential, but insufficient to cause periodontitis and should be controlled.’10


They continued: ‘Although mechanical plaque control is the most effective method of plaque removal, mechanical removal alone is insufficient to control plaque as some residual plaque is frequently left behind after brushing and flossing. A chemotherapeutic agent could be beneficial as an adjunct to self-performed oral hygiene.’10



1. Chapple ILC et al. Interaction of lifestyle, behaviour or systemic diseases with dental caries and periodontal diseases: consensus report of group 2 of the joint EFP/ORCA workshop on the boundaries between caries and periodontal diseases. J Clin Periodontol 2017; 44 (Suppl. 18): S39-S51.

2. Page RC, Kornman KS. The pathogenesis of human periodontitis: an introduction.Periodontol 2000. 1997; 14: 9-11.

3. Kinane DF, Attström R. Advances in the pathogenesis of periodontitis. Group B consensus report of the fifth European Workshop in Periodontology. J Clin Periodontol. 2005; 32(Suppl. 6): 130-131.

4. Chapple ILC et al. Primary prevention of periodontitis: managing gingivitis. J Clin Periodontol. 2015; 42 (Suppl. 16): S71-S76.

5. Adult Dental Health Survey 2009. The Information Centre for Health and Social Care 2011

6. Barnett M L. The rationale for the daily use of an antimicrobial mouthrinse. JADA 2006; 137: 16S-21S.

7. White Paper on Prevention and Management of Periodontal Diseases for Oral Health and General Health. FDI World Dental Federation 2018

8. Araujo MWB et al. Meta-analysis of the effect of an essential oil-containing mouthrinse on gingivitis and plaque. JADA. 2015; 146(8): 610-622.

9. Haas AN. Essential oils-containing mouthwashes for gingivitis and plaque: Meta-analyses and meta-regression. J Dent. 2016; 55: 7-15.

10. Farrok FF, Said KN. A review of the effectiveness of antiseptic mouth rinses for oral health. J Oral Hyg Health. 2018; 6(3): 1000246.




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