A new mouthwash consensus – presenting the science and evidence on the ‘spit’ and ‘rinse’ issue – part two

Towards the end of last year, two advisory panels were held by Johnson & Johnson, one of which created a patient-facing consensus on mouthwash use. Here, we continue to look at the science, evidence and guidance that informed the ‘spit’ and ‘rinse’ elements of the consensus, as steered by the chairman, Professor Iain Chapple.

During both events – the National Advisory Panel (NAP) and Hygienist Advisory Panel (HAP) – the overarching aim of the event was to seek the views of both sets of participants in relation to supporting and maintaining oral health in patients between appointments, specifically looking at mechanical cleaning, any limitations, and possible adjunctive support in the form of a chemotherapeutic mouthwash.

Interestingly, one of the speakers on the day, Professor Chris Deery, explored the evidence that indicates caries and periodontal disease are both biofilm driven.

Whilst there are different bacterial species involved in the development of these two diseases, there are also common risk factors, including genetic, socio-economic, racial, cultural, disability, and gender. Given that caries and periodontal disease are therefore inextricably entwined, you cannot address one without the other.

However, there is a difference in how mouthrinses may be used to best effect depending on whether the patient is experiencing caries or periodontal disease, which is something that the latest version (2021) of the evidence-based toolkit for prevention addresses.

The new toolkit message – differentiating between caries and periodontal disease need

The level of evidence in the updated toolkit (2021) for the ‘spit, don’t rinse’ message has been modified to spit, don’t rinse with water, the exact wording for prevention of dental caries in adults being: ‘Spitting out after brushing rather than rinsing with water, to avoid diluting the fluoride concentration’

It has a strong recommendation based on moderate certainty evidence for value of tooth brushing with fluoride (chapter 13, table 1).

The previous toolkit (2017 version) stated: ‘Spit out after brushing and do not rinse, to maintain fluoride concentration levels’

This was considered to be a grade III recommendation, which is evidence from well-designed trials without randomisation, single group pre-post, cohort, time series of matched case-control studies.

Supplementing the knowledge base, two Duckworth papers on rinsing with a mouthwash provide the necessary evidence for the clinician to add a further plaque management step without compromising the residual levels of salivary fluoride (Duckworth et al, 2009).4

For example: ‘…the findings suggest that the oral hygiene regime that included the fluoridated mouthwash may be beneficial against caries compared to the two regimes that involved toothpaste as the sole fluoride source*’ (Duckworth et al, 2009).

It is critical that clinicians understand the new recommendation and the data that underpins the directive – and professional assessment and evaluation must be applied.

Therefore, the recommendation in the consensus to use mouthwash does not detract from the 2021 Toolkit message of spit, don’t rinse with water. Rather, context, professional judgement and a tailored approach to each patient are key for optimal patient outcomes.

The rationale behind the consensus

Ultimately, those present concluded that there was a need for simple recommendations to be made available in relation to plaque management, resulting in the patient-friendly consensus below: ‘Healthy gums don’t bleed when brushed. Twice daily brushing along the gum line and cleaning in between the teeth is essential to support a healthy mouth. Fluoride mouthwashes clinically proven to reduce germs (plaque) offer additional benefit.’

In practical terms, this suggests professional assessment and modification of spit don’t rinse to introduce adjunctive plaque management benefits in certain circumstances.

Below the age of seven

‘Spit, don’t rinse.’

Supporting the 2021 toolkit recommendation in its entirety.

Over the age of seven

‘For better gum health, after brushing spit and then rinse with a fluoride mouthwash that is clinically proven to reduce germs (plaque).’

This represents a modification to support a better outcome for poor gum health when deemed appropriate by the clinician, again based on evidence, context, professional judgement and a tailored approach.

All evidence/data used on the days and subsequently to support the debate and the resulting articles is peer reviewed, published and listed at the end of every piece discussing both consensuses.

Maximising patient support

Adding to the account of how the consensuses were reached, tomorrow will feature the third and final part of this series, focusing on maximising patient support with evidence-based plaque management, so please do return to Dentistry.co.uk to complete the picture.

In the meantime, Johnson & Johnson looks forward to continuing to work in partnership with dental professionals following the insights gained from both the NAP and HAP.

*The two regimes were: (1) brushing with an NaF toothpaste; and (2) brushing with an NaF toothpaste followed by professional flossing (Duckworth et al, 2009).

References

Duckworth RM, Horay C, Huntington E and Mehta V (2009) Effects of flossing and rinsing with a fluoridated mouthwash after brushing with a fluoridated toothpaste on salivary fluoride clearance. Caries Res 43(5): 387-90

Duckworth RM, Maguire A, Omid N, Steen I, McCracken G and Zohoori F (2009) Effect of rinsing with mouthwashes after brushing with a fluoridated toothpaste on salivary fluoride concentration. Caries Res 43(5): 391-6

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