Iain Chapple and Elena Figuero take a deep dive into the evidence supporting the use of adjunctive chemical agents such as mouthwash.
When we talk about chemical biofilm control, there are two main ways of application: either local application, such as subgingival delivery into the periodontal pocket (a professional treatment), or topical application, such as toothpaste or rinses (Figuero et al, 2023).
Mouth rinses are ideal from many points of view. They have more favourable pharmacokinetics, they are independent of the patient’s ability to perform toothbrushing, they can reach areas that are difficult to access, and they are generally well accepted by patients (Figuero et al, 2023).
What the evidence shows
We were able to demonstrate evidence from 70 randomised clinical trials, each with at least six months of follow-up, assessing the efficacy of antiseptics. That represents more than 6,000 participants in either test or control groups. However, nearly no evidence was found relating to agents other than antiseptics (Figuero et al, 2020).
All combinations of active antiseptic agents were shown to reduce gingival inflammation to a statistically significant degree compared with the placebo. Importantly, there were no statistically significant differences between patients with gingivitis and those in supportive periodontal care (Figuero et al, 2020).
Taken together, this evidence makes it clear that antiseptic rinses can play a useful role. But mouthwash is only one part of the picture. To put these findings into context, we also need to look at other aspects of oral hygiene and adjunctive treatments (Figuero et al, 2020; 2023).
Brushing and flossing
Patients may use either a power toothbrush or manual brushing. The evidence base favours power toothbrushes, but the effect size – the actual difference – is not that large, and there are cost implications. Many patients cannot afford power brushes, so manual brushing remains perfectly acceptable (Sanz et al, 2020).
Flossing is another area of debate. We suggest not using floss as a form of interdental cleaning for periodontal maintenance patients. The reason is that in maintenance patients the gaps are often too wide, so floss is ineffective; interdental brushes should be used instead. However, this does not mean flossing has no role. If a patient has tight spaces where interdental brushes cannot fit, flossing can still be effective.
So, the flossing story is a little complicated: not recommended for maintenance patients with large gaps, but appropriate for prevention or where interdental brushes are not suitable (Sanz et al, 2020; Slot et al, 2020).
Antibiotics and periodontal care
When you look at systemic antibiotics, the evidence shows there can be some additional benefit when used alongside non-surgical periodontal therapy. However, these improvements are modest, and when the risks, costs and impact on antibiotic resistance are considered, routine use cannot be justified (Sanz et al, 2020).
We therefore make a very strong negative recommendation: systemic antibiotics should not be used for managing periodontitis in general dental practice. There is a small caveat – such as in young patients with generalised grade C periodontitis (previously called aggressive periodontitis) – where antibiotics may be considered. But these cases should be treated in level two or level three care settings in the UK.
In other words, general practice should not prescribe systemic antibiotics for periodontitis; these patients should be referred to specialists. This is part of antimicrobial stewardship and the effort to reduce resistance (Sanz et al, 2020).
Returning to mouth rinses
The foundation of managing gingival inflammation is self-performed mechanical biofilm removal – this is the gold standard. If patients can do it effectively, that is all they need. But if they struggle, adjunctive measures, including antiseptics, may be considered in specific cases (Figuero et al, 2023).
For the first time, we have defined the three agents for which there is the strongest evidence: chlorhexidine, essential oils, and CPC. We do not name specific companies, and industry was not involved in this process, but these are the agents most consistently supported by evidence (Figuero et al, 2023).
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References
- Figuero et al. (2020) Efficacy of adjunctive therapies in patients with gingival inflammation: A systematic review and meta-analysis. Journal of Clinical Periodontology 47(22): 125-143
- Figuero et al. (2019) Efficacy of adjunctive anti-plaque chemical agents in managing gingivitis: A systematic review and network meta-analysis. Journal of Clinical Periodontology 46(7): 723-739
- Figuero et al. (2023) Supra and subgingival application of antiseptics or antibiotics during periodontal therapy. Periodontology 2000. doi: 10.1111/prd.12511
- Sanz et al. 2020) Treatment of stage I–III periodontitis: The EFP S3 level clinical practice guideline. Journal of Clinical Periodontology 47: 4-60
- Slot, DE, Valkenburg C, Van der Weijden, GA. (2020) Mechanical plaque removal in periodontal maintenance patients: A systematic review and network meta-analysis. Journal of Clinical Periodontology 47(S22): 144–159
This article is sponsored by Listerine.
