Caries Prevention With Adjunctive Rinses

Dental caries in children remains a significant problem in the United States, as a large portion of youth will develop lesions at some point. Treatment can be costly and, depending on the patient, challenging. As a result, oral health professionals routinely educate pediatric patients and their parents/caregivers about proper oral hygiene strategies in order to reduce the risk of this preventable disease.

In spite of dental teams’ evidence-based recommendations and outreach efforts, many young patients develop interproximal and other smooth-surface caries lesions. When considering the various elements of a preventive program, the fundamentals — such as diet, oral hygiene and fluoride use — must always be addressed with patients and parents/caregivers. Documentation of each patient’s self-care plan for caries prevention should include a careful look at all aspects of prevention. Additionally, regular, ongoing updates to the patient’s reported self-care practices should be noted in the health record. The more specific the interaction with patients regarding their overall self-care plans, the more patients will recognize the importance of caries prevention — not only to oral health, but also to overall health. Patients and parents/caregivers also need to understand their roles in the prevention plan, as well as the roles of the dental team. A discussion of diet and proper hygiene is essential, as these aspects of prevention remain in the hands of patients and caregivers.

GENERAL FLUORIDE RECOMMENDATIONS

Water fluoridation and supplementation, over-the-counter (OTC) fluoride toothpaste, prescription-only, high-concentration fluoride dentifrice, professionally applied topical fluoride, and OTC fluoride mouthrinse are the main forms of fluoride used in caries prevention. This article will focus specifically on the role of fluoride rinse in preventing caries in pediatric populations.

Fluoride mouthrinse is a valuable adjunct for preventing lesions in children age 6 and older. In the American Dental Association recommendations, Maguire¹ notes that use of fluoride rinse is not recommended for children younger than 6, as these patients are likely to swallow the product, which may lead to nausea and vomiting. For those old enough to avoid swallowing a mouthrinse, however, this can be a valuable asset for at-home caries management because these products create a relatively long-lasting fluoride reservoir in saliva.^2,3 As such, when fluoride is swished once or twice daily, it coats the teeth in a somewhat substantive fashion. The small concentration of fluoride on the tooth surface continues to provide benefits to the smooth surfaces of teeth well after rinsing is complete.⁴ This lingering benefit is greater than that provided by the biannual application of topical fluoride.⁵

Because fluoride mouthrinse is in liquid form, it carries active ingredients to all areas of the oral cavity — without the need for the precision of a toothbrush or interdental cleaner. Given that biofilms cover the entire oral cavity — not just teeth — the fact that the fluoride-containing rinse can be delivered to all surfaces is highly advantageous.

Even after the most meticulous oral hygiene measures, plaque biofilm forms quickly and, in most cases, cannot be managed by toothbrushing and flossing alone. As demonstrated in several studies, fluoride mouthrinse offers benefits over and above water fluoridation and fluoride toothpaste.^6,7 In addition to fluoride, these rinses also provide the opportunity to deliver multiple therapeutic benefits at one time.⁸

Using a mouthrinse is typically fun for pediatric patients — and is quickly habit forming. The physical force of the rinsing action itself can dislodge food particles left after brushing, and may — by similar means — assist in plaque reduction. This makes swishing and rinsing, as well as the fluoride agent, particularly useful for patients who have trouble brushing or in circumstances that make brushing challenging. Patients undergoing orthodontic treatment, for example, often experience difficulty in maintaining adequate oral hygiene. Fluoride mouthrinse can greatly benefit patients struggling to avert the potential damage of caries lesions forming around bands, brackets and other appliances.^9–11

ADDITIONAL RINSE BENEFITS

Several studies have shown the incremental benefit of fluoride mouthrinse compared to professionally applied fluoride, fluoride toothpaste and water fluoridation.¹ For patients at higher-than-average risk of dental caries, fluoride rinse can provide the additional benefit needed to prevent refractory interproximal caries lesions that seem to otherwise appear at each recare visit.

At least two Cochrane reviews have analyzed dozens of clinical studies to synthesize a common statement on the incremental benefit of fluoride mouthrinse.^4,12 The 2003 review states: “Use of fluoride mouthrinses by children will reduce tooth decay, even if they drink fluoridated water and use fluoridated toothpaste. This review suggests that the regular and supervised use of fluoride mouthrinse by children is associated with a clear reduction in caries increment. Compared to control groups, daily and weekly/fortnightly rinse programs result, on average, in 26% fewer decayed, missing, or filled permanent tooth surfaces.”¹² The review found no evidence this relative effect was dependent on baseline caries level or exposure to other fluoride sources, fluoride concentration or mouthrinsing frequency — although this result should be interpreted with caution. A higher reduction in decayed, missing or filled surfaces was seen or expected with increased intensity of application (frequency times concentration). This relationship was dependent on the inclusion of one study that demonstrated particularly powerful effects.

This evidence demonstrates the clear advantage of the use of fluoride mouthrinse over and above other fluoride delivery methods. While some practices have neglected to add OTC fluoride rinse to their repertoire of preventive recommendations, the evidence suggests the benefits are significant.

For patients with orthodontic appliances, the risk of white spot lesions near or around brackets and bands is high, particularly when oral hygiene is poor.⁹ Benson et al¹⁰ conducted a Cochrane review of fluoride products in the prevention of white spot lesions during fixed brace treatment. They considered toothpaste, mouthrinse, gel delivery and varnish, as well as fluoride-releasing composite resins and other materials used for bonding or banding. The researchers found some evidence that use of a daily fluoride mouthrinse or fluoride-containing cement will reduce decay if used during treatment with fixed braces. The review determined that a daily sodium fluoride mouthrinse reduced the depth of decay that develops on a tooth during treatment with fixed braces, noting: “Based on current best practice in other areas of dentistry for which there is evidence, we recommend that patients with fixed braces rinse daily with a 0.05% sodium fluoride mouthrinse for added protection against caries and white spot lesions.”¹⁰

FLUORIDE MOUTHRINSE PREPARATIONS

Fluoride mouthrinse is available at various fluoride concentrations. The U.S. Food and Drug Administration (FDA) fluoride monograph¹³ articulates the range of fluoride and other elements of fluoride use in OTC products. The options for fluoride rinse are enormous given the varieties of flavor, fluoride concentration, recommendation for daily use, and other user preferences. Because the active ingredient is the same and all fluoride rinses must be formulated within the range specified by the FDA monograph, user preference in terms of flavor, consistency, and “mouth feel” may help determine which products are best for individual patients.

Some OTC fluoride rinse products are recommended for once-daily use, while others are designed for twice-daily use. Patients and parents/caregivers commonly ask about the need to perform the rinse procedure once versus twice daily. The literature does not precisely distinguish between these regimens,^6,14 and the systematic reviews^1,4 cluster once daily and twice daily into their analyses, as both regimens have shown success. In the experience of this paper’s authors, patients using the product twice daily are more likely to comply overall with caries prevention recommendations.

SUMMARY AND RECOMMENDATIONS

Evidence shows that fluoride mouthrinse is a useful addition to the self-care regimens of patients who face challenges with caries prevention. In addition, whereas water fluoridation is not universally available and compliance with fluoride supplements is often poor, recommending fluoride rinse can be a successful adjunctive measure for caries prevention. In addition, the pleasant taste that remains after use may support compliance. With so many OTC therapeutic rinses on the market, most patients can find a product that suits their taste, feel and caries-prevention requirements.

KEY TAKEAWAYS

• Documentation of each patient’s self-care plan for caries prevention should include a careful look at all aspects of prevention.
• Fluoride mouthrinse is a valuable adjunct for the prevention of lesions in children age 6 and older.
• Because biofilms cover the entire oral cavity — not just teeth — the fact that fluoride-containing rinse can be delivered to all surfaces is advantageous for at-home caries management.
• Using a mouthrinse is typically fun for pediatric patients — and is quickly habit forming.
• In addition, the physical force of the rinsing action can dislodge food particles left after brushing, and may — by similar means — assist in plaque reduction.
• According to a Cochrane review, “The regular and supervised use of fluoride mouthrinse by children is associated with a clear reduction in caries increment.”¹²

REFERENCES

1. Maguire A. ADA clinical recommendations on topical fluoride for caries prevention. Evid Based Dent. 2014;15:38–39.
2. Latimer J, Munday JL, Buzza KM, Forbes S, Sreenivasan PK, McBain AJ. Antibacterial and anti-biofilm activity of mouthrinses containing cetylpyridinium chloride and sodium fluoride. BMC Microbiol. 2015;15:169.
3. Vogel GL, Schumacher GE, Chow LC, Tenuta LM. Oral fluoride levels 1 h after use of a sodium fluoride rinse: effect of sodium lauryl sulfate. Caries Res. 2015;49:291–296.
4. Marinho VC, Chong LY, Worthington HV, Walsh T. Fluoride mouthrinses for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2016;7:CD002284.
5. Souza JG, Tenuta LM, Del Bel Cury AA, et al. Calcium prerinse before fluoride rinse reduces enamel demineralization: an in situ caries study. Caries Res. 2016;50:372–377.
6. Faller RV, Casey K, Amburgey J. Anticaries potential of commercial fluoride rinses as determined by fluoridation and remineralization efficiency. J Clin Dent. 2011;22:29–35.
7. Mystikos C, Yoshino T, Ramberg P, Birkhed D. Effect of post-brushing mouthrinse solutions on salivary fluoride retention. Swed Dent J. 2011;35:17–24.
8. Chaffee BW, Cheng J, Featherstone JD. Non-operative anti-caries agents and dental caries increment among adults at high caries risk: a retrospective cohort study. BMC Oral Health. 2015;15:111.
9. Slutzky H, Feuerstein O, Namuz K, Shpack N, Lewinstein I, Matalon S. The effects of in vitro fluoride mouth rinse on the antibacterial properties of orthodontic cements. Orthod Craniofac Res. 2014;17:150–157.
10. Benson PE, Parkin N, Millet DT, Dyer FE, Vine S, Shah A. Fluorides for the prevention of white spots on teeth during fixed brace treatment. Cochrane Database Syst Rev. 2004;3:CD003809.
11. Benington PC, Gillgrass TJ, Foye RH, Millett DT, Gilmour WH. Daily exposure to fluoride mouthrinse produces sustained fluoride release from orthodontic adhesives in vitro. J Dent. 2001;29:23–29.
12. Marinho VC, Higgins JP, Sheiham A, Logan S. Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2003;1:CD002278.
13. U.S. Food and Drug Administration. Development and Approval Process (Drugs). Available at: www.fda.gov/Drugs/DevelopmentApprovalProcess/. Accessed January 9, 2017.
14. Mason SC, Shirodaria S, Sufi F, Rees GD, Birkhed D. Evaluation of salivary fluoride retention from a new high fluoride mouthrinse. J Dent. 2010;38(Suppl 3):S30–S36.

The authors have no commercial conflicts of interest to disclose.

Feature photo by SZEYUEN/ISTOCK/GETTY IMAGES

From Decisions in Dentistry. February 2017;3(2):32–34.