The value of mouthwash

It is well recognised that fixed orthodontic appliances are considered to be a clinical risk factor for demineralisation of enamel because of plaque accumulation around the bracket base.

According to Tufekci et al, published in The angle orthodontist, ‘the development of white spot lesions during orthodontic treatment is almost inevitable when oral hygiene is poor’.  Demineralisation is more commonly seen on the buccal surfaces of orthodontically treated teeth than on untreated teeth.  This is due to prolonged plaque retention around the brackets.  The development of gingivitis and hyperplastic gingiva is also a well recognised problem during orthodontic treatment with fixed appliances.

Metallic brackets have been found to involve specific changes in the oral environment, such as decreases in pH and increases in plaque accumulation that further increase the risk of demineralisation.

According to Beyth et al, successful orthodontic treatment requires high compliance, especially by teenagers, whose compliance is generally low.  The ability of the orthodontist to continuously monitor patients’ oral hygiene is limited.  Monitoring the oral state is particularly important in certain patients such as those who are handicapped, those who have undergone dental surgery, young children (in early mixed dentition), and those with many (before orthodontic treatment) filled and decayed teeth.  Failure to maintain proper oral hygiene leads to tooth damage, consequently affecting the orthodontic treatment.

Practical interventions

Plaque accumulation and subsequent gingivitis are common in orthodontic patients because of the challenge of controlling oral hygiene with the combination of brackets, bands, wires and elastomeric ligatures present.  

So what can the clinician do to help the patient overcome this problem?  The cornerstone of an at-home oral hygiene routine is toothbrushing with a fluoride containing toothpaste.  According to O’Reilly and Featherstone the role of fluoride as an inhibitor of demineralisation has come to the fore and it has been shown that the presence of fluoride in solution at the time of acidic attack on the enamel may considerably slow down the rates of decay.  It has been suggested that if preventive measures (fluoride supplementation and good oral hygiene) are followed and maintained throughout the course of orthodontic treatment, then the number of white spot lesions may be reduced.

As with all patients, following toothbrushing with a fluoride toothpaste, the use of dental floss is recommended as routine for orthodontic patients.  However, flossing may prove particularly challenging where teeth are wired or a fixed appliance is in place.  Indeed, many orthodontic patients especially children and adolescents fail to floss because they find this procedure time-consuming and tedious in the presence of orthodontic archwires.  Consideration should be given to using an essential oil mouthwash such as Listerine.  Mouthwashes have the advantage that their antimicrobial activity can access hard to reach areas.

Considerable clinical trial evidence shows that oral hygiene status is significantly improved when antibacterial mouthrinses are added to the daily oral hygiene regimen (toothbrushing and flossing) compared with tooth brushing and flossing alone.  Although rinsing with Listerine should not replace flossing, it could be an efficient adjunct to brushing in orthodontic patients who struggle to floss regularly in the presence of fixed appliances.

Listerine will kill a broad spectrum of planktonic (free floating) and plaque bacteria and penetrate deep into the biofilm to kill a significant proportion of plaque bacteria.  Adding Listerine to a patient’s daily oral care routine can significantly reduce plaque levels by up to 56 per cent.

Importantly, some varieties of Listerine also contain sodium fluoride at 100 ppm.  A recent single blinded, randomised study has shown that 100 ppm mouthwash, even when used immediately after brushing maintains the fluoride levels obtained with a fluoridated toothpaste.  For patients who are in the habit of rinsing vigorously with water after brushing, using fluoridated Listerine immediately post brushing can be useful for protection against demineralisation and caries.

The conclusions of the Tufecki et al six month study were that:

• adding Listerine to the daily oral hygiene regimen reduces plaque development in orthodontic patients over a six month period
• as fixed orthodontic appliances may cause enamel decalcification because of plaque accumulation around the bracket base, it is recommended that orthodontists instruct their patients to rinse twice a day with 20 ml of Listerine with fluoride in addition to brushing and flossing. 

References available on request.