Professional Documents
Culture Documents
of an antimicrobial mouthrinse
Michael L. Barnett, DDS
he concept of mouth-
T rinsing as an oral
hygiene measure dates
back thousands of years,
ABSTRACT
Background. This article reviews the rationale
✷
J
A D
A
®
✷
N
CON
with the first reference to
IO
it as a formal practice being attrib- for incorporating effective antimicrobial mouthrinses
T
T
A
N
I
uted to Chinese medicine in the into a daily oral hygiene regimen along with mechan- U
IN U
C
G ED
ical plaque control methods. A 2
year 2700 B.C.1 A variety of ingredi- RT
ents and combinations have been Types of Studies Reviewed. The author ICLE
used for this purpose by various cul- reviewed studies demonstrating the essential etiologic role of a pathogenic
tures in the past, including mix- dental plaque biofilm in the development of gingivitis, as well as studies
tures of betel leaves, camphor, and indicating that most people fail to maintain a level of mechanical plaque
cardamom or other herbs2(p78); a mix- control sufficient to prevent disease. In addition, he did a brief review of
ture of salt, alum and vinegar3; and studies of oral microbial ecology that identified the oral mucosal tissues as
anise, dill and myrrh in white a reservoir of bacteria that colonize tooth surfaces, and he summarized
wine.2(p78) six-month clinical studies of marketed antimicrobial mouthrinse ingredi-
However, it is only relatively ents and products.
recently that the use of therapeutic Conclusions. There is a twofold rationale for daily use of antimicrobial
antimicrobial mouthrinses has been mouthrinses: first, given the inadequacy of mechanical plaque control by
based on a well-documented scien- the majority of people, as a component added to oral hygiene regimens for
tific and clinical rationale. This the control and prevention of periodontal diseases; second, as a method of
began in the 1960s with the clear delivering antimicrobial agents to mucosal sites throughout the mouth that
demonstration of the relationship harbor pathogenic bacteria capable of recolonizing supragingival and
between plaque accumulation and subgingival tooth surfaces, thereby providing a complementary mechanism
the development of gingivitis.4 It is of plaque control. The efficacy of several mouthrinse ingredients and
interesting to note that a few years products is supported by published six-month clinical trials.
later, a prominent periodontist Clinical Implications. The daily use of an effective antiplaque/
wrote that “for the immediate antigingivitis antimicrobial mouthrinse is well-supported by
future, plaque control must rest a scientific rationale and can be a valuable component of oral hygiene
with mechanical means” because of regimens.
a lack of long-term studies to con- Key Words. Plaque control; antimicrobial mouthrinse; gingivitis;
firm the effectiveness and safety of periodontitis; oral bacterial reservoirs.
antimicrobial mouthrinses.5 The JADA 2006;137(11 supplement):16S-21S.
conduct of such long-term studies
was facilitated by the development
Dr. Barnett is a clinical professor, Department of Periodontics/Endodontics, School of Dental Medicine,
of guidelines by the American University at Buffalo, The State University of New York. Address reprint requests to Dr. Barnett at 112
Dental Association (ADA) Council Hidden Ridge Common, Williamsville, N.Y. 14221-5785, e-mail “mlbgums@aol.com”.
Fixed Combination Listerine Antiseptic, Cool 13.8-56.3 14.0-35.9 Lamster and colleagues,52
of Essential Oils ‡ Mint Listerine, FreshBurst Gordon and colleagues,53
Listerine, Natural Citrus DePaola and colleagues,54
Listerine (Pfizer, Morris Overholser and colleagues,55
Plains, N.J.)† Charles and colleagues,56
Charles and colleagues,57
Sharma and colleagues58
Cetylpyridinium
Chloride
0.05 percent Viadent (Colgate-Palmolive, 28.2 24.0 Allen and colleagues59
New York)
0.07 percent Crest Pro-Health Rinse 15.8 15.4 Mankodi and colleagues60
(Procter & Gamble,
Cincinnati)
recolonize the tooth surface and initiate the mucosal surfaces have indicated that the oral
process of plaque re-formation. We also know that mucosae—in particular the dorsum and lateral
after thorough root débridement in periodontal borders of the tongue and, to a lesser degree, the
pockets, the subgingival root surfaces eventually buccal mucosae—serve as reservoirs for bacteria
will be repopulated with a potentially pathogenic and can be the source of pathogens that recolo-
flora. Where do the repopulating bacteria come nize teeth after a dental prophylaxis or peri-
from, and is there anything that can be done to odontal therapy.33,38-44 To illustrate this, in a study
diminish the overall intraoral bacterial burden? in which conventional periodontal therapy was
The supragingival and subgingival tooth sur- shown to significantly decrease the subgingival
faces are, in fact, part of a larger ecological prevalence of three putative pathogens, there was
system that includes oral mucosal surfaces and not a concomitant reduction in the prevalence of
saliva. In the adult, the oral mucosal tissues are these organisms on oral mucous membranes.40 It
estimated to compose approximately 80 percent of also should be noted that supragingival plaque
the total surface area, with the teeth providing has been shown to harbor periodontal pathogens
the other 20 percent.33 These surfaces are a source and thus can serve as a reservoir of these species
of bacteria; in fact, the oral mucosal surfaces in for the spread to, or reinfection of, adjacent sub-
infants have been shown to be colonized by bac- gingival sites.45
teria,34 including gram-negative periodon- The finding that the oral mucosae serve as
topathogens,35,36 well before the time of tooth reservoirs of pathogenic bacteria that can be
eruption. Bacteria are shed constantly from transferred to the tooth surface provides a further
mucosal and tooth surfaces into saliva and car- rationale for supplementing mechanical plaque
ried to other areas of the mouth, which they can control methods with effective antimicrobial
colonize in turn. As unstimulated saliva often mouthrinses; such products would deliver antimi-
contains from 5 × 107 to 1.0 × 108 bacteria per mil- crobial agents to mucosal sites throughout the
liliter, the oral surfaces constantly are bathed in mouth that are unaffected by mechanical plaque
suspended microorganisms.37 Studies comparing control methods. Studies have demonstrated the
the bacterial composition of supragingival and effectiveness of rinsing with an antimicrobial
subgingival plaque with that of saliva and various mouthrinse in significantly reducing both