Is Mouthrinse A Good Idea for Children?

Research evidence supports that good oral health is an important component of good general health and that poor oral health can adversely affect growth, development, cognition, learning and well-being.(1-3) Naturally, as parents, we want to make sure we give our children the best we can provide to ensure healthy and happy growth and development. Toothbrush, toothpaste and dental floss are considered essential items for daily oral hygiene practices. What about mouthrinses? Is mouthrinse a good idea? Is mouthrinse necessary for children?

So, what are the commonly available mouthrinses and how do they work?

Fluoride Mouthrinse (4-6)

Fluoride mouthrinses work by promoting remineralization of early tooth decay lesions, protecting tooth surface from acid attack and reducing enamel demineralization. Fluoride mouthrinses of different fluoride ion (F) concentrations are available. For weekly use, fluoride mouthrinse containing 0.2% sodium fluoride (NaF) or 900ppm F is recommended. For daily use, 0.05% NaF or 230ppm F is recommended and a 0.01% NaF or approximately 100ppm F formulation is also available. Conclusions from a 2016 Cochrane systematic review comparing fluoride mouthrinse with a placebo or no treatment, in 37 trials (over 15 800 children) indicated that “daily and weekly/fortnightly supervised rinse programmes result an average of 27% fewer decayed, missing or filled permanent tooth surfaces”.(1) Although unlikely, inadvertent ingestion of fluoride mouthrinse, may increase risk of dental fluorosis or systemic toxicity.

Chlorhexidine Mouthrinse (7-11)

Chlorhexidine is a broad-spectrum anti-microbial agent and works by decreasing bacterial load in the oral environment and reducing dental plaque-related inflammation. At low concentration, chlorhexidine disrupts bacterial activities and stops bacteria from multiplying (bacteriostatic). At high concentration, chlorhexidine kills the bacteria (bacteriocidal). Chlorhexidine uniquely sticks around for a long time after use and thus provides prolonged actions (high substantivity). Chlorhexidine mouthrinses commonly available in Australia include concentrations of 0.1%, 0.12% and 0.2%. Thirty second rinse with 20mg chlorhexidine twice a day (equivalent to 10mL of 0.2% or 15mL of 0.12% chlorhexidine mouthrinse) has been considered as the optimum regime. Chlorhexidine is generally not recommended for prolonged use because it is associated with adverse effects such as tooth discolouration, changes to taste and calculus accumulation. A 2017 Cochrane systematic review concluded that there is high quality evidence to support the use of chlorhexidine mouthrinse as an adjunct to toothbrushing and flossing for 4-6 weeks and 6mths in adults. Its use resulted in significantly large reduction of dental plaque and reduction in mild gingivitis.(4) chlorhexidine mouthrinse use has also been associated with reduction in bad breath by reducing bacteria in the mouth.(7) A 2015 Cochrane systematic review examining the effects of chlorhexidine treatment on tooth decay prevent in children and adolescents reported findings were inconclusive.(8) Chlorhexidine mouthrinse is generally not recommended to children. Compliance tends to be poor due to the bitter taste of chlorhexidine.

Cetylpyridinium Chloride and Essential Oils Mouthrinses (10,12-15)

Cetylpyridinium chloride (CPC) is a quaternary ammonium compound, commonly used at 0.05% concentration in mouthrinses. Essential oils commonly use in mouthrinses include thymol, menthol and eucalyptol. CPC and essential oils are weak antimicrobial compared to chlorhexidine and at the concentrations found in mouthrinses work mostly by disrupting bacterial activities and inactivating bacteria. Some CPC and essential oils containing mouthrinses may contain undesirably high ethanol content. Regular use of CPC and essential oils containing mouthrinses have been shown to reduce dental plaque and gingivitis in adults.

For children, is mouthrinse a good idea and is mouthrinse necessary?

There is a general lack of research supporting the use of antibacterial mouthrinses as part of oral hygiene routines for children. Regular use of antibacterial mouthrinses such as mouthrinses containing chlorhexidine, essential oils or CPC in children is therefore not a good idea.

On the contrary, there is good evidence for the regular use of fluoride mouthrinses in addition to toothbrushing and flossing, for children and adolescents at high risk of tooth decay.  For children with high risk of tooth decay, using a fluoride containing mouthrinse regularly is a good idea.

However, the prescription of any mouthrinse should be done after a thorough dental examination and oral health risk assessment with a dentist.

In addition:

• Children under the age of 6yo and/or children with swallowing difficulties or who cannot spit out easily, should NOT use a mouthrinse.(4)
• Mouthrinse is an adjunct to flossing and toothbrushing. Mouthrinse cannot replace the functions achieved by flossing and toothbrushing.(4,7)
• The choice of mouthrinse depends on the problem to be addressed. For example, fluoride containing mouthrinse is most appropriate for tooth decay prevention, chlorhexidine containing mouthrinse is recommended for inflammation of gums and oral soft tissues. Mouthrinses containing essential oils, cetylpyridinium chloride (CPC), chlorine dioxide and zinc play a role in reducing bad breath.(10)

In summary, mouthrinses should be considered as medication, with specific therapeutic indications, as well as potential side effects. Mouthrinse is not indicated for every child.  Adding a mouthrinse to your child’s daily oral hygiene practice is best done in consultation with a dentist.  

REFERENCES

1. Perazzo MF, Gomes MC, Neves ET, Martins CC, Paiva SM, Costa EMMB, Granville-Garcia AF. Oral problems and quality of life preschool children: self-reports of children and perception of parents/caregivers. Eur J Oral Sci 2017; 125(4):272-279. doi: 10.1111/eos.12359.
2. Seirawan H, Faust S, Mulligan R. The impact of oral health on the academic performance of disadvantaged children. Am J Public Health 2012; 102(9): 1729-1734. doi: 10.2105/AJPH.2011.300478
3. Torriani DD, Ferro RL, Bonow ML, Santos IS, Matijasevich A, Barros AJ, Demarco FF, Peres KG. Dental caries is associated with dental fear in childhood: findings from a birth cohort study. Caries Res 2014; 48(4): 263-270.
4. Marinho VC, Chong LY, Worthington HV, Walsh T. Fluoride mouthrinse sfor preventing dental caries in children and adolescents. Cochrane Database Syst Rev 2016 Jul 29;7:CD002284. Doi: 10.1002/14651858.CD002284.pub2.
5. Altenburger MJ, Schirrmeister JF, Wrbas KT, Hellwig E. Remineralization of artificial interproximal carious lesions using a fluoride mouthrinse. Am J Dent 2007; 20(6): 385-389.
6. Songsiripradubboon S, Hamba H, Trairatvorakul C, Tagami J. Sodium fluoride mouthrinse used twice daily increased incipient caries lesion remineralization in an in situ model. J Dent 2014; 42(3): 271-278. doi: 10.1016/j.jdent.2013.12.012.
7. James P, Worthington HV, Parnell C, Harding M, Lamont T, Cheung A, Whelton H, Riley P. Chlorhexidine mouthrinse as an adjunctive treatment for gingival health. Cochrane Datase Syst Rev 2017 Mar 31; 3:CD008676. doi: 10.1002/14651858.CD008676.pub2.
8. Keijser JAM, Verkade H, Timmerman MF, van der Weiiden FA. Comparison of 2 commercially available chlorhexidine mouthrinses. J Periodontol 2003; 74(2): 214-218.
9. Matthews D. No Difference between 0.12% and 0.2% chlorhexidine mouthrinse on reduction of gingivitis. Evid Based Dent 2011; 12(1): 8-9. doi: 10.1038/sj.ebd.6400771.
10. Fedorowicz Z, Aljufairi H, Nasser M, Outhouse TL, Pedrazzi V. Mouthrinses for the treatment of halitosis. Cochrane Database Syst Rev 2008 Oct 8;(4):CD006701 doi: 10.1002/14651858.CD006701.pub2.
11. Walsh T, Oliveira-Neto JM, Moore D. Chlorhexidine treatment for the prevention of dental caries in children and adolescents. Cochrane Database Syst Rev 2015 Apr 13;(4):CD008457. doi: 10.1002/14651858.CD008457.pub2.
12. Sreenivasan PK, Haraszthy VI, Zambon JJ. Antimicrobial efficacy of 0.05% cetylpyridinium chloride mouthrinses. Lett Appl Microbiol 2013; 56(1):14-20. doi: 10.1111/lam.12008.
13. 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; 21: 15: 169. doi: 10.1186/s12866-015-0501-x.
14. Quintas V, Prada-Lopez I, Donos N, Suarez-Quintanilla D, Tomas I. Antiplaque effect of essential oils and 0.2% chlorhexidine on an in situ model of oral biofilm growth: a randomised clinical trial. PLoS One. 2015 Feb 17;10(2):e0117177. doi: 10.1371/journal.pone.0117177.
15. Van Leeuwen MP, Slot DE, Van der Weijden GA. Essential oils compared to chlorhexidine with respect to plaque and parameters of gingival inflammation: a systematic review. J Periodontol 2011; 82(2):174-94. doi: 10.1902/jop.2010.100266.