What is oral health? The World Health Organization defines it thus, ‘Oral health is a key indicator of overall health, well-being and quality of life.’¹  

True health cannot indeed be enjoyed unless you have a healthy mouth.  Unfortunately, for many people, this has been hard to achieve. The Global Burden of Disease Study 2017 (Institute for Health Metrics) estimates that oral diseases affect close to 3.5 billion people worldwide. Severe periodontal diseases are estimated to affect nearly 10% of the global population.²

Knowledge is key

The moment we raise the issue of oral health, the first thing people remember is the toothache that they or their friends and family have experienced. ‘There is no pain like a toothache!’ they cry. Bleeding gums, toothaches and bad breath are problems that have concerned humans throughout time.³ Lack of information and knowledge is one of the key factors in driving behaviours that lead to oral health problems.

Our mouth is colonised by about 700 different species of bacteria.⁴ In a clean mouth, at any given time there may be 1000-100,000 bacteria on each tooth surface in comparison to a less clean mouth with potentially between 100 million and 1 billion.⁵ 

Dental plaque can be defined as the soft deposits that form the biofilm adhering to the tooth surface or other hard structures in the oral cavity. The plaque that forms at the gum margin or above is of prime importance in the development of gingivitis. Supragingival plaque and tooth-associated subgingival plaque are critical in calculus formation and root caries, whereas tissue-associated subgingival plaque is important in the soft tissue destruction that characterises different forms of periodontitis.

Despite hundreds of bacterial species colonising the oral cavity, only a small percentage of these bacteria are responsible for gum disease: Actinobacillus actinomycetemcomitans, Bacteroides forsythus and Prophyromonas gingivalis being a few examples of the key offenders.⁶

Long-standing gingivitis may eventually lead to periodontitis, where the permanent destruction of soft and hard tissue becomes established. The gingivitis phase is reversible and manageable, which is good news for every patient and therefore every patient will benefit from more widespread education about oral health.   

Advances in science have improved our understanding of how microorganisms behave and the effects they can have on our health. 

A holistic approach

These advances make it clear that a healthy mouth is certainly the foundation of a healthy body. This latest news is now sufficiently important to become a matter of public health concern, making it vital for clinicians to have in-depth knowledge and to convey such important information to every patient.

Oral hygiene is not simply to save teeth and avoid the immediate challenge of bleeding gums and/or toothache, but part of a holistic approach to maintain and strengthen a healthy body.  Naturally, this is an especially relevant message to everybody in these uncertain times.

Good mechanical cleaning should be enough. However, with an ageing population with complex restoration needs and failing restorations in the 45 to 65 age group (the heavy metal generation), crowded teeth and poor manual dexterity create a challenge whilst attempting to maintain low  plaque levels. Even patients with very good manual dexterity find it difficult to maintain a low dental plaque level in challenging and inaccessible areas.

When the bacteria persist for a period of time, they establish a protective environment where the colony can flourish and cause destruction of soft and hard tissue. This results in gingivitis, which may lead to periodontitis, as well as caries. The gold standard to maintain oral health is mechanical cleaning, using a toothbrush and interdental brushes or floss. It is vital to maintain a low plaque level of course, and luckily any difficulties encountered by patients can be overcome by the use of adjunctive therapies such as an anti-plaque chemical adjunct.⁷

Exploring mouthwash use

There are many papers which have investigated the benefit of mouth rinses. The papers concluded that different mouth rinses used after toothbrushing, as adjunct to mechanical means of oral hygiene, may provide added benefit of plaque reduction.⁸

It is a misconception that the use of mouthwashes is a modern-day phenomenon. They have been used by the Chinese for centuries.⁹ There are hundreds of different brands of mouthwash available throughout the world, which does baffle professionals, not to mention how it can mystify patients.

The burning question that any clinician should ask themselves is – what are we trying to achieve with the introduction of mouthrinse?

Are we worried about gingival and soft tissue health? One of the systematic reviews concluded that there is a strong evidence base supporting the efficacy of chlorhexidine and essential oils as anti-plaque mouth rinses. It also suggested that the clinical benefits of anti-plaque mouth rinses are similar to the benefits of oral prophylaxis and oral hygiene instructions at six-month recall appointments.¹⁰

The systematic reviews and meta-analyses have reported that mouth rinses can provide a benefit beyond mechanical oral hygiene alone in preventing plaque accumulation. Hence, using mouthwash twice daily after brushing can be beneficial.¹¹

The oral bacteria Streptococcus mutans make up a large majority of the oral microbiome. When they metabilise simple dietary sugars and carbohydrates into acids and enzymes, tooth enamel can be affected. Caries prevention can be achieved by brushing with a fluoridated toothpaste. Dietary advice is also key.  

The daily use of mouth rinses can be used as an adjunctive component to mechanical oral hygiene regimens for the control and prevention of plaque. They are also beneficial as a method of delivering antimicrobial agents to mucosal sites throughout the mouth that harbour potentially pathogenic bacteria capable of recolonising on supragingival and subgingival tooth surfaces.¹¹

Experience pays

Since qualifying, I have learned that changing behaviour – as opposed to repeating the ‘brush mantra’ –  and extensively researching adjuncts and communication styles has resulted in better outcomes for my patients. 

I have also realised that patients need to be educated on how to use a mouth rinse. For example, should it be used diluted or not? For how long should they rinse and at what time they should use the mouth wash?

I do make sure I strongly convey the message to my patients that mouth rinse does NOT replace mechanical cleaning at any point and that it should only be used as an adjunctive therapy.

I review the use of mouth rinses at each appointment. Working with my patients using a team approach has helped me to achieve a great success rate in terms of clinical outcomes.

Author

Gulab Singh qualified as a Dental Hygienist and Therapist from GKT Dental institute with distinction. He currently practises at Wensleydale Dental Practice and is Chairman of the BSDHT’s Eastern region.  He won Best Hygienist at the 2019 Oral Health Award, was Highly Commended in the Hygienist of the Year category in both the 2018 and 2019 Dental Awards, and triumphed as The Best Team Member at The Dentistry Awards in 2018. He is also a Clinical Mentor for the NSK Ikigai Oral Hygiene programme.

‘This article is brought to you by Johnson & Johnson, the makers of LISTERINE(R).  The content is the authors own, but their time has been compensated by Johnson & Johnson.’

References:

1. https://www.who.int/health-topics/oral-health/#tab=tab_1. Accessed 22 October 2020
2. https://www.who.int/news-room/fact-sheets/detail/oral-health. Accessed 22 October 2020
3. https://sciencediscoveries.degruyter.com/traditional-methods-oral-hygiene-maintenance/. Accessed 22 October 2020
4. Kilian M et al. The oral microbiome – an update for oral healthcare professionals. BDJ 2016; 221(10): 657-666
5. Stevens JE. Oral Ecology. MIT Technology Review 1997; https://www.technologyreview.com/1997/01/01/275880/oral-ecology/. Accessed 24 November 2020
6. van Winkelhoff AJ et al. Porphyromonas gingivalis, Bacteroides forsythus and other putative periodontal pathogens in subjects with and without periodontal destruction. J Clin Periodontol 2002: 29: 1023-1028
7. Chapple ILC et al. Primary prevention of periodontitis: managing gingivitis. J Clin Periodontal 2015: 42 (suppl. 16): S71-S76
8. Prasad M et al. The clinical effectiveness of post-brushing rinsing in reducing plaque and gingivitis: a systematic review .J Clin Diagn Res. 2016 May; 10(5): ZE01-7. doi: 10.7860/JCDR/2016/16960.7708. Epub 2016 May 1.
9. Fischman SL. The history of oral hygiene products: how far have we come in 6000 years? Periodontology 2000 1997; 15: 7-14
10. Gunsolley JC. Clinical efficacy of antimicrobial mouthrinses, J Dent. 2010 Jun; 38 Suppl 1: S6-10. doi: 10.1016/S0300-5712(10)70004-X.
11. Araujo MWB et al. Meta-analysis of the effect of an essential oil-containing mouthrinse on gingivitis and plaque. JADA 146(8): 610-622