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Oral rinses
Periodontal Disease Oral rinses Background.—In periodontal disease, pathogenic bacteria initiate an inflammatory response, then the chronic inflammation causes the production of tissue breakdown products that these bacteria use as a food source. If the periodontal pathogens can be eliminated, the inflammation can be resolved. Therapies to stop the process of bacterial colonization, biofilm formation, attachment, inflammation, and host response are effective at different stages. Oral rinses are the least invasive of these therapies and can be anti-adhesive, antiseptic, and/or anti-inflammatory in their
action (Table 1). The goal of using oral rinses is to break the microbiologic and inflammatory cascade that progresses to periodontal disease. An overview of the available options and their advantages and disadvantages was offered. Anti-Adhesive Agents.—The anti-adhesive agents are designed to inhibit the formation of plaque without affecting the resident bacteria or the balance of healthy bacteria in the mouth. Delmopinol hydrochloride interferes
Table 1.—Categories of Oral Rinses
(Courtesy of Goldstep F: Oral rinses for periodontal health: Simplified. Oral Health J, Dec, 2014.)
152
Dental Abstracts
with the biofilm matrix formation by preventing the synthesis of glucan polysaccharide, which holds the biofilm together and adherent to the oral surface. This reduces primary plaque-forming bacteria from gaining a foothold and loosens emerging biofilm masses so they are readily removed by patient’s oral hygiene practices. Delmopinol hydrochloride 0.2% mouth rinse reduces plaque and gingivitis to a statistically significant degree, but produces some staining, although it can be removed. Long-term daily use is appropriate, with the rinse having few side effects and maintaining the oral ecosystem. Antiseptic Rinses.—The mechanism of action of antiseptics is cell death, reproductive inhibition, and metabolic inhibition of microorganisms. These agents penetrate the plaque matrix to reach the actual pathogens. Effective antiseptic mouth rinses are required to be nontoxic to oral tissues, have minimal side effects, be efficacious against specific pathogens, demonstrate adequate bioavailability of active ingredients, be stable, have the ability to bind to tissue surfaces and be released slowly to extend therapeutic effect without dilution by saliva (substantivity), and be able to maintain the oral ecological balance. Antiseptics fall into the categories of essential oils, chlorhexidine, and cetyl pyridinium chloride. All three types have beneficial antiplaque and antigingivitis effects when used long-term in conjunction with mechanical oral hygiene. Chlorhexidine has demonstrated the most consistent results and is more effective than essential oils with respect to plaque reduction but comparable in antigingivitis action. Essential oils (EOs) are produced through the steam distillation of odiferous oily portions of plants, specifically, the flowers, leaves, bark, woods, roots, rhizomes, fruits, or seeds. They have bactericidal properties that make them popular alternatives to synthetic products. The product with the longest clinical history in this category is Listerine. Its adverse effects are reportedly few. A 30-second rinse penetrates the biofilm and causes the cell death of pathogens, including those bacteria causing periodontal disease. In addition, EOs denature protein, alter bacterial enzyme activity, extract bacterial endotoxins from gram-negative pathogens, and alter the growth rate of plaque-forming bacteria and biofilm formation. Its anti-inflammatory actions include inhibiting prostaglandin formation and scavenging free radicals generated by neutrophils during the inflammatory response. EOs also have a neutral electrical charge so they don’t interact with charged ions found in dentifrices and mouth rinses, are not inhibited by proteins in blood serum, and do not precipitate dietary chromogens, causing staining. However, EOs’ effects stop as soon as the rinse is expelled. Their action is rapid, so this short substantivity may not be clinically significant. EOs are manufactured
with and without alcohol, but studies show the two formulations are equally efficacious. Chlorhexidine (CHX) has been used as a medical and surgical disinfectant for over 60 years but in the oral cavity only since the 1970s. It is both bacteriostatic and bactericidal, depending on the concentration used. Its effectiveness works against both gram-positive and gram-negative bacteria, some fungi and yeasts, and some viruses, including HIV. Bacteria do not develop resistance even with long-term use. Positively charged CHX molecules bind strongly to negatively charged bacterial cell surfaces, which compromises the integrity of the cell wall. CHX binds to the inner cell membrane, producing permeability and cell damage, rupture of the cell membrane, leakage of cell contents, and eventually cell death. CHX then occupies sites that could be used by pellicle and bacteria, inhibiting early biofilm formation. It is released slowly into the mouth, with action extended up to 12 hours, for a high degree of substantivity. CHX is considered the gold standard for antiseptic agents. CHX has some drawbacks. Although its extreme interactivity with bacterial cell surfaces makes it efficacious, this quality also has negative effects, specifically, it causes staining through precipitation of negatively charged dietary chromogens, can be compromised by components found in toothpaste, alters taste and can cause nausea, and enhances supragingival calculus formation. CHX is usually prescribed for therapy of short duration. Users must wait 30 minutes between brushing their teeth with toothpaste and using CHX rinse. When oral hygiene is compromised, as may occur with elderly, physically disabled, and mentally challenged individuals, CHX use may be long-term. The inclusion of alcohol appears to have no effect on clinical effectiveness. Cetyl pyridinium chloride (CPC) has both bactericidal and bacteriostatic activity against bacteria and yeast. It is more effective against gram-positive than gram-negative bacteria. Its effect on plaque and gingival inflammation is significantly inhibitory. CPC binds to teeth and bacterial cell walls, which interferes with colonization on tooth surfaces. CPC reduces the formation of mature biofilm and disrupts bacterial cell membrane function, causes leakage of cytoplasmic material, and leads to the collapse of the intracellular equilibrium and microorganism death. Various vehicle ingredients, such as preservatives, stabilizers, or colors, may impact CPC’s bioavailability. Crest Pro Health has a unique vehicle that increases the bioavailability of the product over other CPC formulations, making it an especially effective antiplaque and antigingivitis agent. Side effects associated with CPC include staining, although it is less severe than that of CHX. It also
Volume 60
Issue 3
2015
153
demonstrates adverse interactions with other charged ions in dentifrices and rinses. Anti-Inflammatory and Pro-Healing Rinses.—Periodontal disease results from the body’s inability to turn off the inflammatory response to infection, causing chronic maladaptive inflammation. This produces an environment that provides nutrients such as degraded host proteins that are food for pathogenic bacteria. As a result, these pathogens thrive, produce more inflammation, bone resorption, and deeper periodontal pockets where the process can continue unimpeded. When there is chronic unresolved inflammation, the cellular and molecular responses to bacterial challenges must be constantly adjusted; neutrophils and other cells secrete cytokines that promote the release of matrix metalloproteinases, which are involved in normal bone remodeling; tissue destruction is also adjusted by host-bacterial interactions; and alveolar bone destruction occurs, with prostaglandin production possibly contributing to the process. Controlling the inflammation may return the biofilm composition to a healthy profile, which is what anti-inflammatory rinses are designed to achieve. The two major classes are antioxidants and botanicals, or EOs. Xylitol is a new addition to this category. Antioxidants are able to neutralize the free radicals that produce disease. Free radicals are atoms or groups of highly reactive atoms that have one or more unpaired electrons. Although they are formed during normal biochemical reactions, they can also be formed in excess or without control and damage cells. In biological systems, the radicals derived from oxygen and termed reactive oxygen species (ROS) are generated from neutrophils to kill invading pathogens, so higher levels are found during inflammation. These higher levels can contribute to an unhealthy situation. New research shows that antioxidants applied topically to oral tissue can promote gingival healing. As a result, these agents have been incorporated into toothpastes, mouth rinses, lozenges, gels, oral sprays, breath fresheners, and other dental products for use in controlling gingival and periodontal disease. However, antioxidants are inherently unstable, so simply adding them to a preparation may not be efficacious. The gingival and serum antioxidants of patients with periodontal disease tend to be limited. As a result, these individuals cannot benefit from the effect of antioxidants on fibroblast migration and proliferation during gingival healing or periodontal repair.
154
Dental Abstracts
Botanicals (EOs) are being explored for their antiinflammatory and healing properties in new oral agents such as PeriActive botanical rinse. Ideally an antiinflammatory oral rinse should target pro-inflammatory cytokines and enzymes involved in oral inflammation and tissue destruction. The three botanical extracts of PeriActive are antimicrobial, anti-inflammatory, and tissue repair promoting. These are Centella asiatica (gotu kola), which increases effective collagen and supports wound healing; Sambucus nigra, which can inhibit the pro-inflammatory properties of Pseudomonas gingivalis and Actinomyces actinomycetemcomitans; and Echinichia purpurea, which offers antiviral, antibacterial, and anticytotoxic properties. The goal is to modulate the host inflammatory response and interrupt the cycle of inflammation. Studies show these agents inhibit inflammatory cytokines and their tissue destructive products and increase tissue healing products. The rinse has been shown to be clinically equivalent to 0.12% CHX for controlling plaque but more effective than CHX in reducing inflammation at implant and surgical incision sites. Xylitol is not only an anti-caries agent but also decreases the production of inflammatory cytokines in periodontal infections. It may prove useful in periodontal and anti-caries rinses. Discussion.—Periodontal health can be supported through mechanical and chemotherapeutic agents. Oral rinses offer an easy, minimally invasive way to proactively interact with the inflammatory cycle and prevent disease.
Clinical Significance.—Once you understand the pathogenic cycle, patient needs, and the mechanisms of action and advantages and disadvantages of oral rinses, you can counsel patients about how easy it is to maintain periodontal health. A simple rinse designed to interrupt the cycle of pathogenesis allows the patient to quickly and effectively support a healthy biofilm and reduce inflammation.
Goldstep F: Oral rinses for periodontal health: Simplified. Oral Health J, Dec, 2014 Reprints not available
action (Table 1). The goal of using oral rinses is to break the microbiologic and inflammatory cascade that progresses to periodontal disease. An overview of the available options and their advantages and disadvantages was offered. Anti-Adhesive Agents.—The anti-adhesive agents are designed to inhibit the formation of plaque without affecting the resident bacteria or the balance of healthy bacteria in the mouth. Delmopinol hydrochloride interferes
Table 1.—Categories of Oral Rinses
(Courtesy of Goldstep F: Oral rinses for periodontal health: Simplified. Oral Health J, Dec, 2014.)
152
Dental Abstracts
with the biofilm matrix formation by preventing the synthesis of glucan polysaccharide, which holds the biofilm together and adherent to the oral surface. This reduces primary plaque-forming bacteria from gaining a foothold and loosens emerging biofilm masses so they are readily removed by patient’s oral hygiene practices. Delmopinol hydrochloride 0.2% mouth rinse reduces plaque and gingivitis to a statistically significant degree, but produces some staining, although it can be removed. Long-term daily use is appropriate, with the rinse having few side effects and maintaining the oral ecosystem. Antiseptic Rinses.—The mechanism of action of antiseptics is cell death, reproductive inhibition, and metabolic inhibition of microorganisms. These agents penetrate the plaque matrix to reach the actual pathogens. Effective antiseptic mouth rinses are required to be nontoxic to oral tissues, have minimal side effects, be efficacious against specific pathogens, demonstrate adequate bioavailability of active ingredients, be stable, have the ability to bind to tissue surfaces and be released slowly to extend therapeutic effect without dilution by saliva (substantivity), and be able to maintain the oral ecological balance. Antiseptics fall into the categories of essential oils, chlorhexidine, and cetyl pyridinium chloride. All three types have beneficial antiplaque and antigingivitis effects when used long-term in conjunction with mechanical oral hygiene. Chlorhexidine has demonstrated the most consistent results and is more effective than essential oils with respect to plaque reduction but comparable in antigingivitis action. Essential oils (EOs) are produced through the steam distillation of odiferous oily portions of plants, specifically, the flowers, leaves, bark, woods, roots, rhizomes, fruits, or seeds. They have bactericidal properties that make them popular alternatives to synthetic products. The product with the longest clinical history in this category is Listerine. Its adverse effects are reportedly few. A 30-second rinse penetrates the biofilm and causes the cell death of pathogens, including those bacteria causing periodontal disease. In addition, EOs denature protein, alter bacterial enzyme activity, extract bacterial endotoxins from gram-negative pathogens, and alter the growth rate of plaque-forming bacteria and biofilm formation. Its anti-inflammatory actions include inhibiting prostaglandin formation and scavenging free radicals generated by neutrophils during the inflammatory response. EOs also have a neutral electrical charge so they don’t interact with charged ions found in dentifrices and mouth rinses, are not inhibited by proteins in blood serum, and do not precipitate dietary chromogens, causing staining. However, EOs’ effects stop as soon as the rinse is expelled. Their action is rapid, so this short substantivity may not be clinically significant. EOs are manufactured
with and without alcohol, but studies show the two formulations are equally efficacious. Chlorhexidine (CHX) has been used as a medical and surgical disinfectant for over 60 years but in the oral cavity only since the 1970s. It is both bacteriostatic and bactericidal, depending on the concentration used. Its effectiveness works against both gram-positive and gram-negative bacteria, some fungi and yeasts, and some viruses, including HIV. Bacteria do not develop resistance even with long-term use. Positively charged CHX molecules bind strongly to negatively charged bacterial cell surfaces, which compromises the integrity of the cell wall. CHX binds to the inner cell membrane, producing permeability and cell damage, rupture of the cell membrane, leakage of cell contents, and eventually cell death. CHX then occupies sites that could be used by pellicle and bacteria, inhibiting early biofilm formation. It is released slowly into the mouth, with action extended up to 12 hours, for a high degree of substantivity. CHX is considered the gold standard for antiseptic agents. CHX has some drawbacks. Although its extreme interactivity with bacterial cell surfaces makes it efficacious, this quality also has negative effects, specifically, it causes staining through precipitation of negatively charged dietary chromogens, can be compromised by components found in toothpaste, alters taste and can cause nausea, and enhances supragingival calculus formation. CHX is usually prescribed for therapy of short duration. Users must wait 30 minutes between brushing their teeth with toothpaste and using CHX rinse. When oral hygiene is compromised, as may occur with elderly, physically disabled, and mentally challenged individuals, CHX use may be long-term. The inclusion of alcohol appears to have no effect on clinical effectiveness. Cetyl pyridinium chloride (CPC) has both bactericidal and bacteriostatic activity against bacteria and yeast. It is more effective against gram-positive than gram-negative bacteria. Its effect on plaque and gingival inflammation is significantly inhibitory. CPC binds to teeth and bacterial cell walls, which interferes with colonization on tooth surfaces. CPC reduces the formation of mature biofilm and disrupts bacterial cell membrane function, causes leakage of cytoplasmic material, and leads to the collapse of the intracellular equilibrium and microorganism death. Various vehicle ingredients, such as preservatives, stabilizers, or colors, may impact CPC’s bioavailability. Crest Pro Health has a unique vehicle that increases the bioavailability of the product over other CPC formulations, making it an especially effective antiplaque and antigingivitis agent. Side effects associated with CPC include staining, although it is less severe than that of CHX. It also
Volume 60
Issue 3
2015
153
demonstrates adverse interactions with other charged ions in dentifrices and rinses. Anti-Inflammatory and Pro-Healing Rinses.—Periodontal disease results from the body’s inability to turn off the inflammatory response to infection, causing chronic maladaptive inflammation. This produces an environment that provides nutrients such as degraded host proteins that are food for pathogenic bacteria. As a result, these pathogens thrive, produce more inflammation, bone resorption, and deeper periodontal pockets where the process can continue unimpeded. When there is chronic unresolved inflammation, the cellular and molecular responses to bacterial challenges must be constantly adjusted; neutrophils and other cells secrete cytokines that promote the release of matrix metalloproteinases, which are involved in normal bone remodeling; tissue destruction is also adjusted by host-bacterial interactions; and alveolar bone destruction occurs, with prostaglandin production possibly contributing to the process. Controlling the inflammation may return the biofilm composition to a healthy profile, which is what anti-inflammatory rinses are designed to achieve. The two major classes are antioxidants and botanicals, or EOs. Xylitol is a new addition to this category. Antioxidants are able to neutralize the free radicals that produce disease. Free radicals are atoms or groups of highly reactive atoms that have one or more unpaired electrons. Although they are formed during normal biochemical reactions, they can also be formed in excess or without control and damage cells. In biological systems, the radicals derived from oxygen and termed reactive oxygen species (ROS) are generated from neutrophils to kill invading pathogens, so higher levels are found during inflammation. These higher levels can contribute to an unhealthy situation. New research shows that antioxidants applied topically to oral tissue can promote gingival healing. As a result, these agents have been incorporated into toothpastes, mouth rinses, lozenges, gels, oral sprays, breath fresheners, and other dental products for use in controlling gingival and periodontal disease. However, antioxidants are inherently unstable, so simply adding them to a preparation may not be efficacious. The gingival and serum antioxidants of patients with periodontal disease tend to be limited. As a result, these individuals cannot benefit from the effect of antioxidants on fibroblast migration and proliferation during gingival healing or periodontal repair.
154
Dental Abstracts
Botanicals (EOs) are being explored for their antiinflammatory and healing properties in new oral agents such as PeriActive botanical rinse. Ideally an antiinflammatory oral rinse should target pro-inflammatory cytokines and enzymes involved in oral inflammation and tissue destruction. The three botanical extracts of PeriActive are antimicrobial, anti-inflammatory, and tissue repair promoting. These are Centella asiatica (gotu kola), which increases effective collagen and supports wound healing; Sambucus nigra, which can inhibit the pro-inflammatory properties of Pseudomonas gingivalis and Actinomyces actinomycetemcomitans; and Echinichia purpurea, which offers antiviral, antibacterial, and anticytotoxic properties. The goal is to modulate the host inflammatory response and interrupt the cycle of inflammation. Studies show these agents inhibit inflammatory cytokines and their tissue destructive products and increase tissue healing products. The rinse has been shown to be clinically equivalent to 0.12% CHX for controlling plaque but more effective than CHX in reducing inflammation at implant and surgical incision sites. Xylitol is not only an anti-caries agent but also decreases the production of inflammatory cytokines in periodontal infections. It may prove useful in periodontal and anti-caries rinses. Discussion.—Periodontal health can be supported through mechanical and chemotherapeutic agents. Oral rinses offer an easy, minimally invasive way to proactively interact with the inflammatory cycle and prevent disease.
Clinical Significance.—Once you understand the pathogenic cycle, patient needs, and the mechanisms of action and advantages and disadvantages of oral rinses, you can counsel patients about how easy it is to maintain periodontal health. A simple rinse designed to interrupt the cycle of pathogenesis allows the patient to quickly and effectively support a healthy biofilm and reduce inflammation.
Goldstep F: Oral rinses for periodontal health: Simplified. Oral Health J, Dec, 2014 Reprints not available