Many clinical studies, some of which are discussed in this supplement, have proven the effectiveness of antimicrobial mouthrinses in controlling plaque and gingivitis. In conjunction with brushing and flossing, the general population often uses these products as part of a daily oral care regimen to prevent or minimize periodontal disease.
The majority of mouthrinses with antiplaque properties contain pharmaceutical-grade denatured alcohol as a vehicle to deliver antimicrobial ingredients.1 Common alcohol-containing rinses include those composed of essential oils (EOs) and chlorhexidine. Alcohol serves the purposes of solubility, preservability and germicidal activity. Concern has been raised regarding a potential for alcohol-containing rinses to cause adverse effects, including increasing the risk of developing oral cancer, xerostomia and burning or irritation.2 However, numerous published studies have demonstrated the safety of alcohol-containing mouthrinses, and they have failed to find any relationship between these products and the above-mentioned safety concerns.
In this article, we address the potential adverse effects and safety factors that have been associated with alcohol-containing antimicrobial rinses, and we describe the data that support their safety. In addition, we discuss factors that may influence patient compliance with a daily regimen of brushing, flossing and rinsing to control dental plaque biofilm.
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ORAL CANCER
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People who consume excessive amounts of alcoholic beverages are at an increased risk of developing oral cancer. As a result, a number of epidemiologic studies have questioned whether alcohol-containing antimicrobial rinses also may be associated with an increased risk of developing disease.
In reviewing the various studies that evaluated the potential for alcohol in antimicrobial mouth-rinses to cause oral cancer, Biological Therapies in Dentistry3 noted the following deficiencies:
- – lack of a dose-response based on frequency and/or duration of mouthrinse use;
- – inconsistent findings among studies;
- – lack of a scientific or biological basis to explain inconsistencies in findings between men and women;
- – absence of a correction for alcoholic beverage ingestion and tobacco use;
- – inclusion of cases of pharyngeal cancer as oral cancer, an improper classification because mouthrinses are used only in the oral cavity.
A recent study comparing an alcohol-containing mouthrinse with a non–alcohol-containing mouthrinse found no clinically meaningful differences between mouthrinses in effects on salivary flow rates or in subjective sensations of dry mouth.
A recent meta-analysis confirmed that the findings in the literature are inconsistent and contradictory and do not fulfill the basic pharmacological requirement of a dose-response to establish a causal relationship between alcohol-containing rinses and oral cancer.4 In addition, Cole and colleagues5 reviewed the results of six relevant studies, and they determined that these studies provided no support for the hypothesis that use of mouthrinses that contain alcohol increases the risk of developing oropharyngeal cancer.
The American Dental Association (ADA) Council on Dental Therapeutics (now the ADA Council on Scientific Affairs) concluded that "based on available data, patients can continue to safely use the therapeutic mouthrinses accepted by the American Dental Association’s Council on Dental Therapeutics and recommended by their dentists."6 Numerous studies have been conducted in accordance with strict ADA guidelines to establish the safety of long-term use of mouthrinses containing EOs and chlorhexidine.7–14 In addition, most ADA-accepted mouthrinses contain alcohol (Kathy Medic, Acceptance Program, Division of Science, American Dental Association, oral communication, Aug. 21, 2006).
We must caution people who are recovering from alcohol abuse that using an alcohol-containing mouthrinse may put them at risk of experiencing a relapse.
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XEROSTOMIA
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Xerostomia is a subjective perception of dry mouth that results from one or more factors disrupting the quantity or quality of salivary flow. Xerostomia can result in oral sequelae, such as mucosal discomfort, difficulties in mastication and swallowing, caries, insomnia, fungal overgrowth and halitosis, that can have a negative impact on a patient’s quality of life. Some causes of xerostomia include use of antidepressant drugs, use of cardiovascular medications, dehydration, radiation therapy for oral and pharyngeal cancer, and systemic diseases such as diabetes and Sjögren’s syndrome.
Consumer-directed literature has speculated that regular use of alcohol-containing mouthrinses can cause desiccation of the oral mucosal membranes and might increase the subjective sensation of dry mouth. However, a recent study comparing the effect of an alcohol-containing mouthrinse (Listerine Antiseptic, Pfizer, Morris Plains, N.J.) with that of a non–alcohol-containing mouthrinse (ACT Anticavity Fluoride Rinse, Personal Products, division of McNeil-PPC, Skillman, N.J.) on salivary flow and symptoms of dry mouth in healthy adults found no clinically meaningful differences between mouthrinses in effects on salivary flow rates or in subjective sensations of dry mouth.15
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BURNING OR IRRITATION
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Some patients have reported oral burning or irritation after using an alcohol-containing mouthrinse. Reducing the alcohol content of the rinse and adding a less intense flavor, such as citrus, have been shown to be successful modifications to reduce the burning or irritation sensation.15 For patients who dislike the taste of an alcohol-containing mouthrinse, diluting the product for the first few days of use and then reaching full strength gradually often results in acceptance.16
We should note that a new non–alcohol-containing chlorhexidine mouthrinse (Chlorhexidine Gluconate Oral Rinse USP, 0.12%, GUM, Sunstar Butler, Chicago) recently was approved for use in the United States. However, chlorhexidine generally is not recommended for long-term use, because it can cause black-brown stains on the teeth, tongue and restorative dental materials that require professional removal.17
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COMPLIANCE AND ADHERENCE
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"Compliance" is a common term used in the oral health care literature to describe a patient’s willingness to follow instructions. Wilson18 defined it as "the extent to which a person’s behavior coincides with medical or health advice." Consumers’ compliance is important to achieve a successful outcome of daily use of an antimicrobial mouthrinse in conjunction with brushing and flossing. Obviously, if patient compliance is lacking, a daily antimicrobial rinse regimen will be suboptimal. Research has shown that only 30 to 50 percent of patients are highly compliant with suggested oral hygiene procedures up to 30 days after receiving instructions.19,20
Understanding noncompliance.
To motivate patients to follow recommended oral hygiene instructions, including the daily use of an antimicrobial mouthrinse, dentists need to understand the factors leading to noncompliance. The majority of patients do not view chronic periodontal disease as threatening, even though their failure to follow dentists’ advice can result in tooth loss, pain and unnecessary expense.18 Patients often perceive oral health care instructions as difficult to follow and time-consuming. Fear of dental treatment and lack of economic resources also have been identified as major reasons for noncompliance.18
Compliance versus adherence.
Shifting the focus from patient compliance to patient adherence may help facilitate behavioral change. "Adherence," a word whose use has increased in the medical literature in recent years, implies patients’ taking an active and autonomous role in their health care.21 When patients understand and value a particular oral health care behavior, they may be more likely to adhere to a home care regimen. The word "compliance," on the other hand, suggests patients’ taking a passive role and acquiescing or yielding to rules they may not be committed to or understand.21
Adhering to oral hygiene instructions.
Although increasing patient adherence may seem daunting to dentists, the following methods, adapted from Wilson’s18 recommendations and developed from practice-based dental research, may help improve patients’ adherence to a daily oral health care regimen that includes brushing, flossing and rinsing:
- – simplify recommendations and use language that patients can understand;
- – accommodate patients’ specific abilities, motivations and lifestyles and modify oral health care instructions accordingly;
- – remind patients of appointments;
- – inform patients by providing them with a written copy of recommendations;
- – provide positive feedback and reinforcement;
- – identify potential noncompliers and discuss with them the possible consequences of noncompliance/nonadherence (that is, increased risk of developing plaque and gingivitis) before therapy begins.
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TRANSTHEORETICAL MODEL
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Most behavioral change programs are designed for people who are ready to change, yet research has shown that only 20 percent of people are willing to take the action needed to change at any given time.22 Prochaska and colleagues,22,23 who have published widely in the area of behavioral change, developed and validated the Transtheoretical Model as a way to understand how people change intentionally. The model outlines five consecutive, predictable stages through which people move in the process of changing behavior. By identifying the stage patients have reached, either through an oral interview or a questionnaire, oral health care professionals may help promote patient adherence with recommended oral hygiene behavior.24
Prochaska and colleagues22,23 defined the stages of change as follows:
- – precontemplation (not intending to change [for example, "I won’t use a mouthrinse"]);
- – contemplation (considering a change [for example, "I might use a mouthrinse"]);
- – preparation (actively planning a change [for example, "I will use a mouthrinse"]);
- – action (actively engaging in a new behavior for the past six months [for example, "I am using a mouthrinse"]);
- – maintenance (taking steps to sustain change and resist relapse [for example, "I have incorporated a mouthrinse into my daily oral care regimen"]).
The table
illustrates patients’ attitudes and behaviors regarding mouthrinse use that may be exhibited at each of the five stages, as well as oral health care recommendations that dentists can deliver to patients at each stage.22,23
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ABSTRACT
ORAL CANCER
