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Flossing may be its own worst enemy. Long evangelized by dental professionals as a "must" for oral health, few patients actually use floss in their daily self-care programs—and for a variety of reasons. People with arthritis, for example, may lack the manual dexterity to floss properly. Busy professionals may skip flossing due to an overly hectic daily routine. Some people are unsure of how to floss effectively, while others are just averse to putting their fingers in their mouths. Because compliance with flossing is so low, the use of therapeutic mouthrinse may help support oral health despite a lack of mechanical interdental cleaning. This Sunstar E-Brief looks at whether floss is still part of the gold standard in controlling plaque and gingivitis, as well as the benefits of incorporating therapeutic mouthrinse into a daily self-care regimen.

To determine how therapeutic mouthrinses might perform against dental floss in controlling plaque and gingivitis, a group of researchers gathered 156 healthy subjects to participate in an 8-week study.¹ The investigators compared flossing with the efficacy of two mouthrinses (chlorhexidine with fluoride and cetylpyridinium chloride with fluoride) in minimizing interdental plaque and gingivitis. Two groups used a mouthrinse in addition to daily brushing, one group flossed in conjunction with daily brushing, and one group simply brushed. The results revealed that the modified proximal plaque index for subjects in groups that used mouthrinse in addition to daily brushing were significantly lower than the group that brushed and flossed and the group that only brushed.¹

Maria Perno Goldie, RDH, BA, MS, points out in her paper, "The Role of Oral Rinse Technologies in a New Daily Oral Healthcare Regimen," that even patients who conscientiously use mechanical interdental cleaning methods may not be able to sufficiently control plaque and prevent gingivitis.² She explains that saliva can carry harmful bacteria from the dorsum of the tongue or tonsils to dentogingival areas. Mechanical methods are unable to reach distant mucosal sites, but therapeutic mouthrinses can deliver adjunctive antiplaque agents to these regions. According to Perno Goldie, this process reduces the overall microbial burden throughout the oral cavity.²

STILL PART OF THE TEAM

Even so, flossing and floss alternatives remain key tools in the oral health armamentarium, asserts Ann M. Bruhn, BSDH, MS, an assistant professor and continuing education coordinator in the School of Dental Hygiene at Old Dominion University in Norfolk, Va. While acknowledging that the effectiveness of mouthrinses has improved, Bruhn also notes that some research shows therapeutic rinses are less effective than mechanical disruption in patients with heavy interproximal plaque. "Clinicians should educate their patients that the most effective way to maintain oral health is to brush, floss, and rinse with a therapeutic mouthrinse," she tells E-Brief.

Determining exactly which rinse to use can be perplexing, however. With both over-the-counter and prescription therapeutic mouthrinses gaining attention as plaque fighters, some clinicians may wonder which products will yield the best results. Bruhn shares the following advice for matching rinses to particular oral conditions.

In treating gingivitis, for example, she suggests rinses with chlorhexidine (CHX), delmopinol, cetylpyridinium chloride and essential oils. "Research shows that CHX mouthrinses reduce gingivitis by 30.5% to 42.5%, while mouthrinses that contain essential oils reduce gingivitis by 22.1% to 35.9%," Bruhn says.³

She adds that delmopinol is also effective in reducing plaque and gingivitis. While not a traditional antimicrobial, this surface-active cationic agent creates less-adhesive plaque. In addition, it forms a barrier that inhibits plaque from sticking to the teeth and gingiva. Mouthrinses containing delmopinol can be used prior to CHX, as well as during follow-up care once treatment with CHX is completed.⁴

To battle caries, Bruhn recommends using rinses with CHX, essential oils or fluoride, which are able to decrease Streptococcus mutans levels—the main bacteria associated with dental caries. "Mouthrinses containing fluoride as the active ingredient are able to reduce both S. mutans and S. sobrinus within saliva," she explains.

And for patients experiencing dentinal hypersensitivity, Bruhn notes that rinses formulated with stannous fluoride or potassium nitrate can help alleviate discomfort.

Although the latest therapeutic mouthrinses offer an effective adjunct to flossing, they can cause side effects. For example, CHX can temporarily stain structures inside the mouth, including teeth, restorations and mucosa.⁵ Cetylpyridinium chloride-based products can also cause temporary staining, as well as oral ulceration and bitter taste.⁵ In addition, some rinses contain alcohol, which may be contraindicated for certain patients. For these individuals and others who simply prefer to avoid such formulations, alcohol-free products are a better choice.

WHAT THE FUTURE MAY HOLD

As therapeutic mouthrinses continue to evolve, dental hygienists need to remain up to date on these important adjuncts to effective oral self-care. Bruhn suggests clinicians visit the American Dental Association website to learn about the differences between cosmetic and therapeutic mouthrinses. And when making product recommendations to patients, she emphasizes the most important step is to examine the available evidence regarding clinical efficacy.

Therapeutic mouthrinses offer a tool for battling plaque and gingivitis that is capable of reaching all surfaces inside the oral cavity. They are relatively affordable, as well as quick and easy to use. These qualities all seem to point toward an increasingly popular means of encouraging patients to improve their self-care regimens and, ultimately, help them achieve excellent oral health. No strings attached.

1. Zimmer S, Kolbe C, Kaiser G, Krage T, Ommerborn M, Barthel C. Clinical efficacy of flossing versus use of antimicrobial rinses. J Periodontol. 2006;77:1380–1385.
2. Perno Goldie M. The role of oral rinse technologies in a new daily oral healthcare regimen. Compend Contin Educ Dent Suppl. 2011;4(Suppl):9–12.
3. Barnett M. The role of therapeutic antimicrobial mouthrinses in clinical practice: control of supragingival plaque and gingivitis. J Am Dental Assoc. 2003;134:699–704.
4. Bruhn A. Biofilm barrier. Dimensions of Dental Hygiene. 2011;9(9):19–22.
5. Marsh L. Fight gingivitis with therapeutic mouthrinses. Dimensions of Dental Hygiene. 2011;9(11):55–57.