Dental caries in children remains a significant problem in the United States, as a large portion of youth will develop decay at some point. Treatment can be costly and, depending on the patient, challenging. As a result, oral health professionals have been consistently educating patients and their caregivers about proper oral hygiene strategies in order to reduce the risk of this preventable disease.
In spite of dentistry’s evidence-based recommendations and outreach efforts, many young patients frequently and persistently 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 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 is with patients regarding their overall self-care plans, the more patients will recognize the importance of caries prevention—not only to oral health maintenance, but also to overall health maintenance. Patients and caregivers also need to understand their roles in the prevention plan, as well as the roles of the dental care team. A discussion of diet and proper hygiene is essential, as these aspects of prevention remain in the hands of patients/caregivers themselves.
GENERAL RECOMMENDATIONS FOR FLUORIDE USE
Water fluoridation and supplementation; over-the-counter (OTC) fluoride toothpastes; prescription-only, high-concentration fluoride dentifrices; topical fluoride applied professionally at dental visits; and OTC fluoride mouthrinses are the main components of fluoride use in caries prevention. This article will focus specifically on the use of fluoride mouthrinses in the prevention of caries in children.
Fluoride mouthrinses are valuable adjuncts for the prevention of decay in children age 6 and older. Maguire1 notes in the American Dental Association recommendations that fluoride mouthrinses are not recommended for children younger than 6. These patients are likely to swallow the liquid, which may cause nausea and vomiting. For those old enough to avoid swallowing a mouthrinse, however, fluoride rinses can be a valuable asset for at-home caries management.
Fluoride mouthrinses create a relatively long-lasting fluoride reservoir in saliva.2,3 As such, when fluoride is swished around the mouth 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 the rinsing is finished.4 This lingering benefit is greater than that provided by the biannual application of topical fluoride.5
Because fluoride mouthrinse is in liquid form, mouthrinses containing fluoride carry active ingredients to all areas of the mouth, without the need for the precision of a toothbrush or interdental cleaner. Given that biofilms cover the entire mouth—not just teeth—the fact that the fluoride-containing mouthrinse can be delivered to all tooth surfaces is highly advantageous.
Plaque biofilm forms quickly, after even the most meticulous oral hygiene measures, and it cannot be managed by toothbrushing and flossing alone in most cases. Fluoride mouthrinses add efficacy over and above water fluoridation and fluoride toothpastes, as demonstrated in several studies.6,7 They also provide the opportunity to deliver multiple therapeutic benefits, in addition to fluoride, at one time.8
Using a mouthrinse is typically fun for pediatric dental patients and is quickly habit forming. The physical removal force of the rinsing action itself can dislodge food particles left behind after brushing, and may—by similar means—assist in plaque reduction. This makes the swishing and rinsing action, as well as the fluoride agent, particularly useful for patients who have trouble brushing or with circumstances that make brushing more challenging. Patients undergoing orthodontic treatment often experience difficulty in maintaining adequate oral hygiene. Fluoride mouthrinses can greatly benefit patients struggling to avert the potential damage of caries lesions forming around bands, brackets, and other appliances.9–11
Several studies have shown the incremental benefit of fluoride mouthrinse use over professionally applied fluoride, fluoride toothpaste, and water fluoridation.1 For patients at higher-than-average risk of dental caries, fluoride mouthrinse 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 mouthrinses.4,12 The conclusion of the 2003 review states: “The regular and supervised use of fluoride mouthrinse by children is associated with a clear reduction in caries increment.”12 This report continues to talk about the incremental benefit of fluoride mouthrinse: “Regular supervised use of fluoride mouthrinses by children would reduce their 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 that 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) and 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 additional use of fluoride mouthrinses over and above the use of other delivery methods of fluoride. While some practices have neglected to add OTC fluoride mouthrinses to their repertoire of preventive recommendations, the evidence suggests the benefits are significant and should be added where appropriate.
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 toothpastes, mouthrinses, gels, and varnishes, as well as fluoride-releasing composite resins and other materials used for bonding or banding. They found some evidence that a daily fluoride mouthrinse or a fluoride-containing cement will reduce tooth 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
PREPARATIONS OF OVER-THE-COUNTER FLUORIDE MOUTHRINSE
Various forms of fluoride mouthrinse are available with different fluoride concentrations. The US 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. As the active ingredient is the same and all mouthrinses must stay within the range specified by the FDA monograph, user preference in terms of flavor, consistency, and “mouth feel” may help determine which product is best for individual patients.
Some OTC fluoride mouthrinse are recommended for once daily use, while others are designed for twice daily use. Patients commonly ask about the need to perform the rinse procedure twice daily vs once daily. The literature does not precisely distinguish between these regimens,6,14 and the systematic reviews1,4 cluster once daily and twice daily into their analyses, as both have shown success. In our experience, patients using the product twice daily are more likely to comply overall with caries prevention recommendations.
CONCLUSION AND RECOMMENDATIONS
Evidence shows that fluoride mouthrinses are useful additions to the self-care regimens of many patients who face difficulty in preventing caries lesions. In addition, whereas water fluoridation is not universally available and compliance with fluoride supplements is poor, fluoride mouthrinses can be a successful measure to aid in caries prevention. The pleasant taste that remains in the mouth after use may also support compliance. With so many OTC products available, most patients can find a product that suits their taste, feel, and caries-prevention requirements.
- Maguire A. ADA clinical recommendations on topical fluoride for caries prevention. Evid Based Dent. 2014;15:38–39.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- United States Food and Drug Administration. Development and Approval Process (Drugs). Available at: fda.gov/drugs/developmentapprovalprocess/ default.htm. Accessed November 14, 2016.
- 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.
From Dimensions of Dental Hygiene. December 2016;14(12):22,24,26.