Revisiting preprocedural mouth rinses as an infection prevention tool

As more and more antimicrobial mouth rinses are being introduced into the marketplace, I am frequently asked whether it makes sense to have patients use one of these products prior to dental procedures. The short answer is that it cannot hurt. The long answer has some important considerations. There is evidence that spray, spatter, and aerosol are produced during dental procedures using a handpiece, ultrasonic scaler, air-water syringe, and during polishing. The spatter, in particular, can be hazardous to dental team members; hence the OSHA requirement that personal protective equipment (PPE) be worn whenever there is potential for spatter or aerosol of blood or other potentially infectious materials (OPIM).

PPE includes protective eyewear, facemasks, and protective clothing. Spatter of OPIM into the eyes of dental team members can cause serious infections, including herpes infections.

Obviously, the first line of defense against eye injury during dental procedures is wearing PPE, but perhaps it makes sense to try to reduce risks even further. It should also be noted that the use of a dental dam and high volume evacuation also reduce spatter and aerosol, but a dental dam cannot be used for all procedures, especially hygiene or surgical procedures.

In addition, the spatter from polishing during hygiene procedures cannot be controlled by a dental dam. Hygienists rarely have the ability to use high volume suction during polishing. Studies show that the number of microorganisms in saliva can be reduced by using an antimicrobial mouth rinse prior to providing treatment. Armed with this knowledge, dental teams can use these products to further reduce the risk of infection during dental procedures.

In 1997, the American Heart Association recommended the use of preprocedural mouth rinses prior to dental treatment to reduce the risk of introducing microorganisms into the blood during these procedures, known as bacteremia.

Subsequently, the AHA and American Association of Orthopaedic Surgeons have stated that there is no evidence that this protocol is warranted, since there is no evidence that any infections have been prevented. But there is, in my opinion, still a reason to incorporate preprocedural mouth rinses. The type of rinse that is used is a consideration since not all mouth rinses are antimicrobial. An antimicrobial mouth rinse is classified by the Food and Drug Administration as one that contains chlorhexidine gluconate (CHX), cetylpyridinium chloride (CPC), or essential oils. These active ingredients have been shown to kill microorganisms in the oral cavity.

Using a rinse classified as cosmetic, meaning that it freshens breath, will have little value as a preprocedural mouth rinse. Mouth rinses that have been classified and approved by the FDA as therapeutic, antimicrobial CHX rinses include Peridex from 3M ESPE, Periogard from Colgate, Paroex from Sunstar Butler, and Oris from Dentsply. CPC rinses include Pro-Health Rinse from Crest, and Total Advanced Pro-Shield from Colgate.

The most studied essential oils rinse is Listerine from Johnson & Johnson. Rinses come in both alcohol-containing and alcohol-free formulas, which is a consideration for some patients.

The real value, I believe, in using a preprocedural mouth rinse is not so much for the infection prevention benefits, but for the perception of the patients that dentistry is doing one more thing to keep them safe.

In addition, introducing antimicrobial mouth rinses into the routine of the dental practice setting sets an example to the patients that dentists believe in their therapeutic value. Since many studies have shown that these antimicrobial rinses are effective in controlling the number of microorganisms involved in plaque formation, patients can help control their risk factors for periodontal diseases. It's a win-win in my book.

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