The Role of Antimicrobial Mouth Rinses in Infection Prevention

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Introduction Mouth rinses have been studied extensively for their potential benefits to patients for disease prevention, as well as the benefit to dental health professionals for their potential to reduce exposure to oral microorganisms during dental procedures. The studies have focused on three key areas. The first is the role of antimicrobial rinses in treatment and prevention of periodontal disease by killing or inhibiting the growth of bacteria that cause gingivitis and periodontitis. Second is their role in the prevention of bacteremia, by reducing the number of microorganisms in the oral cavity which might be introduced into the bloodstream during dental procedures. The third is infection prevention and safety for the dental team and patients by reducing the number of microorganisms in saliva that may become airborne during dental procedures. In addition, the types of antimicrobial agents in the mouthrinses have also been studied and compared for their effectiveness in reducing microorganisms, as well as potential side effects of using the rinses. This course will examine the uses of antimicrobial mouth rinses prior to dental procedures and the potential benefits to both patients and dental health professionals. In order to understand the value of antimicrobial mouthrinses, it is important to understand the types of rinses available and their mechanism of action. Types of Mouth Rinses Mouth rinses are available in over-the-counter (OTC) formulations as well as in prescription-only formulations. Oral rinses can be categorized by their ingredients or mode of action. For example, many OTC mouth rinses are meant to be cosmetic – to freshen breath, or whiten teeth. They contain active ingredients, such as flavoring oils and/or hydrogen peroxide, which is a whitening agent. Other OTC rinses are categorized as therapeutic, meaning that they contain an ingredient that is meant to protect against disease, such as caries or gingivitis. These rinses may contain fluoride or other ingredients, such as chlorhexadine (CHX) or cetylpyridinium chloride (CPC), or essential oils, which we will discuss later. Many of the OTC oral rinses are a combination of both cosmetic and therapeutic characteristics, while the prescription rinses typically contain one key active ingredient, such as fluoride or CHX. Table 1 compares the characteristics of cosmetic and therapeutic oral rinses. Therapeutic oral rinses are regulated by the Food and Drug Administration (FDA), whether they are OTC or prescription-only. In order to make a claim that a product has therapeutic value, it must go through rigorous testing by the FDA to prove its safety and efficacy. The FDA has taken action against some manufacturers of mouth rinses for unsubstantiated claims of effectiveness in preventing plaque formation and antimicrobial activity. These rinses are approved as antimicrobial “drugs”, since they act chemically to kill bacteria. In addition to FDA approval, OTC therapeutic oral rinses may also receive the Seal of Acceptance from the American Dental Association (ADA), which is a voluntary acceptance or approval for products that have met www.ColgateOralHealthNetwork.com Webinars | On-Demand Courses | Articles | Textbooks 2
certain safety and efficacy requirements. Additional information regarding the FDA approval process is available at: http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ DeviceApprovalsandClearances/default.htm. And information regarding the ADA Seal program is available at: http://www.ada.org/sealprogramproducts.aspx. It should be noted that the FDA has also approved a rinse that forms a physical barrier on teeth – a surfactant – that prevents the attachment of plaque bacteria on tooth surfaces, making it easier to remove. This type of rinse, which contains Delmopinol, is approved by the FDA as a medical device, since its action is physical rather than chemical. It is available as an OTC rinse. While the studies show positive results with this type of rinse,, its action is not one that would lend itself to use as a pre-procedural mouthrinse, since it does not kill microorganisms. Since many therapeutic mouthrinses claim to kill or inhibit the growth of microorganisms that cause periodontal disease, some may be further categorized as antimicrobial oral rinses. These types of rinses typically contain one of three active ingredients: chlorhexadine gluconate (CHX), cetylpyridinium chloride (CPC) or essential oils – containing rinses. The essential oil rinses, sometimes referred to as phenolics, may contain ingredients such as thymol, menthol, eucalyptol, or eugenol; alone or in combination. These antimicrobial oral rinses have been studied extensively for safety and efficacy with regard to treatment and prevention of periodontal disease, their potential for reducing bacteremia during dental procedures and for their potential for reducing the number of microorganisms in the splash, splatter or aerosol of saliva during dental procedures. The research strongly supports the incorporation of antimicrobial mouth rinses into the oral hygiene protocol for patients who have gingivitis and periodontitis., In addition, these rinse agents are often used as irrigating solutions during dental hygiene procedures, such as ultrasonic scaling. Table 2 lists common brands of therapeutic rinses and their active ingredients. Comparison of Active Ingredients in Therapeutic Oral Rinses Chlorhexadine gluconate (CHX) is an antiseptic – a cationic bis-biguanide that is used for numerous applications. In dentistry it is used as a dental unit waterline disinfectant, as a gelatinlike chip for placement into periodontal pockets at high concentration of 36% and as a mouth rinse at lower concentration of 0.12% in the United States. The CHX oral rinse is a prescriptiononly product that has been widely prescribed for periodontal patients for a number of years and its effectiveness is well documented. It is effective on both gram-positive and gram-negative bacteria, which is particularly beneficial in prevention of plaque formation, which is normally composed of gram-positive bacteria and is a key factor in the development of gingivitis and its progression to periodontitis, in which grampositive bacteria and gram-negative bacteria are present. Chlorhexadine gluconate works by adsorption into the pellicle on tooth enamel, to the hydroxyapatite of the enamel, to plaque bacteria and mucous membranes, which provides a long-lasting bacteriostatic and bactericidal effect, inhibiting bacterial colonization of plaque. CHX rinses come in both alcohol and alcoholwww.ColgateOralHealthNetwork.com Webinars | On-Demand Courses | Articles | Textbooks 3
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The Role of Antimicrobial Mouth Rinses in Infection Prevention

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