Dentifrices and Mouthwashes

The aim of promoting oral hygiene is to prevent dental caries and gingivitis or periodontitis.¹ The most important factors for the prevention of both dental and periodontal disease are a good diet with a minimum of sugar and careful attention to oral hygiene.^2,3 This generally involves:¹

• Brushing teeth twice a day
• Flossing teeth three times a week
• Visit a dental practitioner or dental hygienist regularly

A dentist or dental hygienist will recommend the exact frequency of these measures according to the individual circumstances. Especially adapted toothbrushes are available for those who have difficulties in using regular brushes.⁴

Mouth washing also plays a role in patients who are unable to use a toothbrush or where a painful periodontal condition limits tooth brushing. It may also be used in patients with superficial infections of the mouth and can be beneficial in patients suffering from halitosis.

In addition to specific oral hygiene measures, the opportunity to re-iterate the "quit smoking" message should be taken as this group of patients have an increased risk of periodontal disease and oral cancer.¹

Dentifrices are substances used for cleaning teeth: these may be in paste or powder form. Toothpastes are the paste form of dentifrices and have the dual function of cleaning teeth and delivering fluoride.

• Standard toothpaste: 1000-1450ppmF. Contain mild abrasives which give cleaning properties.
• Children's toothpaste: 500ppmF. Suitable until about 6 or 7 years old.
• Whitening toothpaste: 1500ppmF. Similar to standard toothpastes.
• High fluoride toothpaste: up to 2800ppmF - usually used on specialist recommendation only.
• Non-fluoride toothpastes: do not contain fluoride, rely on natural plant extracts.
• Antiseptic toothpastes are available although not widely in use for fear of the emergence of bacterial resistance.

Dentifrices also play a role in reducing dental calculus (also known as tartar: this is calcified plaque, the soft, sticky bacterial deposit that readily forms on exposed surfaces of teeth) through their pyrophosphates, zinc compounds and copolymer content.⁸

These are (usually flavoured) antiseptic solutions, also known as gargles, used for cleaning the mouth and freshening breath.

Saline mouthwash

• Use - superficial oral infections.
• Essence - this has a mechanical cleansing effect and if warmed, causes local hyperaemia.
• Examples - compound sodium chloride solution (prescribable: mix with equal amount of water) or home made: mix half teaspoon of salt in a glassful of warm water.
• Administration - use frequently and vigorously.

Fluoride mouthwashes

• Use - recommended for people who are at particular risk of dental decay (they contain around 1450ppmF).
• Administration - as directed on individual product.

Total mouthwashes

• Use - combine decay prevention with breath freshening properties.
• Administration - as directed on individual product.

Antiseptic mouthwashes

• Chlorhexidine gluconate⁹ - this helps inhibit plaque formation and is used in:
  • The treatment of denture stomatitis
  • The treatment of secondary infection in mouth ulceration
  • The treatment and prevention of gum inflammation, particularly where tooth brushing is difficult (e.g. following oral surgery)
  • Prevention of oral candidiasis in immunocompromised patients
  • Prevention of bacteraemia in patients undergoing dental procedures requiring antibacterial prophylaxis
  • It may reduce the incidence of alveolar osteitis following wisdom tooth extraction
  It has no prophylactic value in periodontal and plaque disease once pocketing has occurred. It may cause mucosal irritation - try diluting with equal volume of water - and reversible brown staining of teeth, silicate or composite restorations and tongue. Limit staining by brushing teeth before using chlorhexidine. Do this at least 30 minutes before using this mouthwash as it may interact with some ingredients of toothpaste.
• Oxidising agents such as hydrogen peroxide, used in Vincent's angina and has a mechanical cleansing effect.
• Povidone iodine is used for oral mucosal infections. Do not use for longer than 14 days as a significant amount of iodine may be absorbed. For this reason, avoid in pregnancy, breast-feeding mothers, patients on lithium therapy and with thyroid disorders.¹⁰ It may also interfere with tests for occult blood. Not for children under 6 years.
• Hexetidine¹¹ is used for general oral hygiene and in the treatment of minor infections e.g. oral thrush and in the prevention and treatment of gingivitis. It can also be used in the management of sore throat and recurrent aphthous ulcers as well as for halitosis. Rarely, it may cause taste disturbance and transient anaesthesia. Not for children under 6 years. Use to rinse the mouth or to gargle and avoid swallowing large quantities.
• Thymol preparations come as mouthwash solution-tablets, which may be handy for travellers.

Mouthwashes are generally used 2-4 times a day, after meals. Refer to instructions on individual product for specific administration.

A word of caution about mouthwashes

These products are generally regarded as useful, easy products to use in oral hygiene. Whilst this is true, they are still medicinal products, a fact that is overlooked possibly due to their wide availability. Mouthwashes can have significant alcohol content and do not always come with child proof caps. There have been case reports of accidental ingestion by young children with two reported deaths. Their bright colourings and pleasant smell/taste make them attractive targets and patients who have young children should be reminded of this when being advised to use mouthwashes.

The alcohol content of mouthwashes has raised questions as to its possible role in the development of oropharyngeal cancers in individuals who use the product heavily.^12,13 However, review of the evidence suggests that this association is an artefact of recall bias and that there is no association between the two.¹⁴

Babies and children

• Tooth brushing should start as soon as the teeth begin to come through (about 6 months): a moist flannel with a small smear of children's toothpaste may be a gentle way to start, progressing onto soft baby tooth brushes.¹⁵
• Until the age of 6 or 7, children should use children's toothpaste unless there is a particularly high risk of dental caries (use standard paste).¹
• Regular supervised tooth brushing will ensure good future habits.
• When using mouthwash in children under 7 soak some on a cotton bud and apply directly (otherwise there is a risk of swallowing it).
• Most of the above mouthwashes are fine to use in children (some have lower age limits - check individual preparation and see above) but avoid hydrogen peroxide in concentrations of > 1.5% as this may cause tissue damage and mouth ulceration.

Elderly

Dentures should be cleaned regularly with a denture brush and plain soap.⁴ Using bleach on them may give rise to denture-associated oral ulceration.

Patients complaining of problems in the mouth usually present to their dentist. However, with NHS dental provision becoming increasingly patchy, they are more likely to turn to medical primary care services for help. Mouth and dental problems cover a very broad range of diseases that do not form part of the routine training of medical staff, so it is usually best dealt with by a dental general practitioner. However, you may find the following records helpful in the initial assessment and management of these patients:

• Dental and periodontal diseases (where you will find more information about oral healthcare)
• Problems in the mouth
• Oral ulceration

The referral criteria set out below are a simple summary guideline. More information is provided in the above records.

Referral to a dentist¹

• Clinically apparent gingivitis (red swollen gums) not responding to simple treatment
• Periodontitis, especially if symptoms are aggressive (rapid and severe)
• Acute necrotizing ulcerative gingivitis (= "trench mouth" : bacterial infection of ulcerated gums)

Referral to the maxillofacial department

• Urgent: unexplained oral mucosal mass or ulceration lasting > 3 weeks
• Urgent: unexplained painful swollen / bleeding red and white patches of the mucosa
• Non-urgent: unexplained non-swollen, non-painful red and white patches that are not bleeding

The link provided in the further reading section can be used to find a local NHS dentist: names, locations and opening hours are provided. It also provides information regarding charges and a number of helpful links to related websites.