Helping to prevent periodontal disease
Johnson & Johnson Ltd. is delighted to bring you this article, with the aim of supporting the ongoing Enhanced CPD needs of dental healthcare professionals in improving and maintaining the oral health of their patients.
This article is equivalent to one hour of Enhanced CPD.
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Learning Outcomes: C
Aims and objectives
The aim of this article is to present an overview of current evidence supporting a three-step oral care regimen for periodontal patients between appointments.
On completing this Enhanced CPD session, the reader will:
- Understand the high prevalence of visible plaque in dentate adults despite data suggesting a reasonable uptake of mechanical cleaning
- Understand that an updated evidence base reaffirms the role of an antibacterial mouthwash in specific circumstances as an adjunct to mechanical cleaning
- Understand that when used for six months or longer, essential oil mouthwashes were shown to equal or exceed the effect of chlorhexidine in controlling plaque as an adjunct to standard care
- Understand that the potential side-effects of chlorhexidine may make it unsuitable for long-term use.
This article presents an overview of current evidence supporting a three-step oral care regimen for periodontal patients between appointments
In 2020, the publication of an updated evidence base reaffirmed the role of an antibacterial mouthwash in specific circumstances as an adjunct to mechanical cleaning (Figuero, 2020).1
Figuero and colleagues (2020) conducted a systematic review and meta-analysis exploring the adjunctive use of 11 different mouthwash formulations and concluded that adjunctive antiseptics in mouthwash provide statistically significant reductions in plaque compared to controls at six months.1
Why use a mouthwash?
It has been recognised that where some patients may require further support for plaque management, an adjunctive mouthwash can help.1
The potential need for such an addition to mechanical plaque control at home is highlighted by the Adult Dental Health Survey of 2009. Data in the Survey indicated that two-thirds of dentate adults in the UK (excepting Scotland) had some visible plaque, despite three-quarters of respondents claiming to brush their teeth twice a day and one-quarter of those reporting they clean interdentally daily.2
Therefore, while the standard recommendation remains to brush the teeth and clean interdentally, evidence suggests that the adjunctive use of a mouthwash may provide benefits beyond mechanical cleaning for some people in specific circumstances.1
Choosing an appropriate formula
As previously mentioned, Figuero and colleagues (2020) conducted a systematic review and meta-analysis exploring the adjunctive use of 11 different mouth rinse formulations.1
They concluded that adjunctive antiseptics in mouthwash provide statistically significant reductions in plaque compared to mechanical cleaning alone at six months.1
They also concluded that, ‘… despite the high variability in the number of studies comparing each active agent and the different risks of bias, CHX [chlorhexidine] and EOs [essential oils], in mouthrinses appeared to be the most effective active agents for plaque … control.’1
The Figuero and colleagues’ (2020) outcomes add to the pre-existing evidence base presented by Araujo and colleagues (2015), which was the first meta-analysis to demonstrate the clinically significant, site-specific benefit of adjunctive essential oil mouthwash in people within a 6-month period (that is, between dental visits).3
The analysis revealed that 36.9% of subjects using mechanical methods with essential oil-containing mouthwash experienced at least 50% plaque-free sites after 6 months, compared to just 5.5% of patients using mechanical methods alone.3
This is further supported by Boyle and colleagues (2014), who explored the differences between a selection of mouthrinses on common oral conditions. They concluded that when a mouthwash is used for fewer than three months, those containing CHX are the most effective of the preparations they considered. However, when used for six months or longer, EO mouthwashes were shown to equal or exceed the effect of CHX in controlling plaque as an adjunct to standard care.4
Adding to their conclusion, Boyle and colleagues (2014) stated: ‘[…] while regular (at least daily) toothbrushing can reduce plaque […], the effect of adjunct flossing appears to be slight if at all. An adjunctive method of plaque control is the use of antiseptics, of which chlorhexidine is the most effective [in studies of less than three months] although its tendency to stain teeth and impair taste makes it generally unacceptable for long-term use.’4
Meanwhile, in 2015, Chapple and colleagues published a report containing the consensus views of Working Group 2 of the 11th European Workshop in Periodontology. They stated that, ‘…where improvements in plaque control are required, adjunctive use of antiplaque chemical agents may be considered. In this scenario, mouth rinses may offer greater efficacy but require an additional action to the mechanical oral hygiene regime.’5
Adding an adjunct
These findings tend to support the idea that there is a role for antimicrobial mouthwash use as an adjunct to brushing and interdental cleaning in certain circumstances, offering a considerable advantage, as it, ‘[….] can reach virtually all residual plaque […]’.4
It would seem, therefore, for patients falling short after brushing and interdental cleaning, certain mouthwash preparations have the potential to offer an adjunctive benefit, with the evidence pointing towards EO and CHX as the most efficacious for plaque control.1,3,4
1. Figuero E et al. Efficacy of adjunctive therapies in patients with gingival inflammation. A systematic review and meta-analysis. J Clin Periodontol 2020; 47(Suppl 22): 125-143
2. Adult Dental Health Survey 2009. The Health and Social Care Information Centre 2011
3. Araujo MWB et al. Meta-analysis of the effect of an essential oil-containing mouthrinse on gingivitis and plaque. JADA 2015; 146: 610-622
4. Boyle et al. Mouthwash use and the prevention of plaque, gingivitis and caries. Head & Neck Oral Diseases 2014; 20(1): 1-76
5. Chapple ILC et al. Primary prevention of periodontitis: managing gingivitis. J Clin Periodontol 2015; 42 (Suppl. 16): S71-S76