Dentifrices and Mouthwashes

The aim of promoting oral hygiene is to prevent dental caries and gingivitis or periodontitis¹. Regular tooth brushing with toothpaste and flossing is the usual way to avoid these problems. Especially adapted toothbrushes are available for those who have difficulties in using regular brushes². A dentist or dental hygienist will recommend the frequency and technique according to the individual circumstances.

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 ³.

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 cancer¹.

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. There is variation on the amount of fluoride contained in tap water (expressed as parts per million Fluoride, ppmF); this remains a controversial issue⁴ - it is suggested that addition to drinking water addresses issues of health inequalities but there are risks of dental fluorosis and evidence is equivocal regarding systemic benefits such as the reduction of hip fractures⁵. The dentist will know what local levels are and can advise on the need for fluoride supplements. There is also a variation in the amount of fluoride in toothpastes⁶:

• 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 resistance¹.

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

• Examples - commercial preparations.⁶
• Use - recommended for people who are at particular risk of dental decay (they contain around 1450ppmF).
• Administration - as directed on individual product.

Total mouthwashes

• Examples - many commercial preparations.⁶
• Use - combine decay prevention with breath freshening properties.
• Administration - as directed on individual product.

Antiseptic mouthwashes

• Chlorhexidine gluconate - this is used in the treatment of denture stomatitis, of secondary infection in mouth ulceration. It helps inhibit plaque formation.⁷ Additional uses include prevention of oral candidiasis in immunocompromised patients, prevention of bacteraemia in patients undergoing dental procedures requiring antibacterial prophylaxis and 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.
• Tetracycline mouthwash preparations are available for the management of recurrent mouth ulceration and herpes simplex infections.
• Oxidising agents - such as hydrogen peroxide, used in Vincent's angina and has a mechanical cleansing effect.
• Povidone iodine - 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 disorders⁸. It may also interfere with tests for occult blood. Not for children under 6 years.
• Hexetidine is used for general oral hygiene and in the prevention and treatment of gingivitis¹. Rarely, this may cause taste disturbance and transient anaesthesia. Not for children under 6 years.
• Thymol preparations come as mouthwash solution-tablets, which may be handy for travellers.
• Administration - mouthwashes are generally used 2-4 times a day, after meals. Refer to individual agent for specific administration.

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 brushes⁹.
• 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 soap². Using bleach on them may give rise to denture-associated oral ulceration.

Referral to a dentist¹

• Clinically apparent gingivitis (red swollen gums) not responding to simple treatment.
• Periodontitis.
• Suspicion of oral cancer.
• Acute necrotizing ulcerative gingivitis (= "trench mouth" : bacterial infection of ulcerated gums).

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

The link below 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.