Mouthwash

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Listerine advertisement, 1932.
Colgate Alcohol Free Mouthwash.jpg
Listerine products.jpg

Mouthwash or mouth rinse is an antiseptic solution used as an effective home care system by the patient to enhance oral hygiene. Some manufacturers of mouthwash claim that antiseptic and anti-plaque mouth rinse kill the bacterial plaque causing cavities, gingivitis, and bad breath. Anti-cavity mouth rinse uses fluoride to protect against tooth decay. It is, however, generally agreed that the use of mouthwash does not eliminate the need for both brushing and flossing.[1][2][3] As per the American Dental Association, regular brushing and proper flossing are enough in most cases although the ADA has placed its Seal of Approval on many mouthwashes that do not contain alcohol (in addition to regular dental check-ups).[4]

History[edit]

The first known references to mouth rinsing is in Ayurveda and Chinese medicine, about 2700 BC, for treatment of gingivitis.[citation needed] Later, in the Greek and Roman periods, mouth rinsing following mechanical cleansing became common among the upper classes, and Hippocrates recommended a mixture of salt, alum, and vinegar.[5] The Jewish Talmud, dating back about 1800 years, suggests a cure for gum ailments containing "dough water" and olive oil.[6]

Anton van Leeuwenhoek, the famous 17th century microscopist, discovered living organisms (living, because they were motile) in deposits on the teeth (what we now call dental plaque). He also found organisms in water from the canal next to his home in Delft. He experimented with samples by adding vinegar or brandy and found that this resulted in the immediate immobilization or killing of the organisms suspended in water. Next he tried rinsing the mouth of himself and somebody else with a mouthwash containing vinegar or brandy and found that living organisms remained in the dental plaque. He concluded—correctly—that the mouthwash either did not reach, or was not present long enough, to kill the plaque organisms.[7]

That remained the state of affairs until the late 1960s when Harald Loe (at the time a professor at the Royal Dental College in Aarhus, Denmark) demonstrated that a chlorhexidine compound could prevent the build-up of dental plaque. The reason for chlorhexidine effectiveness is that it strongly adheres to surfaces in the mouth and thus remains present in effective concentrations for many hours.[8]

Since then commercial interest in mouthwashes has been intense and several newer products claim effectiveness in reducing the build-up in dental plaque and the associated severity of gingivitis (inflammation of the gums), in addition to fighting bad breath. Many of these solutions aim to control the Volatile Sulfur Compound (VSC)-creating anaerobic bacteria that live in the mouth and excrete substances that lead to bad breath and unpleasant mouth taste.[9][10]

Use[edit]

Common use involves rinsing the mouth with about 20ml (2/3 fl oz) of mouthwash two times a day after brushing. The wash is typically swished or gargled for about half a minute and then spat out. Most companies suggest not drinking water immediately after using mouthwash. In some brands, the expectorate is stained, so that one can see the bacteria and debris.[11][12] Some may suggest that it is probably advisable to use mouthwash at least an hour after brushing with toothpaste when the toothpaste contains sodium lauryl sulfate, since the anionic compounds in the SLS toothpaste can deactivate cationic agents present in the mouthrinse.[13] However, many would disagree with this hypothesis; in fact, many of the popular mouthwashes contain sodium lauryl sulfate as an ingredient (e.g., Listerine Total Care).[citation needed]

Active ingredients[edit]

Each commercial brand of mouthwash has different ingredients. The active ingredients are usually alcohol,[14] chlorhexidine gluconate,[12][14][15] cetylpyridinium chloride[14] hexetidine,[14] benzoic acid (acts as a buffer),[14] methyl salicylate,[citation needed] triclosan,[16] benzalkonium chloride,[citation needed] methylparaben,[citation needed] hydrogen peroxide,[citation needed] domiphen bromide[citation needed] and sometimes fluoride,[17][citation needed] enzymes,[citation needed] and calcium[citation needed]. They can also include essential oil constituents that have some antibacterial properties,[14][18] like phenol,[14] thymol,[14] eugenol,[14] eucalyptol[citation needed] or menthol[citation needed]. Ingredients also include water, sweeteners such as sorbitol, sucralose, sodium saccharin, and xylitol (which doubles as a bacterial inhibitor).[19]

A study suggested that cetylpyridinium chloride could be as effective as chlorhexidine in mouthwashes.[20] Another study suggested that mouthwashes based on essential oils could be more effective than traditional mouthwashes.[18]

Sometimes a significant amount of alcohol (up to 27% vol) is added,[21] as a carrier for the flavor, to provide "bite".[22] Because of the alcohol content, it is possible to fail a breathalyzer test after rinsing although breath alcohol levels return to normal after 10 minutes[citation needed]. In addition, alcohol is a drying agent and may worsen chronic bad breath.[citation needed] Recently, the possibility that the alcohol used in mouthrinses acts as a carcinogen was raised, but there is to date no scientific consensus on the issue.[23][24][25] Commercial mouthwashes usually contain a preservative such as sodium benzoate to preserve freshness once the container has been opened. Many newer brands are alcohol-free and contain odor-elimination agents such as oxidizers, as well as odor-preventing agents such as zinc ion to keep future bad breath from developing.[citation needed]

Alternative mouthwash ingredients[edit]

A salt mouthwash is a home treatment for mouth infections and/or injuries, or post extraction, and is made by dissolving a teaspoon of salt in a cup of warm water.

Recently, the use of herbal mouthwashes such as persica is increasing, due to the perceived discoloration effects and unpleasant taste of chlorhexidine.[26] Research has also indicated that sesame and sunflower oils might be alternatives to chlorhexidine.[27][28] Other products like hydrogen peroxide have been tried out as stand-alone[29] and in combination with chlorhexidine, due to some inconsistent results regarding its[clarification needed] usefulness.[30] Another study has demonstrated that daily use of an alum-containing mouthrinse was safe and produced a significant effect on plaque that supplemented the benefits of daily toothbrushing.[31]

Compounding[edit]

Custom mouthwashes, called "magic mouthwash" may be prescribed by dentists for post oral surgeries. Variations are common, and some are done with over-the-counter products.[citation needed]

Health risks[edit]

A literature review by Michael McCullough and Camile Farah, published in the Australian Dental Journal in 2008, focused on a possible connection between mouthwashes that contain alcohol, and an increased risk of oral cancer.

There is now sufficient evidence to accept the proposition that developing oral cancer is increased or contributed to by the use of alcohol-containing mouthwashes. Whilst many of these products may have been shown to be effective in penetrating oral microbial biofilms in vitro and reducing oral bacterial load, it would be wise to restrict their use to short-term therapeutic situations if needed. Perhaps the use of mouthwashes that do not contain alcohol may be equally effective. Further, mouthrinses should be prescribed by dentists, like any other medication. There may well be a reason for the use of alcohol-containing mouthrinses, but only for a particular situation and for a limited and controlled period of time. As such, patients should be provided with written instructions for mouthwash use, and mouthwash use should be restricted to adults for short durations and specific, clearly defined reasons. It is the opinion of the authors that, in light of the evidence currently available of the association of alcohol-containing mouthwashes with the development of oral cancer, it would be inadvisable for oral healthcare professionals to recommend the long-term use of alcohol-containing mouthwashes.

—McCullough and Farah, Australian Dental Journal[32]

McCullough and Farah also state that the risk of acquiring cancer rises almost five times for users of alcohol-containing mouthwash who neither smoke nor drink (with a higher rate of increase for those who do).[33] In addition, the authors highlight side effects from several mainstream mouthwashes that included dental erosion and accidental poisoning of children.

The review garnered media attention[34] and conflicting opinions from other researchers. Yinka Ebo of Cancer Research UK disputed the findings, concluding that "there is still not enough evidence to suggest that using mouthwash that contains alcohol will increase the risk of mouth cancer".[35] Studies conducted in 1985,[36] 1995,[37] 2003,[38] and 2012[39] did not support an association between alcohol-containing mouth rinses and oral cancer. Andrew Penman, chief executive of The Cancer Council New South Wales, called for further research on the matter.[40] In a March 2009 brief, the American Dental Association said "the available evidence does not support a connection between oral cancer and alcohol-containing mouthrinse".[41]

Microbiome research and future products[edit]

Research in the field of microbiomes shows that only a limited set of microbes cause tooth decay, with most of the bacteria in the human mouth being harmless. Focused attention on cavity-causing bacteria such as Streptococcus mutans has led research into new mouthwash treatments that prevent these bacteria from initially growing. While current mouthwash treatments must be used with a degree of frequency to prevent this bacteria from regrowing, future treatments could provide a viable long term solution.[42]

Brands[edit]

See also[edit]

Notes and references[edit]

  1. ^ Gunsolley, JC (2006). "A meta-analysis of six-month studies of antiplaque and antigingivitis agents". Journal of the American Dental Association 137 (12): 1649–57. PMID 17138709. 
  2. ^ Tal, H; Rosenberg, M (1990). "Estimation of dental plaque levels and gingival inflammation using a simple oral rinse technique". Journal of periodontology 61 (6): 339–42. doi:10.1902/jop.1990.61.6.339. PMID 2366142. 
  3. ^ "Listerine no replacement for flossing?". NBC News. 7 January 2005. Retrieved 14 October 2013. 
  4. ^ Simple Routine for Basic Oral Care
  5. ^ Fischman, Stuart L. (1997). "The history of oral hygiene products: How far have we come in 6000 years?". Periodontology 2000 15: 7–14. doi:10.1111/j.1600-0757.1997.tb00099.x. PMID 9643227. 
  6. ^ Shifman, A; Orenbuch, S; Rosenberg, M (2002). "Bad breath--a major disability according to the Talmud". The Israel Medical Association journal 4 (10): 843–5. PMID 12389360. 
  7. ^ Lax, Alistair (Oct 27, 2005). Toxin: The cunning of bacterial poisons. Oxford University Press. ISBN 9780191578502. Retrieved November 26, 2013. 
  8. ^ Budtz-Jörgensen, E; Löe, H (1972). "Chlorhexidine as a denture disinfectant in the treatment of denture stomatitis". Scandinavian journal of dental research 80 (6): 457–64. PMID 4575037. 
  9. ^ Bosy, A; Kulkarni, GV; Rosenberg, M; McCulloch, CA (1994). "Relationship of oral malodor to periodontitis: Evidence of independence in discrete subpopulations". Journal of periodontology 65 (1): 37–46. doi:10.1902/jop.1994.65.1.37. PMID 8133414. 
  10. ^ Loesche, Walter J.; Kazor, Christopher (2002). "Microbiology and treatment of halitosis". Periodontology 2000 28: 256–79. doi:10.1034/j.1600-0757.2002.280111.x. PMID 12013345. 
  11. ^ Kozlovsky, A; Goldberg, S; Natour, I; Rogatky-Gat, A; Gelernter, I; Rosenberg, M (1996). "Efficacy of a 2-phase oil: Water mouthrinse in controlling oral malodor, gingivitis, and plaque". Journal of periodontology 67 (6): 577–82. PMID 8794967. 
  12. ^ a b Rosenberg, M; Gelernter, I; Barki, M; Bar-Ness, R (1992). "Day-long reduction of oral malodor by a two-phase oil:water mouthrinse as compared to chlorhexidine and placebo rinses". Journal of periodontology 63 (1): 39–43. PMID 1552460. 
  13. ^ Rosenberg, Mel (2002). "The Science of Bad Breath". Scientific American 286 (4): 72–9. doi:10.1038/scientificamerican0402-72. PMID 11905111. 
  14. ^ a b c d e f g h i John Toedt, Darrell Koza, Kathleen Van Cleef-Toedt (2005), Chemical composition of everyday products (illustrated ed.), Greenwood Publishing Group, pp. 48–49, ISBN 9780313325793 
  15. ^ Ribeiro, L; Hashizume, L; Maltz, M (2007). "The effect of different formulations of chlorhexidine in reducing levels of mutans streptococci in the oral cavity: A systematic review of the literature". Journal of Dentistry 35 (5): 359–70. doi:10.1016/j.jdent.2007.01.007. PMID 17391828. 
  16. ^ http://drbenkim.com/articles/triclosan-products.htm
  17. ^ Levy, SM (2003). "An update on fluorides and fluorosis". Journal (Canadian Dental Association) 69 (5): 286–91. PMID 12734021. 
  18. ^ a b Stoeken, Judith E.; Paraskevas, Spiros; Van Der Weijden, Godefridus A. (2007). "The Long-Term Effect of a Mouthrinse Containing Essential Oils on Dental Plaque and Gingivitis: A Systematic Review". Journal of Periodontology 78 (7): 1218–28. doi:10.1902/jop.2007.060269. PMID 17608576. 
  19. ^ Giertsen, E.; Emberland, H.; Scheie, A. Aa. (1999). "Effects of Mouth Rinses with Xylitol and Fluoride on Dental Plaque and Saliva". Caries Research 33 (1): 23–31. doi:10.1159/000016492. PMID 9831777. 
  20. ^ Goldberg, S; Konis, Y; Rosenberg, M (1990). "Effect of cetylpyridinium chloride on microbial adhesion to hexadecane and polystyrene". Applied and environmental microbiology 56 (6): 1678–82. PMC 184492. PMID 16348211. 
  21. ^ Lachenmeier, Dirk W; Keck-Wilhelm, Andrea; Sauermann, Anne; Mildau, Gerd (2008). "Safety Assessment of Alcohol-Containing Mouthwashes and Oral Rinses". SOFW Journal 134 (10): 70–8. 
  22. ^ Pader, M. (October 1994). "Oral rinses". Cosmetics & Toiletries 109 (10): 59–68. ISSN 0361-4387.  [unreliable medical source?]
  23. ^ Cole, P; Rodu, B; Mathisen, A (2003). "Alcohol-containing mouthwash and oropharyngeal cancer: A review of the epidemiology". Journal of the American Dental Association 134 (8): 1079–87. PMID 12956348. 
  24. ^ Carretero Peláez, MA; Esparza Gómez, GC; Figuero Ruiz, E; Cerero Lapiedra, R (2004). "Alcohol-containing mouthwashes and oral cancer. Critical analysis of literature". Medicina oral 9 (2): 120–3, 116–20. PMID 14990877. 
  25. ^ Lachenmeier, Dirk W (2008). "Safety evaluation of topical applications of ethanol on the skin and inside the oral cavity". Journal of Occupational Medicine and Toxicology 3: 26. doi:10.1186/1745-6673-3-26. PMC 2596158. PMID 19014531. 
  26. ^ Salehi, P.; Momeni Danaie, Sh. (2006). "Comparison of the antibacterial effects of persica mouthwash with chlorhexidine on streptococcus mutans in orthodontic patients". DARU Journal of Pharmaceutical Sciences 14 (4): 178–82. 
  27. ^ "Efficacy of Oil Pulling on Oral Health Status". Iadr.confex.com. 2008-07-03. Retrieved 2012-10-31. 
  28. ^ "JOHCD Jan.pmd" (PDF). Retrieved 2012-10-31. 
  29. ^ Hasturk, Hatice; Nunn, Martha; Warbington, Martha; Dyke, Thomas E. Van (2004). "Efficacy of a Fluoridated Hydrogen Peroxide-Based Mouthrinse for the Treatment of Gingivitis: A Randomized Clinical Trial". Journal of Periodontology 75 (1): 57–65. doi:10.1902/jop.2004.75.1.57. PMID 15025217. 
  30. ^ Menendez, A.; Li, F.; Michalek, S. M.; Kirk, K.; Makhija, S. K.; Childers, N. K. (2005). "Comparative analysis of the antibacterial effects of combined mouthrinses on Streptococcus mutans". Oral Microbiology and Immunology 20 (1): 31–4. doi:10.1111/j.1399-302X.2004.00189.x. PMID 15612942. 
  31. ^ Putt, MS; Kleber, CJ; Smith, CE (1996). "Evaluation of an alum-containing mouthrinse in children for plaque and gingivitis inhibition during 4 weeks of supervised use". Pediatric dentistry 18 (2): 139–44. PMID 8710717. 
  32. ^ McCullough, MJ; Farah, CS (2008). "The role of alcohol in oral carcinogenesis with particular reference to alcohol-containing mouthwashes". Australian Dental Journal 53 (4): 302–5. doi:10.1111/j.1834-7819.2008.00070.x. PMID 19133944. 
  33. ^ Farah, C; McIntosh, L; McCullough, M (2009). "Mouthwashes". Australian Prescriber, 32:162-4. Available at australianprescriber.com
  34. ^ Weaver, Clair (11 January 2009). "Mouthwash linked to cancer". Daily Telegraph (News Ltd). Retrieved 11 January 2009. 
  35. ^ Ebo, Yinka (14 January 2009). "Does mouthwash cause cancer?". Cancer Research UK. Retrieved 20 June 2009. 
  36. ^ Mashberg, A; Barsa, P; Grossman, ML (1985). "A study of the relationship between mouthwash use and oral and pharyngeal cancer". Journal of the American Dental Association 110 (5): 731–4. PMID 3859544. 
  37. ^ Elmore, J; Horwitz, R (1995). "Oral cancer and mouthwash use: Evaluation of the epidemiologic evidence". Otolaryngology - Head and Neck Surgery 113 (3): 253–61. doi:10.1016/S0194-5998(95)70114-1. PMID 7675486. 
  38. ^ Cole, P; Rodu, B; Mathisen, A (2003). "Alcohol-containing mouthwash and oropharyngeal cancer: A review of the epidemiology". Journal of the American Dental Association 134 (8): 1079–87. PMID 12956348. 
  39. ^ Gandini S, Negri E, Boffetta P, La Vecchia C, Boyle P (2012). "Mouthwash and oral cancer risk quantitative meta-analysis of epidemiologic studies". Ann Agric Environ Med. 19 (2): 173–80. PMID 22742785. 
  40. ^ Weaver, Clair (11 January 2009). "Mouthwash linked to cancer". The Daily Telegraph. Retrieved 12 January 2009. 
  41. ^ Science brief on alcohol-containing mouthrinses and oral cancer, American Dental Association, March 2009, archived from the original on 19 March 2012 
  42. ^ "Hacking the Microbiome for Fun and Profit: Can Killing Just One Mouth Bacterium Stop Cavities? | 80beats | Discover Magazine". Blogs.discovermagazine.com. Retrieved 2012-10-31. 

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