Oral Rinses For Periodontal Health: Simplified · Oral Rinses For Periodontal Health: Simplified Fay Goldstep, DDS, FACD, FADFE E nabling patients to achieve op-timal periodontal

40|oralhealth December 2014 www.oralhealthgroup.com

P R O A C T I V E I N T E R V E N T I O N D E N T I S T R Y

Oral Rinses For Periodontal Health: Simplified

Fay Goldstep, DDS, FACD, FADFE

Enabling patients to achieve op-timal periodontal health is a fundamental goal of the oral

care provider. Periodontal disease is a complex multifactorial pro-cess with a bacterial etiology and an inflammatory progression. A large part of periodontal disease is the result of the host response causing breakdown of surround-ing structures. Pathogenic bac-teria initiate the inflammatory response while chronic inflam-mation supports these bacteria through the production of tissue breakdown products that they use as a food source. Effective elimination of periodontal patho-gens can resolve inflammation. Concurrently curtailing the host inflammatory response can elimi-nate periodontal pathogens from the pocket due to a decreased pathogen-friendly food supply. This is a cyclical process. Once it has begun, the host response must be stopped or there will be a continued downward spiral.

The cyclic timeline of periodon-tal disease begins with bacte-rial colonization, biofilm forma-tion, attachment, inflammation, and host response. Therapies to stop the cascade are effective at different stages of the process. They can be anti-adhesive, anti-septic, and /or anti-inflammatory. Oral rinses are the least invasive of all these therapies. They are an effective method of proactive intervention to help break the

microbiologic and inflammatory cascade that often progresses to periodontal disease.

WHY ORAL RINSES?Oral rinses provide chemothera-peutic agents that compensate for the difficulty in accessing hard-to-reach-areas, poor manual dexter-ity, and lack of compliance to reg-ular mechanical plaque removal.1 Furthermore, only 20 percent of the oral environment is tooth structure. The saliva, tongue and mucosa can serve as reservoirs of periopathogenic bacteria that are routinely missed by mechanical oral hygiene tools.2 Mouth rinsing is preferred by the public because of its ease of use and breath-freshening effect.3 Oral rinses are effective on the three mechanisms of controlling periodontal inflam-mation, as anti-adhesive, antisep-tic and anti-inflammatory agents (Table 1).

The original concept in the etiology of periodontal disease was the “non-specific” plaque hy-pothesis: all plaque is harmful to periodontal health and it is important to curtail the amount of plaque. The currently held view is the “specific plaque” hypothe-sis: specific microbial species cre-ate a toxic periodontal environ-ment among otherwise harmless bacteria.4

Dental Plaque formation pro-gresses as follows:

1. Pellicle—when the clean tooth contacts saliva, it is quickly covered by pellicle (glycopro-teins and polysaccharides). This surface enhances the at-tachment of microorganisms to the tooth, and if left undis-turbed allows for the formation of mature dental plaque.

2. Initial colonizers are mostly non-periopathogenic gram positive sugar metabolizing bacteria.

3. The late colonizers are pro-tein metabolizing anaer-obes (P gingivalis, T forsyth-ensis, T denticola). They have been implicated in periodontal disease and breath malodor.5

4. Disrupting the biofilm fre-quently through various oral hygiene approaches keeps the biofilm in its early stage with non-periopathogenic bacte-ria (since the colonizers always appear in the same sequence).6

5. Dental plaque biofilm starts supragingivally. If it is not adequately controlled at this point, it progresses into the sulcus.

Anti-adhesive and antiseptic oral rinses stop the attachment and maturation of pathogenic bio-film that can progress to peri-odontal disease

ANTI-ADHESIVE AGENTSDelmopinol HydrochlorideA recent chemotherapeutic ap-proach for controlling plaque is

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an agent that inhibits the forma-tion of plaque while having little effect on bacteria or the balance of healthy bacteria in the oral cavity.

Delmopinol hydrochloride in PerioShield (Sunstar USA only, not in Canada at present) is a surface-active agent with low an-timicrobial potency.7 It interferes with biofilm matrix formation by preventing synthesis of glu-can polysaccharide, the substance that keeps biofilm together and attached to oral surfaces. The ad-herence of primary plaque form-ing bacteria is reduced and the emerging biofilm mass is loosely adherent.8 The plaque can then be easily removed by the patient (Fig. 1).

Delmopinol hydrochloride (0.2 percent) mouth rinse (Fig. 2) has shown statistically significant ef-ficacy for reducing plaque and gingivitis.9 There is some stain-ing, but less than with chlorhexi-dine and it is easier to remove. Delmopinol hydrochloride is in-dicated for long term daily use since it has few side effects and maintains the equilibrium of the oral ecosystem.

ANTISEPTIC RINSES Oral antiseptics work by causing

cell death, inhibiting reproduc-tion, or inhibiting the metabo-lism of microorganisms.10 They are formulated to penetrate the plaque matrix to gain access to the pathogens.

Effective antiseptic mouthrinse must have11:1. Non-toxicity to oral tissues and

minimal side effects.2. Efficacy against specific

pathogens.3. Adequate bioavailability of ac-

tive ingredients.4. Stability.5. Substantivity—ability to bind

to tissue surfaces and be re-leased slowly for continued therapeutic effect and be resis-tant to dilution by saliva.

6. The ability to maintain ecolog-ical balance—no overgrowth of microorganisms or bacterial resistance.

Three categories of antiseptic ingredients predominate in the oral rinse market: essential oils, chlorhexidine and cetyl pyridin-ium chloride.

Fixed Combination Of Essential Oils (EO)Essential oils are obtained by the steam distillation of the odifer-ous oily portions of plant matter. They can be derived from flowers,

leaves, bark, woods, roots, rhi-zomes, fruits and seeds. Due to the bactericidal properties of es-sential oils, they are increasingly popular alternatives to synthetic chemical products.

Listerine (Johnson & Johnson), a fixed combination of four es-sential oils (thymol, menthol, eu-calyptol and methyl salicylate), has been in clinical use since the late 19th century (Fig. 3). It has the longest clinical history of the antiseptic agents and minimal reported adverse effects.12

A 30-second rinse penetrates biofilm and provides a signifi-cant antimicrobial effect on the embedded bacteria including periopathogens.13

Mechanism of action: 1. Morphological alteration to the

cell surface after a 30-second exposure leads to cell death for specific periopathogens such as A actinomycetemcomitans.14

2. Denatures protein.3. Alters bacterial enzyme

activity.4. Extracts bacterial endotoxins

from gram negative pathogens.5. Affects growth rate of early

plaque forming bacteria as well as disrupting the forma-tion of biofilm.15

TABLE 1—Categories of Oral Rinses.

FIGURE 1—Delmopinol hydrochloride interferes with biofilm matrix formation. The biofilm mass becomes loosely adherent and easily removed by the patient. Courtesy of Sunstar.



EO also has anti-inflammatory effects:16

1. Inhibits prostaglandin formation.

2. Scavenges free radicals gen-erated by neutrophils in inflammation.

Unlike chlorhexidine and cetyl pyridinium chloride, EO has a neutral electrical change, which

decreases undesirable side effects so that it:1. Does not interact with charged

ions found in dentifrices and mouth rinses to decrease efficacy.17

2. Is not inhibited by proteins in blood serum that may inacti-vate antimicrobial agents.18

3. Does not precipitate dietary chromogens that lead to tooth

staining.19

However, EO has no substan-tivity. The effect stops when the rinse is removed. Since its action is rapid, this may not be clinically significant.

EO has been shown to effec-tively penetrate biofilm to kill bacteria, comparable to the action of chlorhexidine.20

Systematic review studies on EO with or without alcohol showed no significant difference in efficacy. Alcohol contributed no added therapeutic value.21 Lister-ine is now available in non-alcohol based formulations.

Chlorhexidine (CHX)Chlorhexidine gluconate has been both a medical and surgical dis-infectant since the 1950s. It has been used in the oral cavity since the 1970s.

CHX binds via adsorption to surfaces in the mouth as well as the pellicle and saliva achieving high substantivity. It is both bac-teriostatic and bactericidal, de-pending on concentration.

Mechanism of action (Fig. 4):

The positively charged (cationic) CHX molecule binds strongly to the negatively charged (anionic) bacterial cell surface, altering the integrity of the cell wall. CHX then binds to the inner cell mem-brane leading to increased perme-ability and cell damage, rupture of the cell membrane, leakage of cell contents and eventual bacte-rial cell death.22

CHX has a double positive charge and is therefore extremely inter-active with anions. This helps efficacy but also produces unfa-

FIGURE 2—PerioShield (Sunstar USA only, not in Canada at present time), a Delmopinol hydrochloride (0.2 percent) mouth rinse.

FIGURE 3—Listerine (Johnson & Johnson) is a fixed combination of four essential oils (thymol, menthol, eucalyptol and methyl salicylate). It comes in alcohol or alcohol free formulations.

FIGURE 4—The positively charged CHX molecule binds first to the negatively charged bacterial cell surface and then to the inner cell membrane leading to rupture, leakage of cell contents, and bacterial cell death.

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vorable side effects:1. Precipitation of negatively

charged dietary chromogens from food and drinks (such as tea) causing staining.23

2. Its efficacy may be compro-mised by cationic detergents (sodium lauryl sulfate) and anionic fluoride ions found in toothpaste.17 There must be a 30 minute window between

using toothpaste and rinsing with CHX.

3. Taste alterations and nausea.4. Enhanced supragingival calcu-

lus formation.24

For the above reasons, CHX rinses are prescribed for short duration therapy only to control acute or severe bouts of periodon-tal disease.

CHX has a broad spectrum effect against gram-positive and gram-negative bacteria (includ-ing many periopathogens), some fungi and yeasts (including Can-dida) and some viruses (includ-ing HIV). No bacterial resistance with long-term use has been re-ported. 0.2 percent CHX rinse was previously popular in Eu-rope. Less concentrated formula-

FIGURE 5—GUM PAROEX (Chlorhexidine gluconate 0.12 percent) (SUNSTAR Canada) is available alcohol free.

FIGURE 6—The positively charged CPC binds to the bacterial surface to cause disruption of bacterial cell membrane function, leakage of cytoplasmic material, and bacterial cell death. Reprinted with permis-sion: The Journal of Contemporary Dental Practice, vol. 6, no. 1; 2005.

FIGURE 7—The unique vehicle found in Crest Pro Health (Procter & Gamble) has been shown to increase the product’s bioavailability when compared with other CPC containing mouth rinses. This product delivers 0.07 percent CPC in a high-bioavailable, alcohol-free formulation.

FIGURE 8—THE CHRONIC MALADAPTIVE INFLAMMATORY RESPONSEPeriodontal tissues: mature plaque, breakdown of the periodontal ligament, ulcer-ations of the epithelial lining, apical migration of pathogenic bacteria such as P. gingivalis, and bone resorption. Cellular level: an increased number of neutrophils, macrophages, etc. Biochemical level: increased proinflammatory cytokines regu-late release of MMPs (involved in bone resorption and collagen degradation). Collagen fragments provide nutrition for pathogenic bacteria. Production of pros-taglandin, which is involved in bone resorption.



tions (0.12-0.1 percent) were made available to reduce side effects while maintaining efficacy. Most of the popular formulations in Canada are 0.12 percent.

By binding directly to the tooth surface, CHX occupies sites that could be used by pellicle and bacteria, thereby inhibiting early biofilm formation.25 CHX has been shown to penetrate the biofilm and kill embedded pathogens.13 Tight binding to oral structures allows it to be released slowly into the mouth and sustained for up to 12 hours leading to high substantivity.26 CHX rinses are often used as a benchmark control and new prod-ucts are measured according to it. It is considered the “gold-stan-dard”.22 Other chemotherapeutic agents may show either a purely immediate effect or limited per-sistence. CHX’s persistence is the basis of its efficacy.

CHX is especially appropriate for specific populations whose oral hygiene is compromised, such as the elderly, physically-limited and mentally handicapped. Long-term use may be appropriate in these instances.22 Formulation without alcohol has been shown to be as clinically effective in controlling plaque and ginigi-val inflammation as the alcohol based product.27 GUM PAROEX, Chlorhexidine gluconate 0.12 per-cent (SUNSTAR Canada), is now available in an alcohol free formu-lation (Fig. 5).

Cetyl Pyridinium Chloride (CPC)Cetyl pyridinium chloride is a cationic, surface-active agent with bactericidal and bacterio-static activity against bacterial pathogens and yeast. While it is bactericidal to both gram positive and gram negative bacteria, it is more effective against the for-

mer. CPC has a significant inhibi-tory effect on plaque and gingival inflammation.28

Mechanism of action (Fig. 6):

The cationic CPC molecule binds to teeth and bacterial cell walls. Binding interferes with bacterial colonization on the tooth surface. CPC is effective against early colonizers in immature den-tal plaque, reducing the formation of mature biofilm. Binding to the bacterial surface causes disrup-tion of bacterial cell membrane function, leakage of cytoplasmic material, and collapse of the in-tracellular equilibrium leading to death of the microorganism.29

The formulation of vehicle in-gredients, preservatives, stabiliz-ers, colors, etc may impact on the bioavailability of CPC. The unique vehicle found in Crest Pro Health (Procter & Gamble)

FIGURE 9—AO Pro Rinse from PerioSciences contains anti-oxidants with potential beneficial clinical effects.

FIGURE 10—PeriActive botanical rinse has been formulated with three bo-tanical extracts at specific ratios that are antimicrobial, anti-inflammatory, and promote tissue repair.

FIGURE 11—Rinses that contain xylitol may function to promote enhanced health of both hard and soft tissues. X-PUR OptiRinse (Oral Science) is a NaF anti-caries rinse containing 10 percent xylitol



(Fig. 7) has been shown to in-crease the product’s bioavailabil-ity when compared with other CPC containing mouth rinses.30 This product delivers 0.07 per-cent CPC in a high-bioavailable, alcohol-free formulation. Several studies have shown this product to provide significant antiplaque and antigingivitis benefits.31,32

Side effects are due to its cationic structure:1. Staining has a similar dietary

etiology to CHX but it is less severe.33

2. CPC can adversely interact with other charged ions in den-tifrices and rinses (like CHX).

CPC binds strongly to tooth structure and biofilm giving it good substantivity, although not as good as CHX.17

Efficacy Of Antiseptic RinsesIn a systematic literature re-view34 CHX, CPC and EO were all determined to have benefi-cial antiplaque and antigingivi-tis effects when used long-term in conjunction with mechanical oral hygiene tools. CHX had the most consistent results. CHX has been shown to be more effective than EO in plaque reduction but is comparable in anti-gingivitis properties.35

ANTI-INFLAMMATORY PRO-HEALING RINSESIn the healthy periodontium, the innate response attempts to elim-inate foreign bodies and is protec-

tive against injury or infection.36 Periodontal disease results from the body’s failure to turn off its inflammatory response to in-fection. The result is chronic mal-adaptive inflammation.37

This produces an environment that exudes a rich source of nu-trients such as degraded host pro-teins that are specifically what pathogenic bacteria need for survival and growth. Bacterial pathogens continue to exploit this environmental change, leading to more bacteria, more inflamma-tion, bone resorption and a perfect niche space (deeper periodontal pockets) where everything can continue undisturbed.38

In chronic unresolved inflamma-tion (Fig. 8):1. Cellular and molecular re-

sponses to bacterial challenges involve constant adjustment and regulatory feedback.39

2. Neutrophils and other cells secrete cytokines (cell media-tors that the body uses for communication).

3. Cytokines promote the release of MMPs—matrix metallo-proteinases (proteolytic en-zymes implicated in normal bone remodeling, including collagenases).40

4. Tissue destruction is not uni-directional, constantly being adjusted by host–bacterial interactions.39

5. Alveolar bone destruction is the result of the uncoupling of the normally tightly coupled processes of bone resorption

and formation.39

6. Prostaglandin production plays a role in alveolar bone resorption.

The inappropriate host re-sponse is the major contribut-ing factor for chronic maladaptive periodontal disease. A deficient host response initiates the chronic condition and a too vigorous re-sponse leads to further tissue breakdown.41

Emerging data suggests that periodontal pathogens that are present in low numbers use in-flammation to provide an envi-ronment to foster their growth. Control of inflammation may ac-tually return the composition of a pathologic biofilm to a healthy one. The implication is that the pathologic biofilm is a result of periodontal inflammation, as well being the cause of periodontal inflammation. It is the proverbial chicken and egg scenario.

Anti-inflammatory rinses at-tempt to break this pathologic cycle. They are recent arrivals on the oral rinse scene. They are marketed under two major clas-sifications of ingredients: anti-oxidants and botanicals (essential oils). There is some overlap, but they will be discussed separately for clarity.

Anti-OxidantsA free radical is an atom or group of highly reactive atoms that have one or more unpaired electrons. They are formed as intermediates during normal biochemical reac-tions. When they are generated in excess or not controlled, radi-cals can damage cells. Radicals of most concern in biological sys-tems are derived from oxygen and are known as reactive oxygen spe-cies (ROS). ROS are generated by

The implication is that the pathologic biofilm is a result of periodontal inflammation, as well being the cause of periodontal inflammation. It is the

proverbial chicken and egg scenario



neutrophils in host defense to kill invading pathogens, thus raising the level of ROS during inflam-mation. Antioxidants neutralize damaging free radicals that pro-duce disease states.

There is promising new re-search on topical application of anti-oxidants on oral tissue to pro-mote gingival healing.42 Dental manufacturers such as PerioSci-ences (https://www.periosciences.com), have incorporated antiox-idants into toothpastes, mouth rinses/mouthwashes, lozenges, gels, oral sprays, breath freshen-ers, and other dental products for the control of gingival and peri-odontal diseases (Fig. 9). There are potential beneficial clinical effects43 but due to the inherent unstable nature of antioxidants, simply adding an antioxidant to

an oral preparation may not pro-duce an effective agent.42

Patients with periodontal dis-ease have a reduced level of gin-gival and serum antioxidants.44 It is not yet clear whether the lower level of antioxidants contributes to the cause of periodontitis or whether the antioxidant level is reduced as a result of increased ac-tion in neutralizing free radicals.45

In vitro studies have shown anti-oxidants to have a beneficial effect on fibroblast migration and proliferation during gingival heal-ing or periodontal repair.46 Fibro-blasts are critical in the healing process. Their collagen deposition restores tissue strength, integrity and structure.47

Botanicals (Essential Oils)Harnessing the antimicrobial properties of plant matter is not new. Listerine, a fixed combina-tion of essential oils, has been in clinical use for over a hundred and fifty years. However, the concept of using the anti-inflammatory and healing (not only the antimi-crobial) properties of botanicals is now being explored in new oral rinses. The ideal anti-inflamma-tory rinse is one that targets pro-inflammatory cytokines and enzymes involved in oral inflam-mation and tissue destruction.48

PeriActive botanical rinse (http://izunpharma.com/) (Fig. 10) has been formulated with three botanical extracts at specific ra-tios that are antimicrobial, anti-inflammatory, and promote tissue repair. The concept is to help mod-

ulate the host inflammatory re-sponse and break the inflamma-tion cycle. The anti-inflammatory and tissue repair properties of the botanical extracts have been dem-onstrated in multiple bioassays during product development. The bioassays showed inhibition of in-flammatory cytokines and their tissue destructive products (pros-taglandin, MMPs); tissue healing products were increased.

The three herbs are: 1. Centella asiatica (gotu kola),

which has been shown to in-crease effective collagen and is used in wound healing.49

2. Sambucus nigra, which in-hibits pro-inf lammatory properties of two periodontal pathogens (P gingivalis and A

actinomycetemcomitans).50 3. Echinichia purpurea, which

has antiviral, antibacterial and anti-cytotoxic effects.51

The botanical rinse has demon-strated an ability to reduce gin-gival inflammation.52 A study on managing post surgical inflam-mation around implants found the rinse clinically equivalent to 0.12 percent CHX in controlling plaque but more effective than CHX in reducing inflammation at implant sites and areas of surgi-cal incision.53

XylitolXylitol is a well researched anti caries agent. Recently, it has also been shown to act as an anti-in-flammatory agent, by decreasing the production of inflammatory cytokines in periodontal infec-tions.54 These finding bring to light the potential use of xylitol in periodontal as well as anti-caries rinses. X-PUR OptiRinse (Oral Science) is a NaF anti-caries rinse containing 10 percent xylitol (Fig. 11).

CONCLUSIONThere are many tools available, both mechanical and chemothera-peutic, to maintain periodontal health. Oral rinsing is a patient-friendly, minimally invasive way to proactively control the complex inflammatory cycle. The oral care provider must understand the pathogenic cycle, the needs of the patient and the specifics of the oral rinses. With this knowledge, the clinician is in a position to counsel the patient on maintain-ing good periodontal health for a lifetime. OH

Dr. Fay Goldstep has been a featured speaker in the ADA Seminar Series and has lectured at the American Dental Associa-tion, Yankee, American Academy

The ideal anti-inflammatory rinse is one that targets pro-inflammatory cytokines and enzymes

involved in oral inflammation and tissue destruction



of Cosmetic Dentistry, Academy of General Dentistry, and the Big Apple Dental Conferences. She has lectured nationally and interna-tionally on Proactive/Minimal In-tervention Dentistry, Soft-Tissue Lasers, Electronic Caries Detec-tion, Healing Dentistry and In-novations in Hygiene. She has served on the teaching faculties of the postgraduate programmes in Aesthetic Dentistry at SUNY Buf-falo, University of Florida, Univer-sity of Minnesota and University of Missouri-Kansas City. She is a Fellow of the American College of Dentists, International Academy for Dental-Facial Esthetics, Amer-ican Society for Dental Aesthetics and the Academy of Dentistry In-ternational. She has been listed as one of the leaders in continuing ed-ucation by Dentistry Today since 2002. She sits on the editorial board of Oral Health (healing/preventive dentistry). Dr. Goldstep is a consultant to a number of dental companies, and maintains a private practice in Markham, Canada, and can be reached at [email protected].

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Oral Rinses For Periodontal Health: Simplified · Oral Rinses For Periodontal Health: Simplified Fay Goldstep, DDS, FACD, FADFE E nabling patients to achieve op-timal periodontal