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1 UvA-DARE (Digital Academic Repository) Use of brushes, rinses, and cooling solutions in oral care van der Sluijs, E.; Slot, D.E.; van der Weijden, G.A. Published in: Link to publication Citation for published version (APA): van der Sluijs, E., Slot, D. E., & van der Weijden, G. A. (2017). Use of brushes, rinses, and cooling solutions in oral care., 3(2), General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulations If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. UvA-DARE is a service provided by the library of the University of Amsterdam ( Download date: 08 Oct 2018

2 EVIDENCE SUMMARIES AND CRITICAL APPRAISALS Use of Brushes, Rinses, and Cooling Solutions in Oral Care Eveline van der Sluijs, RDH, MSc, PhD(c) 1 Fridus A. van der Weijden, DDS, PhD 2 Dagmar Else Slot, RDH, PhD 3 Oral hygiene is key to oral health, and mechanical methods of oral hygiene are considered the gold standard method for plaque control. An individual s motivation and manual skills contribute to optimal oral hygiene self-care. But certain oral hygiene recommendations, such as to prerinse with water and to start tooth brushing from the lingual aspect first, do not receive scientific support. Evidence suggests that in addition to tooth brushing, gingivitis can be further reduced with use of a mouthwash containing either chlorhexidine or essential oils, and mouthwashes with active ingredients can also be used as a cooling solution during nonsurgical therapy in 1 Researcher, conjunction with ultrasonic devices. However, plain tap water was shown to be a sufficiently Department of effective cooling solution by itself. There is also evidence that drinking or rinsing with water Periodontology, could positively affect morning bad breath. A regimen of tooth brushing with tongue cleaning Academic Centre for and rinsing can be beneficial for improving oral malodor. Int J Evid Based Pract Dent Hygienist Dentistry Amsterdam 2017;3: doi: /ebh.140 (ACTA), University of Keywords: brushing, dental plaque, gingivitis, oral malodor, prevention Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands. 2 Professor, Department of Periodontology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands. 3 Researcher, Department of Periodontology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands. Correspondence to: Dr Eveline van der Sluijs Department of Periodontology Academic Centre for Dentistry Amsterdam (ACTA) University of Amsterdam and Vrije Universiteit Amsterdam Gustav Mahlerlaan LA Amsterdam, The Netherlands e.vd.sluijs@acta.nl 2017 by Quintessence Publishing Co Inc. Oral hygiene is key to oral health, and there are several recommendations for achieving optimal oral hygiene. Mechanical methods of oral hygiene are considered the gold standard method for plaque control, 1 and it is well established that controlling dental plaque is fundamental in order to accomplish and maintain periodontal health. 2 Tooth brushing is effective for reducing dental plaque, 3 and dental care professionals (DCP) generally recommend brushing with a fluoride dentifrice twice daily for 2 minutes each time. 4 Brushing Substantial evidence has indicated that tooth brushing and other mechanical cleaning procedures can reliably control plaque, provided that cleaning is sufficiently thorough and performed at appropriate intervals. 3 The ideal brushing technique is one that effectively removes plaque in the least possible period of time with no damage to the tissues in the oral cavity. 5 In general, brushing methods can be classified based on the position and movement of the toothbrush. Recommendations on tooth brushing techniques differ with respect to how many times a day individuals should brush their teeth and for how long. No particular brushing technique has been found to be clearly superior, but the most common technique recommended is the modified Bass technique. 6 Tooth brushing methods must 145

3 Evidence Summaries and Critical Appraisals be implemented according to the patient s needs, 7,8 and it is recommended that oral hygiene instructions be given during a series of appointments to allow the patient to receive immediate feedback and thus improve the patient s oral hygiene. The design of toothbrushes or a specific tooth brushing method are likely of secondary importance for each individual 9 the individual s motivation and manual skills, as well as the complexity of the dentition, all contribute to an optimal effect. 10 Thus, it is considered important to make the individual aware of their own ability to maintain proper dental health with minimal participation of the DCP, whose role could be limited to one that provides advice and encouragement. 11 However, changing health behavior in case of persistent noncompliance is probably one of the most challenging goals for a DCP. 12 Brushing sequence The lingual surfaces of the mandibular teeth usually harbor an abundance of plaque and are difficult to clean. 13 Therefore, a patient should pay special attention to these surfaces by brushing them first. 14 Recently, a randomized controlled clinical trial 15 (RCT) was published that used a split-mouth design to evaluate this specific brushing sequence. Participants were asked to refrain from any oral hygiene procedure for 48 hours before a subsequent fullmouth plaque score was performed. Two randomly chosen contralateral quadrants were used to start brushing from the lingual surfaces first, and the opposing two quadrants were used to start brushing from the buccal surfaces. After the brushing exercise was completed, postbrushing scores were assessed. Beginning with the lingual surface of the mandible resulted in a mean reduction of plaque score of 55%, compared to 58% when the brushing exercise began with the buccal surface. These scores were not statistically different. The difference in mean plaque index score reduction between brushing sequences was 0.04 and also not significant. Furthermore, none of the subanalyses for the buccal, lingual, and approximal surfaces revealed any significant differences. Within the limitations of this study, the recommendation to start tooth brushing from the lingual aspect first does not receive scientific support. 15 It has also been suggested that when a prebrushing rinse is used, dental plaque might be more easily removed with a toothbrush. The aim of another recently published study 16 was to evaluate whether rinsing the oral cavity with water before tooth brushing resulted in an additional beneficial effect on dental plaque removal. A research design similar to that described above 15 was used. The brushing and rinsing procedure was supervised, and brushing time was tracked by a timer. The participants brushed each quadrant for 30 seconds. When a rinse with 15 ml of water for 1 minute was performed before the manual tooth brushing, plaque scores were reduced by 58%, compared to 57% when participants rinsed with water after brushing. The difference of 0.04 in the mean plaque index reduction score between the two brushing regimens was not significant. Furthermore, subanalyses for the buccal, lingual, and approximal surfaces revealed no significant differences. The results do not support that rinsing with water before brushing results in a greater effect than mechanical plaque removal by a manual toothbrush. Adjunctive rinsing Chemotherapeutic agents have the potential to improve oral health beyond tooth brushing alone. 17 Most types of mouthwash use either a water or water-alcohol base, with flavor, surfactant, humectants, and active ingredients added. Several formulations are marketed with specific chemical agents for the management of plaque and gingivitis. When compared to negative controls (frequently water), only a small number of these provide statistically significant improvements for plaque and gingivitis indices. 18,19 Over the past decades, the use of antimicrobial mouthwashes has become customary following mechanical plaque biofilm control. 20 There are several systematic reviews concerning ingredients in mouthwash products. Based on these systematic reviews, Van der Weijden et al 20 presented the results of a meta-review that evaluated the effect of various types of mouthwash on plaque and gingivitis. Evidence suggests that a mouthwash containing chlorhexidine (CHX) is the first choice, but no difference was observed between CHX and essential oils (EO) mouthwash regarding gingivitis parameters. Similar results were found in a recent systematic review and meta-analysis that compared RCTs assessing the efficacy of different anti-plaque chemical mouthwash products used for 6 months at home with plaque index changes as the outcome parameter. Mouthwash containing EO or CHX exhibited the greatest effect on plaque index score reduction Volume 3, Number 2, 2017

4 van der Sluijs et al Cooling solution Mouthwashes with active ingredients can also be used during nonsurgical periodontal therapy as a preprocedural rinse for reducing bacterial loading within the oral cavity Furthermore, mouthwashes containing additional active ingredients can be used as a cooling solution during nonsurgical therapy with ultrasonic devices. A systematic review evaluated the effect of clinical parameters of periodontal inflammation following nonsurgical therapy with ultrasonic devices and a chemotherapeutic cooling solution. 24 Efficacy was evaluated with clinical parameters of periodontal inflammation, such as probing pocket depth (PPD) and clinical attachment level (CAL), as outcomes. The meta-analysis revealed that even when the ultrasonic cooling solution contained adjuvant active ingredients, the differences in means and CAL were not statistically significant. The subanalysis further indicated that, in conjunction with povidone-iodine (PVP), the use of an ultrasonic cooling solution may result in a very small gain in CAL. PVP is mainly used in a 0.5% to 1.0% concentration. The systematic review 24 concluded that an ultrasonic device with plain tap water used as a cooling solution is sufficiently effective by itself. As an additional advantage, water as coolant ensures good visibility for the DCP because the work field is continuously flushed. 25 Oral malodor The oral fluid present in the mouth helps food and water pass through the mouth and throat. 26 The salivary glands of a healthy individual produce roughly 0.75 to 1.5 liters of saliva each day. 27 Saliva production is significantly reduced during sleep, and furthermore, microbial metabolic activity can be increased during sleep due to lack of physiologic oral cleansing through the movement of the facial and oral muscles. 28 This phenomenon can cause morning bad breath, 29 which contains elevated concentrations of volatile sulfur components (VSC). Morning bad breath is considered a surrogate target for interventions on breath quality 30 and has been accepted as an alternative model for testing treatment strategies for halitosis. 31 Tooth brushing alone is not enough to reduce oral malodor, although a quick internet search claims that eliminating morning bad breath is rather simple: drink water, eat breakfast, perform oral hygiene, and rinse your mouth with water or mouthwash. In a facultative manner, one could eat more raw foods, such as carrots, celery, and apples; gargle with a glass of water containing cinnamon powder; or chew sugarless gum. Another suggestion is to drink water right before going to bed since no food or fluids are consumed during sleep, the mouth can dry out. One could also drink water when waking up during the night. Layman s literature has suggested drinking a glass of water and swirling it around the mouth. The main goal established by these recommendations is to remain hydrated by drinking water regularly. Staying hydrated is especially important before and after heavy exercise, when rapid breath can increase the likelihood of dry mouth. 35 To diagnose oral malodor, the organoleptic score (ORG) is considered as the gold standard. 36 There are also specific apparatuses that objectively assess the levels of VSC, which are considered to be the most significant gases with regard to oral malodor: hydrogen sulfide (H 2 S), methyl mercaptan (CH 3 SH), and dimethyl sulfide ((CH 3 ) 2 S)). Of these three compounds, H 2 S and CH 3 SH are the main contributors. 37 Water The suggestion that the use of water could positively affect morning bad breath was the subject of a recently published clinical trial. 38 Participants were randomly divided into two groups: one that rinsed with water for 30 seconds and one that drank a glass of water within 30 seconds. Assessments were carried out during a morning appointment, between 7:30 am and 12:00 pm. The participants had fasted overnight. ORG was the primary outcome parameter, and the output of the apparatuses that evaluate VSC the OralChroma (FIS Inc) and the Halimeter (Interscan) were the secondary outcome parameters. Both rinsing with water and drinking a glass of water had a statistically significant effect on the morning bad breath parameters, but no significant difference was found between the two. Oral hygiene regimen Professional advice for oral malodor has focused on improving oral hygiene practices, including tooth brushing and interdental cleaning. Additionally, when tongue coating is present, the use of a tongue cleaning device 39,40 and the use of chemical agents with proven efficacy are recommended. 33,41,42 A recent clinical trial 43 evaluated a tooth brushing regimen that consisted of a tooth/tongue gel, tongue cleaner, 147

5 Evidence Summaries and Critical Appraisals and mouthrinse, with ORG, VSC, and tongue surface appearance scores as outcome parameters. During this 3-week, parallel, single-blind RCT, the test group regimen used a tooth/tongue gel, tongue cleaner, and mouthrinse that contained a combination of amine fluoride, stannous fluoride, and zinc lactate to counteract oral malodor. The control group regimen consisted only of a standard fluoride dentifrice. A significant effect on morning bad breath was observed after 24 hours for most of the parameters in favor of the test regimen. On day 21, the decrease in H 2 S and the Halimeter outcomes were maintained for the test group regimen, and a significant increase in tongue surface discoloration was observed in the test regimen. Participants self-perceptions also indicated that their breath felt fresher when they woke up. Tongue surface characteristics Tongue surface characteristics are of interest with regard to oral malodor. Tongue coating is closely associated with clinical oral malodor, whereas a high plaque index is closely associated with perceived oral malodor. 44 In young people, the main etiology of oral malodor is tongue coating, and in the older generation, it is a combination of periodontal diseases and tongue coating. 45 Several methods have been used to assess the presence of tongue coating. One approach is to carefully remove the tongue coating with a tongue scraper and either estimate the wet weight 46 or use an ordinal index to assess the amount. 47,48 The tongue surface appearance can be differentiated by distribution area, 45 color, and quality. 49 Other methods have visually divided the dorsum of the tongue into different areas, and the tongue surface discoloration and tongue coating thickness are given a score per area. 50 The presence of a tongue surface coating does not necessarily lead to oral malodor, and moreover, reduction of VSC production can be achieved in the presence of tongue coating. 50 However, the tongue surface is the strongest odor-forming site in the mouth, and the removal of tongue coating has the potential to reduce VSC, although the evidence for the beneficial effect of mechanical tongue cleaning in oral malodor patients remains weak. 51 Only one study has evaluated the additional effects of mouthwash tongue cleaning over a 2-week period. No additional effects on oral malodor were found, 52 but different types of mouthwash reduce oral malodor. 53 Several studies have indicated that, given the potential social consequences of oral malodor, it is vital for the DCP to make patients aware of its presence. Patients with potential oral malodor do not always receive appropriate care, which may be due to a lack of knowledge on this specific outcome or even reluctance on the part of the DCP, which seems to interfere with adequate professional care Patients with oral malodor may even experience psychologic discomfort and disability. 41 Optimal oral health and hygiene can improve patients oral health related quality of life (HRQoL) and well-being. 57 In general, oral malodor may not receive appropriate attention, since dental caries and periodontal diseases are the two main reasons why patients visit the DCP. 20 Conclusions Water was found to be an effective coolant solution with an ultrasonic device. Water was also shown to have a positive effect on morning bad breath. Prerinsing with water did not contribute to a more effective plaque removal during tooth brushing. Mouthrinses containing CHX and EO are both significantly more effective than water alone. Acknowledgments The preparation of this review was self-funded by the authors and their institutions. The authors declare that they have no conflict of interest. References 1. Gunsolley JC. Clinical efficacy of antimicrobial mouthrinses. J Dent 2010;38(suppl):s6 s Pihlstrom B. Treatment of periodontitis: Key principles include removing subgingival bacterial deposits; providing a local environment and education to support good home care; providing regular professional maintenance. J Periodontol 2014;85: Van der Weijden FA, Slot DE. Efficacy of homecare regimens for mechanical plaque removal in managing gingivitis a meta review. J Clin Periodontol 2015;42(suppl):s77 s Chapple IL, Van der Weijden F, Doerfer C, et al. Primary prevention of periodontitis: Managing gingivitis. J Clin Periodontol 2015;42(suppl):s71 s Van der Weijden F, Danser MM. Toothbrushes: Benefits versus effects on hard and soft tissues. In: Addy M, Embery G, Edgar WM, Orchardson R (eds). Tooth Wear and Sensitivity: Clinical Advances in Restorative Dentistry. London: Martin Dunitz, 2000: Wainwright J, Sheiham A. An analysis of methods of toothbrushing recommended by dental associations, toothpaste and toothbrush companies and in dental texts. Br Dent J 2014;217:e5. 7. Davies RM, Davies GM, Ellwood RP. Prevention. Part 4: Toothbrushing: What advice should be given to patients? Br Dent J 2003; 195: Volume 3, Number 2, 2017

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7 Evidence Summaries and Critical Appraisals 50. Winkel EG, Roldán S, Van Winkelhoff AJ, Herrera D, Sanz M. Clinical effects of a new mouthrinse containing chlorhexidine, cetylpyridinium chloride and zinc-lactate on oral halitosis. A dualcenter, double-blind placebo-controlled study. J Clin Periodontol 2003;30: Van der Sleen MI, Slot DE, Van Trijffel E, Winkel EG, Van der Weijden GA. Effectiveness of mechanical tongue cleaning on breath odour and tongue coating: A systematic review. Int J Dent Hyg 2010;8: Slot DE, De Geest S, van der Weijden FA, Quirynen M. Treatment of oral malodour. Medium-term efficacy of mechanical and/or chemical agents: A systematic review. J Clin Periodontol 2015;42(suppl):s303 s Blom T, Slot DE, Quirynen M, Van der Weijden GA. The effect of mouthrinses on oral malodor: A systematic review. Int J Dent Hyg 2012;10: Romano F, Pigella E, Guzzi N, Aimetti M. Patients self-assessment of oral malodour and its relationship with organoleptic scores and oral conditions. Int J Dent Hyg 2010;8: Rayman S, Almas K. Halitosis among racially diverse populations: An update. Int J Dent Hyg 2008;6: Buunk-Werkhoven YA, Buls JG, Osinga E, Bruers JJ. Diagnosis and treatment of patients with halitosis by dental hygienists and dentists in the Netherlands. Int Dent J 2015;65: Buunk-Werkhoven Y, Dijkstra-le Clercq M, Verheggen-Udding E, de Jong N, Spreen M. Halitosis and oral health-related quality of life: A case report. Int J Dent Hyg 2012;10: Volume 3, Number 2, 2017