by Stuart Fischman, DMD
In the field of dentistry and research, one of the primary goals is identifying preventive strategies to reduce oral disease. The last decades have seen great improvements in products and devices that aid the mechanical removal of disease-causing plaque. Research has focused on chemical agents that can supplement patient-dependent methods. Success in this area continues to depend greatly on our patients, who must do their part in maintaining their own oral health.
The most important step in the fight against dental diseases is the daily disruption of plaque buildup. If microbial plaque development is not controlled, it results in gingivitis. In less than 20 days, both supragingival and subgingival plaque can form calculus. The subgingival calculus contributes to the progression of periodontal disease. Brushing and flossing, the mechanical methods that are the most widely accepted for controlling bacterial plaque, have limitations that can prevent individuals from achieving optimum oral health.
Motivating patients to practice proper techniques and maintain compliance is not always easy. Because of these challenges, it is not surprising that more than half of adults in the U.S. have gingivitis on an average of three to four teeth. Two-thirds of the population has subgingival calculus and about one-third has periodontitis on three to four teeth.
Research presented earlier this year at the IADR meeting demonstrated that rinsing with Listerine® Antiseptic Mouthrinse (Pfizer Consumer Health Care, Morris Plains, N.J.) is as effective as daily flossing in improving gingival health and reducing plaque, particularly in the hard-to-reach areas of the mouth. These findings further support the benefit of chemotherapeutic products and their role in disrupting plaque and gingivitis.
In the mid 1980s, researchers first demonstrated the therapeutic value of antimicrobial mouthrinses and their efficacy in preventing and reducing plaque and gingivitis. Before that time, mouthrinses were accepted primarily for cosmetic reasons, both by clinicians and the public. Antimicrobial mouthrinses contain chemical agents that either kill microorganisms or interfere with their reproduction or metabolism. Based on individual patient needs, clinicians began recommending mouthrinses as adjuncts to mechanical plaque control. Recent, long-term studies further validate this recommendation by providing positive proof of their clinical effectiveness.
Two six-month clinical trials at different research centers compared the efficacy of brushing and antimicrobial mouthrinse use to brushing and flossing on the inhibition of plaque and gingivitis. In both studies, Listerine was clinically comparable to flossing in controlling interproximal gingivitis and better for plaque reduction. All comparisons were versus a control.
The two randomized, evaluator-blinded, controlled-parallel group studies included more than 600 patients ages 18 to 63, with mild to moderate levels of gingivitis, but without moderate or advanced periodontitis.
Subjects were randomized into three groups: brushing and flossing; brushing and Listerine antiseptic mouthrinse; and a control: brushing and placebo mouthrinse.
All subjects received a prophylaxis, toothbrush, and fluoride dentifrice. Subjects in the flossing group were trained to floss by a dental professional and demonstrated correct flossing technique at baseline. These subjects flossed once a day, the frequency generally recommended for flossing.
Subjects in the rinsing groups used 20 ml. of their assigned rinse (Listerine or placebo) for 30 seconds twice a day, which is the usual antiseptic mouthrinse regimen. All subjects were monitored monthly for compliance with their assigned regimen and re-examined at three and six months after baseline.
In patients who rinsed twice a day with Listerine, interproximal plaque accumulation was reduced by 37.5 percent and 20 percent (p<0.001) at the two study sites, respectively. In comparison, those patients who flossed daily showed a 2.1 percent (p = 0.305) and 3.4 percent (p=0.134) reduction in interproximal plaque accumulation, a reduction that was not significantly different from the control group. In addition to site-specific plaque reduction, patients who rinsed twice a day with Listerine showed a 7.9 percent and 11.1 percent (p<0.001) reduction in interproximal gingivitis vs. an 8.3 percent (p<0.001) and 4.3 percent (p=0.006) reduction in those who flossed daily. When deciding what regimen to recommend, clinical judgment should be based on the proven scientific validity of the products, as well as their relationship to each patient's specific symptoms.
Creating a regimen tailored to an individual's specific needs and abilities will most likely yield the best results. Dentists should take every opportunity to repeatedly convey the proper usage, value, and purpose of each item and each step in the oral healthcare routine. They also should explain how all of these adjuncts work in combination to inhibit plaque growth. Establishing these interactions is a valuable way to increase compliance.
Another tool in the fight against widespread oral disease is increased public awareness of the importance of oral health on a larger scale, and the dissemination of current literature and the findings of clinical studies. By getting involved with our communities and with educational outreach programs, we can create additional forums to promote the cause of proper oral hygiene.
Aiding in this goal is the U.S. Surgeon General's report on oral health. In 2000, the U.S. Surgeon General, Dr. David Satcher, released Oral Health in America: A Report of the Surgeon General, which was commissioned by Health and Human Services Secretary Donna E. Shalala. The findings further validate what our profession has long known: that there is an undeniable connection between oral health and overall health.
The report charts a broad course of action, including an expansion of the science base to determine the people and populations most at risk for serious oral health conditions. It also charts the acceleration of the application of research findings into targeted and effective health prevention methods, and promotes of the adoption of these findings by the public and health professions. This support certainly will help our profession as we move forward.
Instruction, demonstration, and encouragement can help our patients achieve the results we seek however, home care routines practiced by our patients ultimately will provide the greatest long-term benefits. Brushing and flossing should not be replaced by brushing and rinsing alone. The clear advantage of adding adjunctive rinse therapy should be highlighted for patients at risk of periodontal disease.
