How to guide your patients to the products that are right for them.

By Rachel Wall, RDH, BS

Text version of the article from the Modern Hygienist Magazine

Click Here To Download A PDF Version

We’ve all seen it. The poor souls lost on the dental aisle of the local discount retailer. You want to reach out to them but you’re afraid of invading their privacy. They stand there, scanning the mountain of products available, confused about what to buy. But don’t worry. There is a way you can help, a way you can make a difference and it starts with your patients. As oral healthcare professionals, we are asked every day what products we use and recommend. With so many high-quality, safe and effective oral care products on the market, it is difficult for patients to go wrong in general. But our guidance can help patients target the products that may best serve their individual needs. A professional recommendation rescues your patients from navigating the sea of homecare products alone. It helps them zero in on what works and supports their dental investment.

WHAT DO YOU USE?

Are you using the same products you recommend? Seems like a silly question, but aligning your recommendations with what you use in your own mouth can help you practice as a professional with the utmost integrity. What products do you use to keep your breath fresh, protect your pristine restorations and keep bacteria at bay? Do you make those products available for your patients, or are you sending them into the black hole that is the dental care aisle?

This is the first of a series of articles that will review a variety of oral care products now available and how making a strong professional recommendation can build your patients confidence in you, their personal oral health expert.

MOUTHRINSE

Let’s look at mouthrinses. Americans spend millions of dollars every year on mouthwash. The primary reason for using mouthwash is to prevent or cover up bad breath or halitosis. What we know about some rinses is that all they do is cover up odor for a short time. The good news is that there are now products that can eliminate bad breath at its source for many hours. The causes of halitosis are numerous, but by far the most common cause is the presence of volatile sulfur compounds (VSC). VSC are gases that result when anaerobic bacteria metabolize sloughed epithelial cells and decaying food particles. The gases consist primarily of hydrogen sulfide, methyl mercaptan, dimethyl sulfide and dimethyl disulfide. For example, hydrogen sulfide is the gas that creates the smell of rotten eggs, and methyl mercaptan is the smell we experience in barnyards. No wonder halitosis can be embarrassing and offensive! VSC levels have also been linked to the occurrence of periodontal disease. Even in a low number, VSC have been shown to have a negative effect on the oral mucosa’s ability to resist bacterial invasion. In fact, methyl mercaptan is produced primarily by periodontal pathogens¹. Even more disturbing is news that the permeability of mucosa is increased by up to 75 percent following exposure to hydrogen sulfide, and 103 percent with methyl mercaptan due to the VSC concentration. ²With this evidence, it becomes very clear that eliminating VSC is not just about creating fresh breath. It is also a critical component in the fight against periodontal disease. Recommending homecare products that can stop VSC in their tracks is one way you can support your patients in their search for a healthy, fresh mouth. Periodontal therapy without supporting homecare products is incomplete.

THE ALCOHOL QUESTION

Progressive dental professionals are always looking for ways to serve their patients’ individual needs. As healthcare professionals, it is our responsibility to give our patients the information they need to make good choices about their health. This includes advice on alcohol-free products for those patients for whom alcohol is contraindicated. Patients who suffer from Xerestomia or others who are sensitive to alcohol need not be denied the benefits of mouthrinse. Scientific research is showing that some products without alcohol are just as effective as those containing it. Some clinicians are moving away from alcohol-based products toward alternative ingredients.

The controversy remains over the effects of alcohol on soft tissues and dental materials. There currently is no evidence that alcohol causes oral cancer in humans, but a study in 1979 by Bernstein and Carlish found that when an alcohol-based mouthrinse was placed in the cheeks of mice for 45 minutes, 100 percent of the mice experienced hyperkeratotic changes in the exposed tissue. More recent research states that clinicians should be alert to the potentially adverse effect of alcohol-containing mouthrinses.³ Depending on the material, alcohol may also pose a danger to the longevity of certain dental restorations.⁴ The use of an alcohol-free rinse will moisten the mouth and reduce the risk of increased dryness, which contributes to the lack of saliva and bad breath. Xerostomia is the No. 1 side effect of many prescription medications and it is not uncommon for dental professionals to encounter this on a daily basis. Two independent studies using a chlorhexidine rinse with alcohol and one without alcohol indicated there was no difference in the effectiveness of the two rinses. We can gather that alcohol is not essential to create a chlorhexidine mouthrinse that is effective in reducing bactebacteria. With that information, it is clear to say that an effective, safe mouthrinse should be one that eliminates VSC, reduces bacteria and, for patients who are sensitive to alcohol, is alcohol-free. There are several active ingredients that have proven effective at reducing bacterial levels in the mouth as well as eliminating volatile sulfur compounds, the primary culprits behind bad breath. The good news is that they are all now available in alcohol-free formulas and there is clinical research to support their efficacy.

These ingredients include:

Cetylpyridium Chloride (CPC) – Clinical research shows that CPC breaks down the bacterial cell membrane, effectively killing bacteria. It also has been shown to reduce oral malodor. In one study, the use of a .07-percent CPC mouthrinse when used over a six-month period provided antiplaque and antigingivitis benefits when used twice a day with brushing⁵.

Chlorine Dioxide (ClO2) –CLO2 may also be known as as Sodium Chlorite. It is a strong oxidizing agent and broad spectrum antimicrobial. The oxidizing properties work best against dangerous anaerobic bacteria that cause destructive periodontal disease. Sodium chlorite has been shown to have an equivalent plaque inhibitory action as compared to chlorhexidine without the side effect of staining⁶. CLO2 has been shown to significantly reduce mouth odor and reduce VSC concentrations in mouth air for at least 8 hours.⁷

Zinc (Zn) – Clinical trials have shown that zinc ions are able to reduce the levels of VSC.⁸ A study of the effects of VSC on oral mucosa showed that treatment of the mucosa with Zinc Chloride nullified the effect of VSC and restored the permeability of the mucosa to a healthy state.2 Zinc has also been shown to enhance the antimicrobial effect of chlorine dioxide.

Chlorhexidine (CHX) – Chlorhexidine is widely recognized as helpful in reducing bacterial plaque. In the past, most CHX rinses contained alcohol. Fortunately, alcohol-free CHX rinses are now available and have been shown to be as powerful at controlling plaque and gingivitis as those with alcohol.⁹ The side effects of CHX remain as staining and taste alteration.

Fluoride – Longheld as the gold standard for caries control, fluoride in mouthrinses can give extra protection against root decay and protect the margins of restorations.

Xylitol – Recently, xylitol has been the topic of numerous research studies and articles. It is a naturally occurring sugar substitute that has been show to be effective in reducing dental caries, middle ear infections and in the relief of xerostomia by stimulating salivary flow.¹⁰

Essential Oils – The term essential oils as related to oral hygiene products usually refer to such oils as Thyme oil (thymol), Clove oil (eugenol) and Eucalyptus oil. Essential oils are germicidal and they work best in liquid form. In one study, the presence of alcohol actually reduced the effectiveness of essential oils.¹¹

Clinical research strongly supports the efficacy of these active ingredients in breath control as well as protecting periodontal health without the addition of alcohol. Help your patients support their dental investment. Do your own research and find a product you use and believe in. Then give your patients the gift of a strong professional recommendation.

Clinician, speaker and writer Rachel Wall, RDH, BS is a contributing editor to Modern Hygienist and founder of the hygiene consulting practice, Inspired Hygiene. You can contact her and get free monthly tips for boosting production at www.inspiredhygiene.com.

REFERENCES

1. Ratcliff PA, Johnson PW The Relationship between oral malodor, gingivitis, and Periodontitis. J Perio. 1999 May;70(5):485-9.
2. Ng W, Tonzetich J Effect of hydrogen sulfide and methyl mercaptan on the permeability of oral mucosa. J Dent Res. 1984 Jul;63(7):994-7.
3. Poggi P, Rodriguez y Baena R, et al. Mouthrinses with alcohol: cytotoxic effects on human gingival fibroblasts in vitro. J Periodontol. 2004 Feb; 75(2):333-4; author reply 334-5.
4. Yap AU, Tan BW, et al. Effect of mouthrinses on microhardness and wear of composite and compomer restoratives. Oper Dent. 2003 Nov-Dec;28(6):740-6.
5. Mankodi S, Bauroth K, Witt JJ, Bsoul S, He T, Gibb R, Dunavent J, Hamilton A. A 6-month clinical trial to study the effects of a cetylpyridinium chloride mouthrinse. Am J Dent 2005;18:9A-14A.
6. Yates R, Moran J, Addy M, et al. The comparative effect of acidified sodium chlorite and chlorhexidine mouthrinses on plaque regrowth and salivary bacterial counts. J Clin Periodontology. 1997 Sep;24(9 Pt 1):603-9.
7. Frascella J, Gilbert RD, Fernandez P, et al. Efficacy of chlorine dioxidecontaining mouthrinse in oral malodor. Compend Contin Educ Dent. 2000 Mar;21(3):241-4, 246, 249 passim; quiz256.
8. Loesche Wj, Kazor C. Microbiology and treatment of halitosis. Periodontol 2000. 2002;28:256-79.
9. Leyes Borrajo JL, Garcia VL, Lopez CG, et al. Efficacy of chlorhexidine mouthrinses with and without alcohol: a clinical study. J Periodontol. 2002 Mar;73(3):317-21.
10. Kacerik M, Prajer R. The benefits of xylitol for fresh breath and caries prevention. J Pract Hyg. 2006 Jan/Feb;15:17-18.
11. Meeker H, Linke H. The antibacterial action of eugenol, thyme oil and related essential oils used in dentistry. Breath Rx website. Accessed March 2006.

Free for all

Alcohol-free that is. New research proves that non-alcoholic mouth rinses can pack the same bacteria-killing power
as those formulated with alcohol. That’s great news for you and your patients who are sensitive to alcohol. The products
below are just a small sample of what’s available.

DISCUS BreathRx Available OTC as well as in the dental practice, BreathRx helps patients stick to the brush/scrape/rinse protocol of home hygiene care. It is formulated to eliminate the bacteria that cause oral malodor and actively neutralize the volatile sulfur compounds they emit. Call 800-471-7747 or visit www.breathrx.com.	ROWPAR PHARMACEUTICALS CloSysII CloSysII oral rinse uses a proprietary chlorine dioxide formula to eliminate volatile sulfur compounds that can cause halitosis. It is available in 1-gallon, 32-ounce, and 16-ounce bottles. A toothpaste product is also available. Call 800-643-3337 or visit www.rowpar.com.	PROCTER & GAMBLE Crest Pro-Health Rinse Crest Pro-Health Rinse is said to kill 99% of germs causing plaque, gingivitis and bad breath. Its alcohol-free composition prevents any burning sensation in the mouth, leading to more regular use. It can be used before, during, and immediately after prophy, scaling and root planning. Call 800- 285-9139 or visit www.crest.com.
OXYFRESH WORLDWIDE Power Rinse Power Rinse alcohol-free mouthrinse is available in a zesty lemon-mint flavor. The lemon is said to stimulate salivary flow, and the combination of chlorine dioxide and zinc eliminates VSC, resulting in fresh breath for hours. Call 800-333-7374 or visit www.oxydental.com.	SUNSTAR BUTLER GUM CHX Rinse GUM CHX mouthrinse is available exclusively in-office, giving dental pros the opportunity to counsel patients on its use. In addition, the patient can now obtain the product without the hassle of a time-consuming prescription. The rinse is available in a 16-ounce bottle, with separate dose cup. Call 800-528- 8537 or visit www.sunstarbutler.com.	THE NATURAL DENTIST Healthy Gums Healthy Gums oral rinse uses naturally occuring antimicrobial agents to fight gingivitis, and botanicals to soothe and protect soft tissue in the mouth. The rinse does not contain alcohol, harsh chemicals, artificial dyes, flavors, or sweeteners. Call 800-615-6895 for details or go to www.thenaturaldentist.com.

Modern Hygienist - April 2006