Oral cancer and mouthwash use: evaluation of the epidemiologic evidence

Mouthwash With Alcohol and Oral Carcinogenesis: Systematic Review and Meta-analysis

BACKGROUND

It has been shown that the risk of developing oral cancer is closely related to the intensity and duration of exposure to alcohol and tobacco. Even so, the use of mouthwashes with alcohol in their compositions and the increased risk of oral cancer has been a source of controversy for decades.

OBJECTIVE

This study proposes a systematic review and a meta-analysis of the literature, to assess the possible relationship between the use of mouthwashes with alcohol and the development of oral and pharyngeal cancers.

MATERIALS AND METHODS

A systematic search was done using the Medline and PubMed databases. Exclusion criteria were as follows: articles published in languages other than English or Spanish, systematic reviews, and expert opinions. No limitations were used for publication date.

RESULTS

A total of 14 articles were obtained, 11 case-control studies and 3 clinical trials. Three case-control studies found no statistically significant evidence between the relationship of mouthwash use and oral cancer and the remaining 8 case-control studies found statistically significant evidence. The 3 clinical trials observed a relationship between the use of mouthwashes with alcohol and the possibility of developing cancer due to the genotoxicity and mutagenic capacity of alcohol in chronic contact with oral tissues and mucous membranes. The meta-analysis resulted in an OR = 1.480 and a P-value = .161 (95% CI: 0.855; P-value = 2.561) for the analysis of studies of cancer risk and consumption of mouthwashes with alcohol and OR = 1.057 0.364 (95% CI: 0.951; P-value = 1.174) for studies that related the risk of cancer and mouthwash use without taking into account the presence of alcohol.

CONCLUSIONS

There is no sufficient evidence to accept the proposition that the use of mouthwashes containing alcohol can influence the development of oral cancer.

Potential hazards due to food additives in oral hygiene products

Food additives used to preserve flavor or to enhance the taste and appearance of foods are also available in oral hygiene products. The aim of this review is to provide information concerning food additives in oral hygiene products and their adverse effects. A great many of food additives in oral hygiene products are potential allergens and they may lead to allergic reactions such as urticaria, contact dermatitis, rhinitis, and angioedema. Dental practitioners, as well as health care providers, must be aware of the possibility of allergic reactions due to food additives in oral hygiene products. Proper dosage levels, delivery vehicles, frequency, potential benefits, and adverse effects of oral health products should be explained completely to the patients. There is a necessity to raise the awareness among dental professionals on this subject and to develop a data gathering system for possible adverse reactions.

Can Chemical Mouthwash Agents Achieve Plaque/Gingivitis Control?

Also note that structured abstracts are not allowed per journal style: What is the effect of a mouthwash containing various active chemical ingredients on plaque control and managing gingivitis in adults based on evidence gathered from existing systematic reviews? The summarized evidence suggests that mouthwashes containing chlorhexidine(CHX) and essential oils (EO) had a large effect supported by a strong body of evidence. Also there was strong evidence for a moderate effect of cetylpyridinium chloride(CPC). Evidence suggests that a CHX mouthwash is the first choice, the most reliable alternative is EO. No difference between CHX and EO with respect to gingivitis was observed.

In vitro antimicrobial and cytotoxic effects of Anacardium occidentale and Mangifera indica in oral care

Background:

Oral health is an integral and important component of general health. Infectious diseases such as caries, periodontal, and gingivitis indicate the onset of imbalance in homeostasis between oral micro biota and host. The present day medicaments used in oral health care have numerous side effects. The uses of herbal plants as an alternative have gained popularity due to side effects of antibiotics and emergence of multidrug resistant strains. Anacardium occidentale (cashew) and Mangifera indica (mango) have been used as traditional oral health care measures in India since time immemorial.

Materials and Methods:

The ethanol extracts of cashew and mango leaves were obtained by maceration method. The antimicrobial activity was evaluated by clear zone produced by these plant extracts against Enterococcus faecalis, Staphylococcus aureus, Streptococcus mutans, Escherichia coli, and Candida albicans in agar plate method, determination of minimum inhibitory concentration (MIC), minimum bactericidal/fungicidal concentration (MBC/MFC), and suppression of biofilm. The cytotoxic effects of plants extract was determined by microculture tetrazolium assay on human gingival fibroblast and Chinese hamster lung fibroblast (V79) cell lines.

Results:

Cashew and mango leaf extract significantly (P < 0.05) produced larger zone of inhibition against test pathogens when compared to povidone-iodine-based mouth rinses. Although the MIC and MBC/MFC values of mouth rinses were effective in lower concentrations; plant extracts significantly (P < 0.001) suppressed the biofilms of oral pathogens. The leaf extracts were less cytotoxic (P < 0.001) compared to mouth rinses.

Conclusions:

Plant extracts are superior to the mouth rinses and have a promising role in future oral health care.

Clinical evidence demonstrating the utility of inorganic nitrate in cardiovascular health

The discovery of nitric oxide and its role in almost every facet of human biology opened a new avenue for treatment through manipulation of its canonical signaling and by attempts to augment endogenous nitric oxide generation through provision of substrate and co-factors to the endothelial nitric oxide synthase complex. This has been particularly so in the cardiovascular system and it is well recognized that there is reduced bioavailable nitric oxide in patients with both cardiovascular risk factors and manifest vascular disease. However, these attempts have failed to deliver the expected benefits of such an approach. Recently, an alternative pathway for nitric oxide synthesis has been elucidated that can produce authentic nitric oxide from the 1 electron reduction of inorganic nitrite. Furthermore, it has long been known that symbiotic, facultative, oral microflora can facilitate the reduction of inorganic nitrate, that is ingested in the average diet in millimolar amounts, to inorganic nitrite itself. Thus, there exists an alternative reductive pathway from nitrate, via nitrite as an intermediate, to nitric oxide that provides a novel pathway that may be amenable to therapeutic manipulation. As such, various research groups have explored the utility of manipulation of this nitrate-nitrite-nitric oxide pathway in situations in which nitric oxide is known to have a prominent role. Animal and early-phase human studies of both inorganic nitrite and nitrate supplementation have shown beneficial effects in blood pressure control, platelet function, vascular health and exercise capacity. This review considers in detail the pathways of inorganic nitrate bioactivation and the evidence of clinical utility to date on the cardiovascular system.

Periodontal disease and mouthwash use are risk factors for head and neck squamous cell carcinoma

PURPOSE

The purpose of this study was to examine associations between oral hygiene, including history of periodontal disease and mouthwash use, and risk of head and neck squamous cell carcinoma (HNSCC).

METHODS

We measured history of oral hygiene and dental care on 513 HNSCC cases and 567 controls from a population-based study of HNSCC. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (95% CI).

RESULTS

Periodontal disease was associated with a slightly elevated risk of HNSCC (OR = 1.09, 95% CI: 1.02, 1.16). Using any type of mouthwash at least once per day was associated with increased risk compared to never using mouthwash (OR = 1.11, 95% CI: 1.02, 1.20). HNSCC was associated with frequent use of non-alcoholic mouthwash compared to using any kind of mouthwash rarely or never (OR = 1.24, 95% CI: 1.05, 1.47).

CONCLUSIONS

Our results support an association between periodontal disease and HNSCC. Our data suggest that mouthwash use is associated with HNSCC, but we noted no difference between the effects of alcohol-containing and non-alcoholic mouthwashes.

Physiological role for nitrate-reducing oral bacteria in blood pressure control

Circulating nitrate (NO(3)(-)), derived from dietary sources or endogenous nitric oxide production, is extracted from blood by the salivary glands, accumulates in saliva, and is then reduced to nitrite (NO(2)(-)) by the oral microflora. This process has historically been viewed as harmful, because nitrite can promote formation of potentially carcinogenic N-nitrosamines. More recent research, however, suggests that nitrite can also serve as a precursor for systemic generation of vasodilatory nitric oxide, and exogenous administration of nitrate reduces blood pressure in humans. However, whether oral nitrate-reducing bacteria participate in "setting" blood pressure is unknown. We investigated whether suppression of the oral microflora affects systemic nitrite levels and hence blood pressure in healthy individuals. We measured blood pressure (clinic, home, and 24-h ambulatory) in 19 healthy volunteers during an initial 7-day control period followed by a 7-day treatment period with a chlorhexidine-based antiseptic mouthwash. Oral nitrate-reducing capacity and nitrite levels were measured after each study period. Antiseptic mouthwash treatment reduced oral nitrite production by 90% (p < 0.001) and plasma nitrite levels by 25% (p = 0.001) compared to the control period. Systolic and diastolic blood pressure increased by 2-3 .5mmHg, increases correlated to a decrease in circulating nitrite concentrations (r(2) = 0.56, p = 0.002). The blood pressure effect appeared within 1 day of disruption of the oral microflora and was sustained during the 7-day mouthwash intervention. These results suggest that the recycling of endogenous nitrate by oral bacteria plays an important role in determination of plasma nitrite levels and thereby in the physiological control of blood pressure.

Cytological changes in the oral mucosa after use of a mouth rinse with alcohol. A prospective double blind control study

AIM

The aim of this preliminary study was to detect cytological changes in the oral mucosa after using a mouth wash with alcohol.

MATERIAL AND METHODS

A prospective double-blind, controlled study was performed, for 6 months. Group 1 consisted of 30 subjects who used a mouth rinse with 26.9% of alcohol [Listerine] and Group 2 consisted of 30 subjects who used a mouth rinse with the same ingredients but with no alcohol. We obtained three cytological samples from the oral mucosa. The presence of cytological atypia, binucleation and karyorrhesis, and type of cells were studied. We also used a fluorescent in situ hybridization technique (FISH) in 15 samples in each group, for the micronucleus.

RESULTS

We found no clinical mucosal alteration after using the mouth wash at the end of the study in either group. We observed no cytological differences between the groups at the end of the study (p>0.05). Regarding the study of the micronucleus by FISH, we observed no significant difference between the groups (p>0.05).

CONCLUSIONS

Our results showed no cytological alteration in patients using a mouth rinse with alcohol, but these findings should be considered preliminary results, to be confirmed in a greater sample of patients.

Efficacy of essential oil mouthwash with and without alcohol: a 3-day plaque accumulation model

Background

The aim of this study was to evaluate the antiplaque effect of a new alcohol free essential oil mouthwash with respect to a control of an essential oil with alcohol mouthwash, using an in vivo plaque regrowth model of 3-days.

Methods

The study was designed as a double-masked, randomized, crossover clinical trial, involving 30 volunteers to compare two different essential oil containing mouthwashes, during a 3-day plaque accumulation model. After receiving a thorough professional prophylaxis at the baseline, over the next 3-days each volunteer refrained from all oral hygiene measures and had two daily rinses with 20 ml of the test mouthwash (alcohol free essential oil) or the control mouthwash (essential oil with alcohol). At the end of the each experimental period, plaque was assessed and the panelists filled out a questionnaire. Each subject underwent a 14 days washout period and there was a second allocation.

Results

The essential oil mouthwash with ethanol shows a better inhibitory effect of plaque regrowth in 3-days than the mouthwash test with only essential oil in the whole mouth (plaque index = 2.18 against 2.46, respectively, p < 0.05); for the lower jaw (plaque index = 2.28 against 2.57, respectively, p < 0.05); for the upper jaw (plaque index = 2.08 against 2.35, respectively, p < 0.05); for the incisors (plaque index = 1.93 against 2.27, respectively, p < 0.05); and the canines (plaque index = 1.99 against 2.47, respectively, p < 0.05).

Conclusion

The essential oil containing mouthwash without alcohol seems to have a less inhibiting effect on the plaque regrowth than the traditional alcoholic solution.

Trial Registration

ClinicalTrials.gov NCT01411618

Antimicrobial activity of Citrox bioflavonoid preparations against oral microorganisms

BACKGROUND

Citrox is a formulation of soluble bioflavonoids obtained from citrus fruits. The non-toxic and antimicrobial properties of natural bioflavonoids are well documented, and consequently there has been interest in the therapeutic application of these substances.

OBJECTIVE

To determine the antimicrobial activity of two Citrox formulations (BC30 and MDC30) with different bioflavonoid combinations against a range of oral microorganisms.

METHODS

The antimicrobial activity of both formulations was tested against 14 bacterial species and six Candida species. The two Citrox formulations (dilution range 0.007-8% v/v) were firstly evaluated by determining the in vitro Minimal Inhibitory Concentration (MIC) against planktonic microorganisms in a broth microdilution assay. Secondly, the ability of the same serial dilutions to inhibit microbial growth was assessed in a modified microtitre biofilm assay.

RESULTS

Both Citrox formulations exhibited antimicrobial activity. The BC30 formulation demonstrated greater activity than MDC30 and significantly inhibited growth of all bacterial species and most candidal species tested at a concentration of 1% (v/v) in both the broth and the biofilm assay.

CONCLUSION

Bioflavonoid preparations of Citrox have a broad-spectrum of antimicrobial activity against oral microorganisms, and as such have the potential to be used within therapeutic preparations for the control of the oral microflora.

Essential oils compared to chlorhexidine with respect to plaque and parameters of gingival inflammation: a systematic review

BACKGROUND

The purpose of this review is to systematically evaluate the effects of an essential-oil mouthwash (EOMW) compared to a chlorhexidine mouthwash with respect to plaque and parameters of gingival inflammation.

METHODS

PubMed/MEDLINE and Cochrane CENTRAL databases were searched for studies up to and including September 2010 to identify appropriate articles. A comprehensive search was designed, and the articles were independently screened for eligibility by two reviewers. Articles that evaluated the effects of the EOMW compared to chlorhexidine mouthwash were included. Where appropriate, a meta-analysis was performed, and weighted mean differences (WMDs) were calculated.

RESULTS

A total of 390 unique articles were found, of which 19 articles met the eligibility criteria. A meta-analysis of long-term studies (duration ≥ 4 weeks) showed that the chlorhexidine mouthwash provided significantly better effects regarding plaque control than EOMW (WMD: 0.19; P = 0.0009). No significant difference with respect to reduction of gingival inflammation was found between EOMW and chlorhexidine mouthwash (WMD: 0.03; P = 0.58).

CONCLUSION

In long-term use, the standardized formulation of EOMW appeared to be a reliable alternative to chlorhexidine mouthwash with respect to parameters of gingival inflammation.

Salivary acetaldehyde increase due to alcohol-containing mouthwash use: a risk factor for oral cancer

Increasing evidence suggests that acetaldehyde, the first and genotoxic metabolite of ethanol, mediates the carcinogenicity of alcoholic beverages. Ethanol is also contained in a number of ready-to-use mouthwashes typically between 5 and 27% vol. An increased risk of oral cancer has been discussed for users of such mouthwashes; however, epidemiological evidence had remained inconclusive. This study is the first to investigate acetaldehyde levels in saliva after use of alcohol-containing mouthwashes. Ready-to-use mouthwashes and mouthrinses (n = 13) were rinsed in the mouth by healthy, nonsmoking volunteers (n = 4) as intended by the manufacturers (20 ml for 30 sec). Saliva was collected at 0.5, 2, 5 and 10 min after mouthwash use and analyzed using headspace gas chromatography. The acetaldehyde content in the saliva was 41 +/- 15 microM, range 9-85 microM (0.5 min), 52 +/- 14 microM, range 11-105 microM (2 min), 32 +/- 7 microM, range 9-67 microM (5 min) and 15 +/- 7 microM, range 0-37 microM (10 min). The contents were significantly above endogenous levels and corresponding to concentrations normally found after alcoholic beverage consumption. A twice-daily use of alcohol-containing mouthwashes leads to a systemic acetaldehyde exposure of 0.26 microg/kg bodyweight/day on average, which corresponds to a lifetime cancer risk of 3E-6. The margin of exposure was calculated to be 217,604, which would be seen as a low public health concern. However, the local acetaldehyde contents in the saliva are reaching concentrations associated with DNA adduct formation and sister chromatid exchange in vitro, so that concerns for local carcinogenic effects in the oral cavity remain.

Safety evaluation of topical applications of ethanol on the skin and inside the oral cavity

Ethanol is widely used in all kinds of products with direct exposure to the human skin (e.g. medicinal products like hand disinfectants in occupational settings, cosmetics like hairsprays or mouthwashes, pharmaceutical preparations, and many household products). Contradictory evidence about the safety of such topical applications of the alcohol can be found in the scientific literature, yet an up-to-date risk assessment of ethanol application on the skin and inside the oral cavity is currently lacking.The first and foremost concerns of topical ethanol applications for public health are its carcinogenic effects, as there is unambiguous evidence for the carcinogenicity of ethanol orally consumed in the form of alcoholic beverages. So far there is a lack of evidence to associate topical ethanol use with an increased risk of skin cancer. Limited and conflicting epidemiological evidence is available on the link between the use of ethanol in the oral cavity in the form of mouthwashes or mouthrinses and oral cancer. Some studies pointed to an increased risk of oral cancer due to locally produced acetaldehyde, operating via a similar mechanism to that found after alcoholic beverage ingestion.In addition, topically applied ethanol acts as a skin penetration enhancer and may facilitate the transdermal absorption of xenobiotics (e.g. carcinogenic contaminants in cosmetic formulations). Ethanol use is associated with skin irritation or contact dermatitis, especially in humans with an aldehyde dehydrogenase (ALDH) deficiency.After regular application of ethanol on the skin (e.g. in the form of hand disinfectants) relatively low but measurable blood concentrations of ethanol and its metabolite acetaldehyde may occur, which are, however, below acute toxic levels. Only in children, especially through lacerated skin, can percutaneous toxicity occur.As there might be industry bias in many studies about the safety of topical ethanol applications, as well as a general lack of scientific research on the long-term effects, there is a requirement for independent studies on this topic. The research focus should be set on the chronic toxic effects of ethanol and acetaldehyde at the point of impact, with special regard to children and individuals with genetic deficiencies in ethanol metabolism.

Oral health, hygiene practices and oral cancer

OBJECTIVE: To assess the association between oral health and hygiene practices and oral cancer. METHODS: Hospital-based case-control study in the metropolitan area of São Paulo, southeastern Brazil, from 1998 to 2002. A total 309 patients with squamous cell carcinoma of the mouth and the pharynx and 468 controls matched by sex and age were included in the study. Cases were recruited in seven reference hospitals and controls were selected in five out of the seven participating hospitals. Detailed information on smoking, alcohol consumption, schooling, oral health status and hygiene practices were obtained through interviews. Odds ratios (OR) and 95% confidence intervals (95% CI), adjusted by sex, age, schooling, smoking, alcohol consumption as well as the variables oral health status and hygiene practices were estimated using unconditional logistic regression analyses. RESULTS: The use of complete dental prosthesis was not associated with oral cancer but regular gum bleeding showed a strong association (OR 3.1; 95% CI 1.2-7.9). Those who never attended a dental visit were more likely to have oral cancer (OR 2.5; 95% CI 1.3-4.8). Daily mouthwash use showed a stronger association to pharynx (OR 4.7; 95% CI 1.8-12.5) than mouth cancer (OR 3.2; 95% CI 1.6-6.3). CONCLUSIONS: Gum bleeding, no dental care, and daily mouthwash use were factors associated with oral cancer regardless of tobacco and alcohol consumption.

Efficacy of two alcohol-free cetylpyridinium chloride mouthwashes - a randomized double-blind crossover study

AIM

(1) To determine the plaque inhibition properties of two formulations of alcohol-free mouthwash [0.1% w/w cetylpyridinium chloride (CPC) (B) and 0.05% w/w CPC (A)] versus a placebo mouthwash (C). (2) To compare the plaque-inhibiting activity between these two new CPC mouthwashes.

MATERIAL AND METHODS

A double-blind, crossover study with three 1-week periods was used. Subjects were randomly assigned to one of the following groups. Group 1 (n=10) received the mouthwashes A, C and B in the periods 1, 2 and 3, respectively, group 2 (n=11) received the mouthwashes in the order B, A, C, while group 3 (n=11) received the mouthwashes in the order C, B, A. Mean plaque areas and Quigley & Hein plaque index scores were analysed using anova (analysis of variance). Measurements were made at the start of each period (baseline) and at 16, 24 and 40 h.

RESULTS

Mean plaque scores were similar across the groups at baseline. At all time points thereafter, volunteers using mouthwash A or B had significantly lower plaque areas and plaque index scores than those using mouthwash C (p<0.05), but there were no significant differences between the test formulations. At 16 h, the reduction in plaque area relative to mouthwash C was 22% for mouthwash A and 18% for mouthwash B; at 24 h, 11% for mouthwash A and 15% for mouthwash B; and at 40 h, 15% for mouthwash A and 16% for mouthwash B.

CONCLUSIONS

The use of both CPC mouthwashes resulted in less plaque accumulation compared with the control. There was no statistically significant difference in plaque accumulation between the two CPC mouthwashes.

The long-term effect of a mouthrinse containing essential oils on dental plaque and gingivitis: a systematic review

BACKGROUND

The purpose of this study was to review the literature on the effects of a mouthrinse containing essential oils (EO) on plaque and parameters of gingival inflammation.

METHODS

The MEDLINE and Cochrane Central Register of Controlled Trials were searched up to and including December 2006 to identify appropriate studies. The primary outcome measure was gingivitis. Secondary parameters were plaque and, when reported, staining.

RESULTS

Independent screening of titles and abstracts of 566 papers resulted in 11 publications that met the criteria of eligibility. In all studies, EO was used as an adjunct to regular daily toothbrushing. A statistically significant reduction in overall gingivitis was noted compared to the control (weighted mean difference [WMD]: -0.32, 95% confidence interval [CI]: -0.46 to -0.19, P <0.00001; test for heterogeneity: P <0.00001, I(2) = 96.7%). For interproximal sites the use of the test mouthrinse resulted in significantly more gingivitis reduction compared to control mouthrinse (WMD: -0.29, 95% CI: -0.48 to -0.11, P = 0.002; test for heterogeneity: P <0.00001, I(2) = 95.18%), whereas no differences were observed compared to dental floss. With respect to plaque scores, EO produced significant overall reductions in plaque (WMD: -0.83, 95% CI: -1.13 to -0.53, P <0.00001; test for heterogeneity: P <0.00001, I(2) = 96.1%). Separate analysis for interproximal areas revealed that EO resulted in more pronounced plaque drops compared to the control mouthrinse (WMD: -1.02, 95% CI: -1.44 to -0.60, P <0.00001; test for heterogeneity: P <0.00001, I(2) = 96.1%) or the use of floss (WMD: -0.75, 95% CI: -1.15 to -0.363, P <0.0002; test for heterogeneity: P <0.0002, I(2) = 93.0%). Most studies agreed that EO did not produce more staining than the control products.

CONCLUSION

When used as an adjunct to unsupervised oral hygiene, EO provides an additional benefit with regard to plaque and gingivitis reduction as compared to a placebo or control.

Antiseptic effect of a novel alcohol-free mouthwash: A convenient prophylactic alternative for high-risk patients

We developed an efficacious and non-irritant mouthwash that is alcohol-free and that has a low concentration of chlorhexidine, in order to be used for preventing oral cavity infections in immunocompromised and cancer patients. The novel mouthwash solution was tested for its antimicrobial efficacy against both free floating (planktonic) and the biofilm forms of Candida albicans. The solution was also tested against Klebsiella pneumoniae, Pseudomonas aeruginosa, and methicillin-resistant Staphylococcus aureus (MRSA), using a modification of a previously published method. The activity of the novel mouthwash was also compared with that of three commercially available mouthwashes. The experimental mouthwash showed efficacy against C. albicans, both in free-floating form and in biofilm. With higher concentration of chlorhexidine, the solution was also efficacious in inhibiting the growth of K. pneumoniae, P. aeruginosa, and MRSA. The antiseptic activity of the alcohol-free mouthwash against other bacterial organisms and C. albicans was comparable to other commercially available alcohol-based mouthwash solutions. A novel alcohol-free mouthwash solution, that has low concentration of chlorhexidine, showed antiseptic effect against planktonic and biofilm forms of C. albicans and against K. pneumoniae, P. aeruginosa, and MRSA.

Mouthrinses containing alcohol and oral cancer: revision of epidemiological studies

The strong association between alcohol usage and the development of oral cancer (OC) has been reported in numerous papers. As some mouthrinses contain significant amounts of ethanol, a possible relationship to this pathology has been considered. The purpose of the present paper is to analyze several epidemiological studies which evaluated the association between commercial mouthrinses and the etiology of OC. Although some authors report an association, most of the studies are unclear and sometimes contradictory. The controversial aspects regarding the role of alcohol in OC may also make difficult to find a clear relationship between the use of mouthrinses containing alcohol and OC.

How to select the right mouthrinses in periodontal prevention and therapy. Part II. Clinical use and recommendations

Based on scientific proof, only few mouthrinse solutions can be recommended. However, it is impossible to construct an extended table that would provide precise recommendations or advices for mouthrinse utilisation related to any possible discomfort or diseases. Only reliable information on the drugs available against periodontal disease can be offered to the therapist. By evaluation of her or his individual experiences, she or he has to judge all the armamentarium she or he possesses to react in the best possible way in each specific situation.

Differences in efficacy of two commercial 0.2% chlorhexidine mouthrinse solutions: a 4-day plaque re-growth study

BACKGROUND

The purpose of this clinical cross-over study was to examine the antibacterial and plaque-inhibiting properties of two chlorhexidine solutions compared with a negative control.

MATERIAL AND METHODS

Twenty-one volunteers refrained from all oral hygiene measures, but rinsed instead twice daily with 10 ml of a conventional chlorhexidine solution (0.2%; CHX), a chlorhexidine solution with anti-discolouration system (ADS) (0.2%, alcohol-free chlorhexidine solution (CSP)) or a placebo solution (Pla). Plaque index (PI), plaque area (PA) and bacterial vitality were assessed after 24 h (PI1, vital flora (VF)1) and 96 h (PI2; VF2, PA). After a 10-day wash-out period, a new test cycle was started.

RESULTS

Results for Pla were 0.94, 1.59, 27.4 (PI1, PI2, PA) and 79% and 72% (VF1 and VF2). CSP significantly reduced the parameter PI1, PI2 and PA to 0.67 (p=0.012), 1.0 and 15.7 (p<0.001). VF1 and VF2 (63% and 53%) were not significantly affected. The corresponding figures of CHX were 0.42, 0.43, 6.77, 33 and 16%, which were all significantly lower (all p<0.001). On comparing the two chlorhexidine solutions, CHX showed significantly higher reductions of all parameters.

CONCLUSION

The results suggest that the 0.2% alcohol-containing solution showed superiority in inhibiting plaque re-growth and reducing bacterial vitality compared with the solution with ADS.

A Combined Therapeutic Approach to Manage Oral Halitosis: A 3-Month Prospective Case Series

BACKGROUND

Clinical research assessing different therapeutic protocols aimed at treating oral halitosis is scarce. The aim of this study was to evaluate the effects of a combined mechanical and pharmacological approach to treat oral halitosis on clinical and microbiological outcomes on patients followed for 3 months.

METHODS

Nineteen subjects with oral malodor participated. At baseline, all subjects completed a questionnaire and carried out an examination including full-mouth organoleptic and volatile sulfur compound (VSC) levels and the Winkel tongue coating index. Standard periodontal outcome variables were assessed at six teeth. Standardized microbiological samples of subgingival plaque, unstimulated saliva, and tongue coating were obtained for culture analysis. The treatment protocol included supragingival prophylaxis; instructions in oral hygiene (toothbrushing, interproximal cleaning, and tongue scraping); and gargling with a mouthrinse containing chlorhexidine, cetylpiridinium chloride, and zinc lactate. The same outcome variables were registered 1 and 3 months after baseline.

RESULTS

Statistically significant reductions in organoleptic scores (P <0.001), VSC levels (P <0.05), and tongue coating index (P <0.05) were observed after 1 and 3 months. Mean probing depth and plaque levels also demonstrated significant reductions after 3 months (P <0.05). Total anaerobic counts were significantly reduced at all three locations after 1 month (P <0.05), and in samples from tongue coating and subgingival plaque at 3 months (P <0.05). Aerobic counts were significantly reduced in saliva at 1 month (P <0.05), and the anaerobic/aerobic ratio significantly increased in the tongue samples. Among the selected pathogens evaluated, Porphyromonas gingivalis was the most affected of the three microflora evaluated.

CONCLUSIONS

The evaluated therapeutic approach demonstrated its efficacy in the management of oral halitosis, demonstrating statistically significant improvements in both organoleptic and VSC values at 1 and 3 months. The proposed clinical protocol significantly affected the microbial composition in tongue coating, saliva, and subgingival microflora.

Influence of alcohol in mouthwashes containing triclosan and zinc: an experimental gingivitis study

OBJECTIVES

An experimental gingivitis model was used to analyse the influence of alcohol in mouthwashes containing 0.15% triclosan and zinc chloride on the formation of supragingival plaque, the development of gingivitis and the appearance of adverse events.

MATERIAL AND METHODS

Using a double-blind crossover design, 30 subjects underwent two consecutive experimental phases with two 0.15% triclosan and zinc chloride mouthwashes, differentiated mainly by their excipient (hydroalcoholic or aqueous). In each phase, the subjects discontinued all oral hygiene measures and were treated solely with the randomly assigned experimental mouthwash for 21 days. Each experimental phase was preceded by a 14-day washout period in which, after receiving a complete oral prophylaxis, the subjects were instructed to perform thorough oral hygiene procedures. Gingivitis and plaque levels were assessed at the start and end of both the experimental phases.

RESULTS

The evolution of the gingivitis and plaque indices showed no statistically significant differences between both treatments. The mean gingival index increased from 0.30 to 0.38 with the non-alcoholic mouthwash and from 0.32 to 0.42 with the hydroalcoholic mouthwash. The respective changes in plaque index were from 0.88 to 1.93 and from 0.94 to 1.92. The hydroalcoholic mouthwash produced a larger number of fresh symptoms (p=0.033), oral itching being the most reported.

CONCLUSIONS

Alcohol does not influence the effectiveness of a 0.15% triclosan and zinc chloride mouthwash against gingivitis development and supragingival plaque formation. The absence of alcohol significantly decreases the incidence of adverse events produced by the mouthwash.

Plaque inhibition of two commercially available chlorhexidine mouthrinses

BACKGROUND

Chlorhexidine (CHX) 0.2% solution is still "the leading oral antiseptic" for controlling gingivitis. Side effects, however, limit the acceptability to users and the long-term employment of a 0.2% CHX antiseptic in preventive dentistry. This stimulated the development of new formulations. The aim of the present study was to assess the effect on plaque inhibition and taste perception of two commercially available mouthrinses (0.12% CHX non-alcohol base with 0.05% cetyl pyridinium chloride (Cpc) versus 0.2% CHX alcohol base).

METHODS

The study was designed as a single-blind, randomized two group parallel experiment, to compare two different commercially available mouthrinses, during a 3-day plaque accumulation model. Forty healthy volunteers were enrolled in the study and received a thorough dental prophylaxis at the beginning of the test period. Over a 72-h experimental non-brushing period, during which subjects abstained from all forms of mechanical oral hygiene, one group (test) used a 15 ml alcohol free 0.12% CHX (=18 mg) mouthrinse on a Cpc base (Perioaid), CHX plus sign in circleCpc), twice daily for 30 s. The other group (control) used a 10 ml 0.2% CHX (=20 mg) mouthrinse on an 11.8% ethanol alcohol base (Corsodyl), CHX plus sign in circleAlc), twice daily for 60 s. After 72 h of plaque formation, the amount of plaque was evaluated. By the use of visual analogue scale, the subjects were asked for their appreciation of the taste of the mouthrinse they had used.

RESULTS

The mean plaque index for the CHX plus sign in circleCpc group was 0.97 and for the CHX plus sign in circleAlc group 0.78. After 72 h of non-brushing, there was no significant difference in plaque accumulation between the two groups. The answers to the questions (taste perception and after-taste) showed a statistically significant difference between the two groups. The mean visual analogue scale (VAS) scores for taste appreciation on a scale from very bad to very good taste (0-10) were 5.92 for the CHX plus sign in circleCpc group and 4.10 for the CHX plus sign in circleAlc group (p=0.02). The mean visual analogue scale (VAS) scores for the after-taste on a scale from very short to very long (0-10) were 7.24 for the CHX plus sign in circleCpc group and 5.38 for the CHX plus sign in circleAlc group.

CONCLUSIONS

Within the limitations of the present study design, it can be concluded that rinsing with a 0.12% CHX mouthrinse on a non-alcohol base with 0.05% Cpc (Perio-Aid) is not significantly different from rinsing with a 0.2% CHX mouthrinse on an alcohol base (Corsodyl). It appears that the subjects appreciated the taste of the non-alcohol CHX solution better but the after-taste of the rinse remained longer in the mouth.

A 0.05% cetyl pyridinium chloride/0.05% chlorhexidine mouth rinse during maintenance phase after initial periodontal therapy

BACKGROUND

Chlorhexidine (CHX) mouth rinse/spray can still be considered the gold standard in the chemical prevention of plaque formation and development of gingivitis. The product unfortunately has some side effects, such as extrinsic tooth staining, poor taste, taste disturbance, sensitivity changes in tongue, pain and irritation because of the alcohol content. These side effects led to the search of new formulations.

METHODS

In this double-blind, randomized, long-term, parallel study, 48 moderate periodontitis patients rinsed for 6 months (starting immediately after a "one-stage, full-mouth" disinfection) with one of the following products: CHX 0.2%+alcohol (Corsodyl), CHX 0.05%+ cetyl pyridinium chloride (CPC) 0.05% and no alcohol (Perio-Aid Maintenance, a new formulation), or the placebo of the latter. After 1, 3 and 6 months a series of clinical and microbiological parameters were recorded for the supra- and subgingival area as well as for saliva.

RESULTS

Although there was a significant treatment impact (mechanical debridement) in all groups, both CHX solutions further decreased both plaque and gingivitis indices (p<0.001 and p<0.05, respectively), when compared with placebo. This was also reflected by additional reductions in the number of CFU/ml of aerobic and especially anaerobic species and by a suppression of Streptococcus mutans (versus an overgrowth for the placebo), in all niches. Differences between both CHX solutions were never encountered. The subjective ratings were slightly in favour of the new CHX-CPC formulation when compared with the other CHX-alcohol formulation, especially for taste of the product (p<0.05), but less impressive for the staining of teeth and tongue.

CONCLUSIONS

The results of this study demonstrated the potential of a new CHX 0.05%+CPC 0.05% non-alcoholic formulation as an effective antiplaque agent for long-term use with reduced subjective side effects.

Essential oil mouthwashes: a key component in oral health management

This Supplement provides clear evidence that essential oil (EO) mouthwashes can be a beneficial, safe component of daily oral health routines. However, despite the wealth of supporting evidence, several issues are worthy of discussion. Patient compliance is a clear issue with oral home-care routines, and the emphasis is on dental professionals to communicate the importance of adherence. The reasons for each step of the oral-care routine (i.e. brushing, flossing, rinsing) should be clearly explained, and if required, additional motivation should be provided. Most mouthwashes contain denatured alcohol as a delivery vehicle, and some concern has been raised about the association of alcohol with oral cancer. However, a review by the Food and Drug Administration and American Dental Association found that the supporting evidence to date is inconsistent and contradictory. Some mouthwashes have a pH below 5.5, and some researchers believe that this can lead to tooth erosion. Studies have shown that although the pH of an EO mouthwash is below 5.5, salivary pH remains above 5.5 following rinsing and for 15 min postrinse.

Differences in antimicrobial activity of four commercial 0.12% chlorhexidine mouthrinse formulations: an in vitro contact test and salivary bacterial counts study

AIM

To evaluate the in vitro and in vivo antimicrobial activity of four commercial 0.12% chlorhexidine mouthrinses.

MATERIAL AND METHODS

The in vitro antimicrobial activity test consisted in a modified contact test where 20 selected bacterial species were tested during 1 min with each test product. After the contact, the inoculum was cultured, and the results were expressed in terms of survival/resistance and the percentage of survival as compared to a saline control. The in vivo test consisted of a double-blind, randomized, crossover salivary bacterial counts study. 10 volunteers rinsed during 1 min with each tested product. Saliva samples were obtained before rinsing, and after 5 min, and 1, 3, 5 and 7 h. These samples were cultured both aerobically and anaerobically. Percentages of survival, in regard to baseline, were calculated for each time point. Comparisons among products were tested using anova and selected paired t-test.

RESULTS

The in vitro contact test showed no survival in any tested species with CHX+CPC, while three species (Lactobacillus casei, Streptococcus mitis and Peptostreptococcus micros) were resistant to the other three products. CHX and CHX+NaF demonstrated additional resistant species (three and four species, respectively). The in vivo salivary bacterial counts test showed higher reductions of CHX+CPC and CHX+ALC in aerobic and anaerobic bacteria, lasting for 5 h. Significant differences were detected at multiple time points, when these two products were compared both with the control and the other tested products.

CONCLUSION

Important differences in activity, among 0.12% CHX products, were detected by both in vitro and in vivo tests. The formulation with alcohol was more active than those without alcohol, excepting the formulation with CHX+CPC, in which the reformulation and addition of CPC not only compensate but rather increase the antimicrobial activity.

Effect of different chlorhexidine formulations in mouthrinses on de novo plaque formation

BACKGROUND

Chlorhexidine (CHX) 0.2% solution, still the golden standard as mouthrinse for the prevention of plaque formation and development of gingivitis, has some limited side-effects such as extrinsic tooth staining, poor taste, taste disturbance, sensitivity changes in tongue, pain, and the content of alcohol. These side effects led to the search of new formulations.

METHODS

In this double-blind, randomised, cross-over study, 16 young dental students with a healthy periodontium, abolished all means of mechanical plaque control during 4 experimental periods of 11 days (separated from each other by a washout period of 3 weeks). During each experimental period, they rinsed 2x daily with one of the following mouthrinses in a randomised order: CHX 0.2% + alcohol (Corsodyl), CHX 0.12% + alcohol (Perio.Aid), CHX 0.12% + sodium fluoride 0.05% (Cariax Gingival) and CHX 0.12% + CPC 0.05% (Perio.Aid, new formulation). After 7 and 11 days of undisturbed plaque formation, clinical parameters were recorded, questionnaires completed and plaque samples (supragingivally and saliva) collected.

RESULTS

The CHX 0.12% + alcohol and the CHX 0.12% + CPC 0.05% formulations were as efficient as the CHX 0.2% mouthrinse in retarding de novo plaque formation (proven by clinical observations as well as by anaerobic and aerobic culture data), and always superior (p<0.001) to the CHX 0.12% + sodium fluoride 0.05% solution. The subjective ratings were in favour of the new CHX formulation when compared with the other CHX formulations, especially for taste (p<0.05).

CONCLUSIONS

The results of this study demonstrated the potential of a new CHX 0.12% + CPC 0.05% non-alcoholic formulation as an effective anti-plaque and anti-inflammatory agent with reduced unpleasant subjective side-effects.

Poor dental status increases acetaldehyde production from ethanol in saliva: a possible link to increased oral cancer risk among heavy drinkers

Epidemiological data support evidence that poor dental status increases oral cavity cancer risk especially among heavy alcohol consumers, but the causality of this finding is unclear. The enzymatic conversion of ethanol by the physiological oral microflora may lead to an accumulation of the highly carcinogenic intermediate acetaldehyde. This study was conducted to evaluate the role of dental status on the microbial production of acetaldehyde from ethanol in saliva. The microbial acetaldehyde production from ethanol was related to the dental score in 132 volunteers. After adjustment for smoking, alcohol consumption, age and gender, poor dental status was shown to lead to an approximately twofold increase in salivary acetaldehyde production from ethanol (P=0.02). Our results could be an important factor underlying the role of poor dental hygiene and status in oral cancer risk associated with ethanol drinking.

Increased salivary acetaldehyde levels in heavy drinkers and smokers: a microbiological approach to oral cavity cancer

The pathogenetic mechanisms behind alcohol-associated carcinogenesis in the upper digestive tract remain unclear, as alcohol is not carcinogenic. However, there is increasing evidence that a major part of the tumour-promoting action of alcohol might be mediated via its first, toxic and carcinogenic metabolite acetaldehyde. Acetaldehyde is produced from ethanol in the epithelia by mucosal alcohol dehydrogenases, but much higher levels derive from microbial oxidation of ethanol by the oral microflora. In this study we investigated factors that might alter the composition and quantities of the oral microflora and, consequently, influence microbial acetaldehyde production. Information about dental health, smoking habits, alcohol consumption and other factors was obtained by a questionnaire from 326 volunteers with varying social backgrounds and health status, e.g. oral cavity malignancy. Paraffin-induced saliva was collected and the microbial production of acetaldehyde from ethanol was measured. Smoking and heavy drinking were the strongest factors increasing microbial acetaldehyde production. Whether poor dental status may alter local acetaldehyde production from ethanol remained unanswered. Bacterial analysis revealed that mainly gram-positive aerobic bacteria and yeasts were associated with higher acetaldehyde production. Increased local microbial salivary acetaldehyde production due to ethanol among smokers and heavy drinkers could be a biological explanation for the observed synergistic carcinogenic action of alcohol and smoking on upper gastrointestinal tract cancer. It offers a new microbiological approach to ethanol-associated carcinogenesis at these anatomic sites.

Inhibition of microflora associated with oral malignancy

Changes in the microflora on oral carcinoma surfaces may lead to both local and systemic infections, which may complicate the morbidity of the patient suffering from oral malignant neoplasms. Thus, anticancer therapy, irradiation, chemotherapy or surgery impairs the defence mechanism of the oral mucosa and is accompanied by proliferation of the mucosal biofilm with overgrowth of yeast and bacteria. This study investigates the inhibition of the biofilm present on the surface of oral squamous cell carcinomas. Biofilm samples were obtained from the central surface (1 cm2) of each lesion in 10 patients (eight male, two female; mean age: 47.6 years; SD +/- 7.6) before any antibiotherapy or tumour treatment. Patients were randomly divided into two groups and were rinsed with Meridol mouthrinse (amine fluoride) or placebo (saline solution) for 7 days. Samples were repeatedly taken from the same site after rinsing. Samples were transported in pre-reduced brain heart infusion broth and cultured within 1 h of removal, using aerobic and anaerobic complete and selective media. Total aerobic and anaerobic counts were determined and isolated bacteria were identified. The median counts of colony forming units (CFU/ml) after rinsing with Meridol were significantly lower for both aerobes and anaerobes than before rinsing with Meridol. (For aerobes before rinsing: 1.35 x 10(6), after rinsing: 7.55 x 10(5); p = 0.025; for anaerobes before rinsing: 1.39 x 10(6), after rinsing: 7.15 x 10(5); p = 0.011. Rinsing with placebo: no significant difference was found. Aerobe median counts before rinsing: 1.17 x 10(6), after rinsing: 1.03 x 10(5), and for anaerobes: before rinsing 1.75 x 10(6), after rinsing: 1.51 x 10(6); p > 0.05 [Wilcoxon test].) It was concluded that 7-days (three times a day) Meridol rinsing significantly reduced the surface biofilm of oral carcinoma compared to rinsing with placebo. Clinical examination indicated no irritation of the mucosa. The mouthrinse was well tolerated by the patients, who commented on a reduction in burning sensation and bad breath. Besides routine oral hygiene, rinsing itself could reduce patient morbidity. The findings of the present study indicate that in addition to any other oral focus, the lesion itself, when ulcerated, should receive direct antimicrobial treatment so as to reduce patient morbidity and enhance quality of life.

Antibacterial agents in the control of supragingival plaque--a review

This review considers the main agents which have been used as antibacterial agents in mouthwashes and other vehicles to inhibit the growth of supragingival plaque. The agents discussed are bisguanide antiseptics, quaternary ammonium compounds, phenolic antiseptics, hexetidine, povidone iodine, triclosan, delmopinol, salifluor, metal ions, sanguinarine, propolis and oxygenating agents. The plaque inhibitory, anti-plaque and anti-gingivitis properties of these agents are considered along with their substantivity, safety and possible clinical usefulness. Clinical trials of these agents that have been published are also reported. The possible clinical uses of antiseptic mouthwashes are finally considered along with some advice about assessing manufacturers claims. Throughout this review the terms plaque inhibitory, anti-plaque and anti-gingivitis have been used according to the clarification of terminology suggested by the European Federation of Periodontology at its second workshop. This defines a plaque inhibitory effect as one reducing plaque to levels insufficient to prevent the development of gingivitis; an anti-plaque effect as one which produces a prolonged and profound reduction in plaque sufficient to prevent the development of gingivitis; and anti-gingivitis as an anti-inflammatory effect on the gingival health not necessarily mediated through an effect on plaque.