Home Care Devices and Compliance

Fundamentals of Prevention: Home Care Devices and Compliance

Outline

• The notes detail the use of oral hygiene devices.
• Focus is given to:
• Dentifrice
• Mouth rinses
• Manual vs electric toothbrushes
• Interproximal brushing

Dentifrices

• A dentifrice, or toothpaste, is a substance used with a mechanical device (toothbrush) to clean teeth, tongue, and gingiva.
• They can be used for cleaning, therapeutic and cosmetic properties.
• They come in paste or gel form.

Desirable Properties of Dentifrices

• Should prevent plaque formation.
• Should disrupt plaque and optimize plaque removal.
• Should include agents that prevent demineralization and aid remineralization.
• Should prevent and reduce periodontal inflammation and disease.
• Should not be an irritant to oral tissues.
• Should prevent or reduce halitosis.
• Should be effective without damaging the tooth surface or gingiva.

Main Components of Dentifrices

• Cleansing and polishing agents make up 10-40%.
• Humectants make up 20-70%.
• Water makes up 5-30%.
• Binders/gelling agents make up 1-2%.
• Detergents/surfactants/foaming agents make up 1-3%.
• Preservatives make up 2-3%.
• Flavoring agents approx 2%.
• Sweeteners make up 2-3%.
• Coloring or dye agents make up 2-3%.

Cleaning & Polishing Agents

• Cleaning (abrasive) agents include aluminum, calcium and tin.
• Polishing agents include silicas, carbonates and phosphates.

Humectants

• Sorbitol maintains moisture.
• Mannitol prevents evaporation.
• Glycerin prevents hardening.
• Propylene glycol increases shelf life.

Binders

• Natural gums thicken.
• Seaweed extracts are used as a stabilizer.
• Synthetic cellulose prevents solids from settling out.

Surfactants

• Sodium Lauryl Sulfate is stable/compatible, has some antibacterial properties, flavor easy to mask and low surface tension.

Flavoring Agents

• Synthetic flavors include Spearmint, Wintermint, Vanilla, Cinnamon, Peppermint, Citrus.
• Essential oils include Thymol, Menthol, Eucalyptol and Methyl salicylate.
• Good flavoring agents taste pleasant, and are immediate and long lasting.

Sweetening Agents

• Early sweeteners were Sugar and Honey
• Non-cariogenic sweeteners include:
• Saccharin
• Cyclamate
• Sorbitol*
• Mannitol*
• Glycerin*
• Xylitol
• Are also humectants

ADA Seal of Acceptance

• Requires studies demonstrating safety & effectiveness.
• Studies must be at least 6 months in length.
• Toothpastes must demonstrate statistically significant reductions in both plaque & gingivitis.
• Must have FDA-approved ingredients, assured purity & uniformity.
• Packaging claims must be supported by science.
• All must contain Fluoride, and none can contain sugar.

Types of Dentifrices

• Anti-Caries Dentifrices.
• Desensitizing Dentifrices.
• Anti-Gingivitis & Anti-Plaque Dentifrices.
• Natural/Herbal Dentifrices.

Anti-Caries Dentifrices

• Fluoride is the most common therapeutic agent.
• Most OTC dentifrices have approximately 1000 ppm.
• Prescription F dentifrices have 5000 ppm fluoride content.
• Fluoride acts by being incorporated to the tooth substrates (enamel and dentin) rendering teeth more resistant to acid attack associated with cariogenic bacteria and diet.
• Types of Fluoride:
• Sodium Fluoride (NaF) -0.22% at 1,100 ppm
• Sodium Monofluorophosphate (MFP) -0.76% at 1,000 ppm
• Stannous Fluoride (CnF2) -0.4% at 1,000 ppm
• Prescription strength dentifrice- Sodium Fluoride at 5000 ppm

Dentifrices with Desensitizing Properties

• Contain potassium salts.
• They work by depolarization of nerve endings.
• The relief only tends to last as long as the product is used.

Desensitizing Ingredients

• Stannous fluoride acts by tubular occlusion, SNF2 products are successful desensitizers by precipitating the stannous (tin) ion to occlude the dentinal tubules.
• Amorphous Calcium Phosphate (ACP) dentifrice designed to deliver calcium and phosphate salts, which have provided relief from sensitivity greater than the control product without ACP
• ACP and fluoride provide semi-permanent occlusion with fluorapatite and long lasting relief.

Anti-Plaque & Anti-Gingivitis Properties

• Triclosan is discontinued.
• Stannous Fluoride is an alternative.
• Only Colgate Total and Crest Pro-Health are the only two dentifrices with antiplaque and anti-gingivitis properties accepted by the ADA.

Triclosan (Tcs)

• Was a broad-spectrum antimicrobial agent.
• Had anti-inflammatory effects because of its inhibition of the cyclooxygenase/lipoxygenase pathway of arachidonic acid metabolism.
• The environmental and health effects of Tcs were widely discussed.
• Some animal studies demonstrated an alteration in hormone regulation, and Tcs might influence bacterial resistance.
• Was used to be included in many products in addition to dentifrices, such as soaps, deodorants, toys and kitchen utensils.
• Is no longer available in the USA.

Stannous Fluoride (SnF2)

• Was first introduced in the 1950s
• Due to tooth staining and bitter taste, it is reformulated as stabilized SnF2.
• It reduces gingival inflammation and bleeding through its effect as a broad-spectrum antimicrobial agent.
• Manages and prevents dental caries by promoting enamel mineralization.

Dentifrices with Natural/Herbal Ingredients

• In recent years, there has been an increased preference for natural remedies/herbal products.
• Several herbs/natural products have been studied.
• A few include Aloe Vera, Neem, Miswak, Tea tree oil and Turmeric.

Natural/Herbal Ingredients in Dentifrices

• Aloe Vera is used for its natural bactericidal properties.
• Gel of the Aloe Vera leaf has immuno-simulation, anti-inflammatory effects, wound healing, antibacterial, anti-fungal and anti-cancer action.
• Studies have shown mixed results.
• A recent study showed a significant reduction in plaque and gingivitis with the use of a dentifrice containing aloe vera however the results were not statistically significant when compared to a fluoride dentifrice.
• Neem has been used in treatment of gingivitis and periodontitis.
• Neem demonstrates anti-inflammatory action by inhibiting prostaglandin E and 5HT thus reducing inflammation.
• Azadirachtin in Neem contributes to its antibacterial property by destroying bacterial cell wall.
• A double-blind controlled trial showed, use of Neem containing dentifrice provided a significant reduction of dental plaque accumulation and improved gingival health compared to a control dentifrice.
• Miswak is derived from salvadora persica, a small tree or shrub with a spongy stem and root, which is easy to crush between the teeth.
• It is inexpensive and has been reported to have anti-plaque and many therapeutic pharmacological properties.
• A miswak extract-containing toothpaste (salvadora persica) on gingival inflammation was compared with that of herbal and conventional toothpaste showing similar effect as the herbal toothpaste and can be safely used for domestic oral hygiene in patients with gingivitis.

Clinical Considerations

• Almost any dentifrice can cause contact stomatitis, also known as dentifrice stomatitis presenting with burning sensation, tissue irritation, vesicle formation and tissue sloughing
• Ingredients such as Sodium Lauryl Sulfate (SLS) is linked to this reaction as it enhances the permeability
• A few ingredients in dentifrice added as “anti-calculus” are associated with a higher burning sensation of the gingiva and oral mucosa.

Mouthwashes

• Defined as a liquid product that can be cosmetic, for a pleasant taste and temporary fresher breath, or therapeutic, with active ingredients to reduce halitosis, plaque, gingivitis or dental caries.
• Therapeutic mouthwashes are frequently recommended as part of patient's oral self-care plan, as an adjunctive to daily mechanical methods for reduction of plaque and gingivitis.

Formulation and Use

• Mouthwashes have oral antiseptics with ability to:
• Inhibit the growth and development of the microbiota
• Cause little or no oral or systemic toxicity
• Be effective against a wide range of bacteria
• Approximately half of the US population has used or uses mouthwashes daily.
• It is generally recommended to rinse twice daily for 30 seconds.
• Oral rinses reach inaccessible areas missed by mechanical methods.
• Like dentifrices, these rinses have a limited effect on the subgingival pathogenic bacteria

Ideal Properties of Oral Rinses

• Safe to use over long periods of time.
• Palatable to user.
• Inexpensive.
• Highly soluble and stable in storage.
• Effective.
• Broad spectrum of effectiveness.
• Adequate bioavailability to bacteria.
• Minimal side effects.
• Adequate retention.

Active Ingredients (Oral Antiseptics)

• Chlorhexidine (CHX)
• Essential Oils (EO)
• Cetylpyridinium Chloride (CPC)

ADA Seal of Acceptance

• Requires studies demonstrating safety and effectiveness.
• Must be at least 6 months in length.
• Must demonstrate statistically significant reductions in both plaque and gingivitis.
• Must be FDA-approved ingredients, with assured purity and uniformity.
• Packaging and advertising claims that are supported by science.

Chlorhexidine (CHX)

• Available through prescription only in the USA.
• Considered the gold standard of therapeutic mouthwashes, and the most effective antiplaque and antigingivitis agent.
• Provides antibacterial action through disruption of bacterial cell membrane, increasing permeability, cell lysis and death.
• Has superior substantivity (8-12-hour binding to oral tissues), with side effects of tooth and tongue staining, unpleasant taste, taste sensation, and increased calculus accumulation.
• Dosage is 15mL (0.5 fl. oz.) for 60 seconds bid for 14 days.
• Instruct user to rinse and not swallow, allowing at least 30 minutes between rinsing with CHX and toothbrushing either before or after, to avoid interaction with the detergent sodium lauryl sulfate from the dentifrice, which deactivates CHX.
• Advise user to wait to eat, drink or rinse for 30 minutes after use.
• Brand names include Peridex, PerioGard, and Paroex.

Essential Oils (EO)

• Components of plants that contain phenolic compounds that destroy microorganisms by compromising the cell membrane and inhibiting enzyme activity.
• Therapeutic Effects:
• Prevents bacterial aggregation
• Slows bacterial multiplication
• Reduces bacterial load in oral cavity, and prevents biofilm maturation
• Reduces pathogenicity of biofilm and exerts anti-inflammatory benefit.
• Suitable for long-term use due to:
• No associated stain
• Safe product
• No changes produced in bacterial composition
• No evidence of opportunistic oral pathogens
• No evidence of antimicrobial resistance
• One of the most studied mouthwashes, with evidence of effectiveness, while CHX remains as the first choice for gingivitis reduction.

Cetylpyridinium Chloride (CPC)

• Contains quaternary ammonium chemical compounds with antimicrobial properties.
• Destroys microorganisms by interacting with the bacterial cell membrane, increasing permeability, and losing its contents, bactericidal to Gram-positive bacteria, and moderately bactericidal to Gram-negative bacteria.
• Has low substantivity when compared to CHX.
• Commercial rinses have demonstrated benefit as an adjunct to mechanical plaque control for biofilm and gingivitis reduction, for example:
• Crest Pro-Health Rinse 0.07%
• Colgate Total Rinse 0.075%
• Scope Rinse 0.07%
• Side effects, warnings, other benefits:
• Increased tooth staining
• CPC, like CHX, can be inactivated by sodium lauryl sulfate from dentifrices
• Breath-freshening qualities and reduction of halitosis

Natural Products: Rationale

• Healthcare providers are no longer the only source for oral health information due to internet and social media being readily available.
• Many of these platforms promote lack of alcohol, artificial preservatives, flavors and colors.
• A US survey with 26,000 respondents: approximately 35% use herbal medicines.
• Main reason to use herbal medicine: dissatisfaction with conventional medicine, with "herbal" meaning plant-based
• Most popular published trials for dentistry: mouthwashes and dentifrices.

Plant Based Ingredients

• The table shows plant based ingredients and their properties:
• Acacia arabica/babul is antibacterial, antihistaminic, anti-inflammatory, astringent, and hemostatic
• Aloe vera has anti-inflammatory, antibacterial, antioxidant, immune-boosting, astringent effect, hypoglycemic properties and reduces scars
• Cashew is antinociceptive, anti-inflammatory and antimicrobial
• Neem is anti-inflammatory, antipyretic, analgesic, immunostimulatory, antiulcer, hypoglycemic, antifertility, antimalarial, antifungal, antibacterial, antiviral, anticarcinogenic, hepatoprotective, and antioxidant
• Pot marigold is antibacterial, antifungal, wound healing and re-epithelization, anti-inflammatory, antioxidant, immunomodulatory, and antimutagenic
• Turmeric is anti-inflammatory, antioxidant, and antimicrobial
• Lemongrass is antibacterial, antifungal, antioxidant, antiseptic, astringent, anti-inflammatory, analgesic, antipyretic, and carminative
• Surinam cherry is antimicrobial, antioxidant and anti-inflammatory
• Green tea is antioxidant and antibacterial
• Chamomile is anti-inflammatory, analgesic, and antioxidant
• Magnolia is anti-inflammatory, antimicrobial, and antioxidant
• Holy basil/tulsi is anticancer, antidiabetic, antifungal, antimicrobial, cardioprotective, analgesic, and antispasmodic
• Propolis is antibacterial, antiviral, fungicidal, anti-inflammatory, antitumor, and wound-healing
• Golnaar is antibacterial
• Christmas berry antimicrobial, anti-inflammatory, and anti-ulcerogenic
• Salvadora persica had antibacterial, antifungal and antiviral effects
• Chebulic myrobalan is antimicrobial, anticariogenic, antidiabetic, hepatoprotective, anti-inflammatory, and antioxidant

Products undergoing study

• Mouthwash ingredients currently undergoing study are:
• Chitosan
• Teas
• Salvadora persica
• Taurolidine
• Pomegranate
• Edible oils
• Aloe vera
• Propolis
• Sodium hypochlorite (bleach)
• Turmeric
• Neem tree products
• Cinnamon
• Algae
• Witch hazel
• Polyherbals

Natural Products: Conclusion

• Studies suggest positive effects on biofilm control and reduction of gingival inflammation.
• Most studies lack adequate design or proper control, while studies should be ideally 6 months or longer
• Adverse effects need to be examined and reported in detail in the literature.
• It is difficult to draw firm conclusions from current studies, with not enough evidence to shift from products approved by regulatory dental bodies

Miscellaneous Products

• Alcohol-containing mouthwashes are contraindicated for recovering alcoholics and for people unable to expectorate.
• Should not be used with patients being treated with head and neck radiation, with oral mucositis, or individuals with sodium-restricted diets should know that some brands of mouthwashes may be significant sources of sodium.
• Sodium lauryl sulfate (SLS) can result in sloughing of the mucosa

Miscellaneous ingredients

• Triclosan is restricted or banned in most countries, including the USA
• It's a broad-spectrum antibacterial agent, but manufacturers failed to provide the FDA conclusive proof regarding hormonal effects and antibiotic resistance.
• Has unclear evidence of being hazardous to humans, and low resistance and cross-resistance rates in community settings.
• Presents a low environmental burden (0.03%)
• Chlorine Dioxide is a powerful oxidizing agent popular as an oral malodor agent more so than anti-plaque or anti-gingivitis.
• Hydrogen Peroxide will combines tooth whitening and reduction of gingival inflammation but are not for long-term use due to concerns with its side effects.
• Pre-Brushing Mouthwash was introduced in 1985, and the manufacturer claims a detergent action which removes part of the biofilm and softens the remainder for easy removal with toothbrushing. Majority of clinical studies do not support its use to reduce both biofilm and gingival inflammation.

How Often and For How Long To Brush?

• It's generally recommended to brush twice daily with a fluoride-containing toothpaste for 2 minutes in order to eliminate plaque, to prevent caries and gingivitis, and also to give a feeling of oral freshness.
• Self-reported infrequent brushers demonstrated higher incidence and increment of carious lesions than frequent brushers.
• A 2-minute brushing time is more effective than 1 minute, and increasing the brushing time to 3 minutes or longer does not appear to improve the effectiveness of plaque reduction and will most likely demotivate most users. More frequent/shorter brushing times may increase the risk of adverse effects.
• Oral hygiene instruction should not primarily focus on a fixed brushing time because of strong interindividual differences, for example, anatomic conditions, individual performance at home, and the patient's dexterity.

What Is the Additional Effect of Dentifrice to Mechanical Toothbrushing?

• Toothbrushing with dentifrice does not appear to have an additional mechanical effect on plaque removal compared with brushing alone.
• Plaque scores are reduced by approximately 50% following a toothbrushing exercise either with or without the use of dentifrice.
• Dentifrice is of major importance for the delivery of fluoride in order to prevent the development of caries, or to deliver anti-inflammatory agents.
• In the absence of fluoride the preventive effect of personal oral hygiene is questionable.
• Dentifrice with high abrasivity might be harmful to enamel and dentine, but this effect is largely dependent on boundary conditions such as the presence and the quality of the acquired pellicle.

How Effective Is a Power Toothbrush Compared With a Manual Toothbrush?

• Use of manual toothbrushes achieves an average plaque score reduction in a single brushing exercise of 42% (30%-53%).
• Cross-angled bristle tuft designs appear to work better than flat or multilevel tuft designs; there is no firm evidence regarding the superiority of tapered compared with end-rounded toothbrush filaments.
• Power toothbrushes reduce average plaque score by 46% (36%-65%).
• 11% reduction in the plaque index score in short-term studies (1-3 months), and 21% reduction in long-term studies (>3 months), for oscillating-rotating toothbrushes compared with manual toothbrushes. Similar results were demonstrated for parameters of gingivitis, which improved by 6% in short-term and by 11% in long-term studies.
• For children and adolescents (aged 4-17 years), some studies found power toothbrushing to be superior to manual brushing, while other studies did not find any difference.
• For patients with an intellectual disability, a randomized clinical trial found that the use of a power toothbrush was as effective and safe as a manual toothbrush.

What Are the Effects of Different Interdental Cleaning Devices?

• Many devices are used for interdental cleaning, including dental floss, interdental brushes, and woodsticks.
• The variety of products makes it difficult for the patient and the dental care professional to choose.The choice is usually individually made depending on patient preference
• The size and shape of the interdental space, contour of the gingiva, tooth alignment, dexterity, and motivation of the patient all influence the type of interdental device to use.
• Good interdental oral hygiene will require a device that can comfortably penetrate between adjacent teeth/will be well accepted by the patient without injury to soft or hard tissues.

Dental Floss

• Use is demanding for the patient, requiring a high level of tactile and fine motor skills together with a good knowledge of anatomic conditions.
• Typically manufactured as monofilament made up of expanded polytetrafluoroethylene and polyfil made up of twisted single filaments of varying numbers, in which the diameter, degree, and orientation of the filaments depends on the product, or pseudopolyfil when the single filaments are embedded in a matrix.
• The type that is the most effective remains uncertain, and lubricant reduces risks.

Interdental Brushes

• Built of helically aligned filaments fixed to twisted central wire, and structures can differ in shape, for example, cylindrical or conical, angled or straight, and they vary with respect to the stiffness of filaments.
• Teeth with attachment loss, the concavities in the approximal root surfaces are not accessible for plaque removal using dental floss or woodsticks, while brushes remove plaque as far as 2-2.5 mm below the gingival margin.
• Large effect size expected when interdental brushes are used correctly, for approximately 30% reduction of gingivitis and plaque when compared to merely tooth-brushing.

Dental Woodsticks

• Have a trapezoidal profile and are slightly curved along their length, or are made of shatterproof fibre.
• The evidence for the use is weak with regards to gingival index, and the evidence in support of plaque reduction is inconclusive.

Oral Irrigators

• Designed to flush away loosely adherent plaque through mechanical action (shear forces), the evidence for use is weak/of unclear magnitude.
• One discussed adverse event is its potential to cause bacteremia.