Earn 4 CE credits This course was written for dentists, dental hygienists, and assistants.

Brushing

Flossing Rinsing Essential Elements of Oral Care A Peer-Reviewed Publication Written by Gary Kaplowitz, DDS, MA, MEd

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This course has been made possible through an unrestricted educational grant. The cost of this CE course is $59.00 for 4 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. Educational Objectives Brushing and flossing are typically considered to be Upon completion of this course, the clinician will be able to basic procedures for good . The first modern do the following: with nylon bristles was available by 1938, and 1. Understand the incidence of caries and and use in modern times of a floss-type oral hygiene aid was first preventive measures to use against these diseases. addressed by Parmly in 1819 when he recommended that pa- 2. Understand the various devices and techniques available tients with gingivitis use “waxed silk” to clean their teeth in- for oral hygiene maintenance and their effectiveness. terdentally.4 By the mid-1900s clinicians were recommending 3. Understand patient compliance issues related to both toothbrushing and flossing for effective oral hygiene.5,6,7 brushing and flossing and the potential impact that lack More recently, electrically driven devices (first the electric of compliance has on oral health. toothbrush in 1960, followed later by electric interdental de- 4. Understand the various chemotherapeutic rinses vices and oral irrigators) have become available as alternatives that are effective against plaque and gingivitis, the to manual devices. Chemotherapeutic pastes and rinses have considerations required in selecting a mouthrinse, and been added to the arsenal of home care oral hygiene aids since the benefits of mouthrinsing in addition to brushing 1914 (Figure 1). and flossing. Figure 1. Evolution in Oral Care Abstract 1810 1914 1938 mid-1900s 1960 1970 Gains in oral health have been considerable in the last 50 years. However, by adolescence 68% of people have and gingivitis is also prevalent, with 50% of US adults experienc- Floss-type Modern nylon Clinicians First ing this around a minimum of three to four teeth. Brushing waxed silk bristle recommend electric gluconate and flossing are typically considered to be the basic procedures and essential toothbrush brushing toothbrush mouthrinses oil mouthrinse AND flossing introduced required for good oral hygiene; yet oral hygiene is generally introduced inadequately performed. Patient compliance issues related to brushing and flossing are well documented and well rec- Standard oral hygiene techniques ognized. Rinsing offers an opportunity to reduce plaque and Brushing and flossing are commonly known by the general gingivitis, incremental to the reductions obtained by brushing population to be important, and they have significantly con- and flossing alone. Use of a chemotherapeutic mouthrinse to- tributed to improved oral health. Clinical trials in the 1960s gether with brushing and flossing as a three-step program may demonstrated the importance of toothbrushing in preventing help to reduce plaque accumulation and prevent the formation and reducing gingivitis in children and students.8,9 The clas- of mature plaque and the onset of disease. sical study by Loe et al. demonstrated that cessation of brush- ing induces gingivitis.10 Introduction and Overview Regular removal of before it matures will Gains in oral health, together with the wider variety and im- prevent the development of anaerobic-rich subgingival proved designs of oral hygiene aids, have been considerable plaque. Until the third day of development, plaque is mostly in the last 50 years. However, oral health statistics indicate streptococcal and rod species. The streptococci are acid-pro- that there is still room for improvement. Gingivitis is preva- ducing, resulting in the initiation and progression of caries, lent, with 50% of US adults experiencing gingivitis around a and dominate plaque from between two and six hours after minimum of three to four teeth.1 Gingivitis is a preventable the plaque starts to form until anaerobic bacteria appear in in- and reversible disease, provided that adequate oral hygiene creasing numbers from day three onward.11 This corresponds measures are in place and dental plaque is diligently removed. with the findings of Lang et al. that experimental gingivitis Gingivitis presents with gingival inflammation and redness can be induced by avoiding brushing for more than 48 hours.12 and bleeding upon probing. Left untreated, gingivitis may Immature plaque removal helps prevent the development of progress to with soft and hard tissue gingivitis associated with anaerobic microbiota and prevents destruction. Advanced periodontal disease occurs in only a the development of a thick, well-differentiated supragingival small proportion of patients, affecting between 5% and 15% of and subgingival plaque (Figure 2). adults. The presence and progress of periodontal disease de- Brushing alone has not been found to be effective in pends on the host response and other factors. In the absence of reducing caries unless done in combination with anticaries periodontal bacteria and gingivitis it would not occur.2 Recent agents — predominantly as 1,000–11,000 ppm fluoride in decreases in caries have been slight, based upon data from the regular dentifrices. Brushing without flossing — and with- 1999–2002 NHANES study in comparison to the previous out use of an alternative interdental oral hygiene aid such as NHANES study in the early 1990s. By adolescence, 68% of interdental brushes — is ineffective at removing plaque inter- people have tooth decay, 90% of adults over the age of 40 have dentally. Flossing in addition to brushing was found to reduce coronal caries, and 32% of adults over age 50 have root caries.3 the incidence of interproximal caries by 50% in one study of

2 www.ineedce.com Figure 2. SEM agents as a rinse. One study found that using chlorhexidine gluconate in a home-use pulsed resulted in sta- tistically significant reduction in plaque vitality compared to rinsing with chlorhexidine gluconate.23

Oral Hygiene Habits Rigorous brushing and flossing with an appropriate technique and for an appropriate length of time are effective in remov- ing dental plaque. Even with intense patient education and well-designed brushes and floss (as well as other oral hygiene devices), oral hygiene generally is inadequately performed. The reasons for this range from lack of patient compliance to dexterity and health issues. Patient compliance issues related to brushing and flossing are well documented and well recognized. Based on a study of dental students, it has been found that brushing effectively for plaque removal can take up to five minutes.24 Brushing Courtesy of Dr. Gary Carr may be performed with either a manual or electric tooth- brush. Electric may be easier to use, particularly first-grade children when compared to contralateral teeth that where dexterity is an issue. Electric and manual toothbrushes were not flossed.13 are both effective. Most patients in the developed world have Most periodontal disease starts interdentally, specifically been found to brush for only one minute.25 in the col area,14 where brushing alone is ineffective. One study While it can be said that for lazy brushers, use of an found a 67% reduction in bleeding sites with both brushing electric toothbrush for one minute might result in speedier and flossing over a three-week period, versus a 35% reduc- removal of plaque compared to a manual toothbrush, the tion with brushing alone,15 indicative of the ineffectiveness duration of brushing may be reduced and/or areas skipped. of brushing alone and the effectiveness of flossing. Studies Neither a manual nor an electric toothbrush can adequately comparing the efficacy of different types of floss found no dif- interdental areas to mechanically remove interdental ferences in results achieved with waxed, unwaxed, or flavored plaque. For this, use of floss or another interdental cleaner is floss variants.16,17 essential. The majority of people either do not use floss daily Studies suggest that interdental brushes offer an al- or in some cases do not use floss at all. Surveys have found that ternative that may be more acceptable to patients and/or at least 50% of patients state they do not floss at all and that at easier to use than floss and provide superior reductions least 90% do not floss daily26 (Figure 3). When dental profes- in plaque and gingivitis compared to flossing. Kiger et al. sionals are surveyed or report patient data, the results show found in a 30-day study that interproximal plaque scores that a small minority of patients floss on a daily basis.27,28,29 were significantly lower in patients brushing and using in- A study assessing flossing skills and compliance a year after terdental brushes compared to patients brushing and floss- training in the use of floss found that although participants ing.18 In one study, 95% of interdental plaque was removed retained their flossing skills, their clinical indices were back to using interdental brushes.19 the baseline values at the start of the study — indicating non- More recently, electric interdental devices such as the compliance.30 With repeated education and reinforcement on Hummingbird (Oral B) and Interclean have been intro- the importance of brushing and flossing, patients still revert duced. Clinical trials assessing these found them to be as over a relatively short period of time to their previous poor effective as regular floss in reducing plaque and gingivitis, oral hygiene habits for both brushing and flossing.31,32 but not more effective.20,21,22 Other adjunctive or alternative oral hygiene devices in- Figure 3. Patient reported percentage flossing clude oral irrigation devices. These may be used with water or with the addition of a chemotherapeutic agent. Studies have 0 20 40 60 80 100 produced varying results with use of these devices; however, they may be a useful adjunct for some patients. One study comparing use for two minutes of either an electric toothbrush or an oral irrigator found the oral irrigator to remove signifi- Do not floss daily cantly more plaque than the electric toothbrush. The addition of a chemotherapeutic agent to oral irrigators may provide incremental benefits over the use of the chemotherapeutic Do not floss www.ineedce.com 3 The other main issue which is implicated in poor oral gluconate to help reduce plaque and gingivitis, aid healing hygiene is a lack of dexterity. Compared to interdental clean- and prevent infection, and reduce the bacterial load. It has ing, toothbrushing is relatively uncomplicated and, except also been used preprocedurally34 and in endodontic therapy.35 for patients with severe disabilities, can be accomplished with Use of CHX in the absence of any other oral hygiene mea- either a manual or an electric toothbrush. Interdental clean- sures has demonstrated its ability to prevent the development ing requires more coordination and dexterity than brushing, of plaque and gingivitis over a 21-day period36 — making it even with the use of electric devices. Physically challenged in- useful for situations such as immediately postsurgically when dividuals may be unable to adequately perform oral hygiene regular brushing and flossing procedures may be difficult measures, and as the population ages, it can be anticipated that due to tenderness. Loe et al. demonstrated that twice-daily the number of people with dexterity issues or systemic health rinsing with CHX can also be effective in inhibiting smooth issues precluding good brushing and flossing will increase. surface caries,37 and it has been shown to reduce the levels of cariogenic bacteria. Chemotherapeutic Agents Adjunctive use of CHX results in incremental plaque and Chemotherapeutic agents for home use for the prevention gingivitis reduction over and above reductions due to regular and treatment of oral disease are widely available today as oral hygiene procedures (brushing and flossing). Clinical pastes, gels, and rinses. They include over-the-counter and trials have repeatedly demonstrated plaque and gingivitis re- prescription products for caries prevention, plaque reduction, ductions with CHX use in addition to brushing and flossing. and the reduction and prevention of gingivitis. Fluoride use Taller found a 33% reduction in bleeding compared to brush- in has been the largest single contributing factor ing and flossing only with twice daily rinsing for five weeks,38 in the decline of dental caries, and it is the most widely used and plaque reductions in the range of 41% to 65% have been oral care chemotherapeutic. For patients at higher caries risk found with chlorhexidine gluconate usage. — such as orthodontic patients, patients with a high caries Essential oil mouthrinses were first introduced in 1914. rate or recent caries experience, and patients with xerostomia These rinses are a mixture of phenolic compounds with a — fluoride is available at concentrations of up to 5,000 ppm bactericidal effect. Measurement of the bactericidal effect in prescription pastes and gels. Chemotherapeutic rinses and during an in situ study found that following rinsing with pastes that target plaque and gingivitis are available in the US essential oil mouthrinse, 78.7% of bacteria were dead in test with various active ingredients, including chlorhexidine glu- samples versus 27.9% after rinsing with a negative control.39 conate, essential oils, zinc chloride, cetylpyridinium chloride Essential oil mouthrinse has been shown in vitro to interfere (CPC), stannous fluoride, and combinations of these. Che- with cell-surface-related activities — demonstrated by inhi- motherapeutic pastes typically replace a regular dentifrice, to bition of the platelet aggregation activity of oral bacteria.40 provide enhanced benefits. The most widely used in the US A recent in vivo study found that an essential oil mouthrinse is a /copolymer dentifrice ( Total), which has ( Antiseptic™) interfered with the inflamma- been shown in clinical trials to significantly reduce plaque tory process. During a two-week period, rinsing was carried and gingivitis as well as to inhibit the progress of periodontal out twice daily without brushing and flossing, either with disease.33 This particular formulation has also been shown Listerine or chlorhexidine gluconate. While slightly more to provide anticaries benefits over and above the benefits of plaque formed during the two weeks with Listerine use than the fluoride contained in either this formulation or a regular with chlorhexidine use, there was no significant difference fluoride dentifrice. in gingival bleeding41 (Figure 4).

Chemotherapeutic Rinses Figure 4. Chemotherapeutic rinses The most widely used chemotherapeutic mouthrinses in the Anti- US are essential oils and chlorhexidine gluconate mouthrinses, Rinse Mode of plaque/ Staining Effecton both of which have been found to be effective for plaque and action gingivitis efficacy gingivitis reduction. Chlorhexidine gluconate rinses were first introduced in Chlorhexi- dine Bacteri- Yes Yes Increases Europe, in the 1970s (Corsodyl, ICI). In the US, chlorhexi- gluconate cidal dine gluconate (CHX) is available by prescription only, at ® Essential Bacteri- a concentration of 0.12% (Peridex , Zila Pharmaceuticals; oils cidal Yes No None Periogard®, Colgate Oral Pharmaceuticals; GUM®, Sunstar Cetyl- Butler). Chlorhexidine is cationic and binds to bacteria and pyridinium Bacteri- Yes No None oral surfaces that are mostly anionic. It is bactericidal, induc- chloride cidal ing rupture of bacterial cell walls and cell death. Chlorhexi- dine gluconate is regarded as the gold standard antimicrobial Zinc Bacteri- chloride cidal Yes No Decreases rinse for short-term use. Studies have shown chlorhexidine

4 www.ineedce.com Adjunctive use of essential oil mouthrinse in addition to and to combat oral malodor. Use of 0.09% zinc chloride over brushing and flossing in one controlled trial produced a 54% a 16-week period has been found to reduce calculus by 21%.56 reduction in plaque and 34% reduction in bleeding with twice Plaque reductions and reductions in plaque acidogenicity daily use for 30 seconds.42 Two other trials assessed essential have also been found in zinc chloride mouthrinse trials.57 oil mouthrinse adjunctively after brushing and flossing. One trial resulted in a 34% reduction in plaque and gingivitis after Brushing, Flossing, and Rinsing six months of use compared to brushing and flossing and use Regularly removing a maximum amount of plaque is key for of a placebo rinse.43 A study over a six month period compar- oral health maintenance. Brushing and flossing are irregularly ing use of the essential oil mouthrinse versus a control rinse and often haphazardly performed, allowing plaque to mature used adjunctively found a 21% and 51.9% reduction in modi- and enabling the onset of gingivitis. Mature plaque also de- fied gingival and plaque indices respectively.44 creases the impact of chemotherapeutic rinses. Once a thick Essential oil mouthrinse has also been found to decrease layer of plaque is present, mouthrinses cannot penetrate into the anaerobic and aerobic bacteria associated with bacteremia the depths of the plaque.58 The problem is compounded by when used as a subgingival irrigant prior to scaling. Preproce- the fact that bacteria are more vital within the deepest areas dural rinsing can decrease the number of bacteria aerosolized of the plaque.59 during dental procedures, and both are used preprocedurally Rinsing is easier than either brushing or flossing and takes in clinics.45 Studies have shown that both essential oil and less time, therefore requiring a shorter attention span. Patients chlorhexidine mouthrinses have anti-Candida properties also tend to be more concerned with “fresh breath” than with and are therefore helpful for immunocompromised patients plaque and gingivitis levels, and patient compliance with subject to opportunistic candidiasis.46 Essential oil mouth- rinsing may be superior to patient compliance with adequate rinse has been found to be effective in reducing the levels of brushing and flossing (or other ). cariogenic bacteria intraorally. Subjects rinsing with Listerine Optimally, mouthrinsing should be performed twice for 30 seconds twice daily for 12 days were found to have daily. The substantivity of current mouthrinses is of less than 75% reductions of Streptococcus mutans in plaque and 39.2% 12 hours duration60,61 and after four days of not rinsing, it has reductions in saliva.47 been shown that bacterial composition of plaque returns to Long-term use of essential oil and chlorhexidine glu- its baseline level before rinsing was initiated.62 While once- conate mouthrinses have found no evidence of microbial daily rinsing will effectively reduce bacterial levels for several resistance.48,49 While CHX has a strong affinity for oral hard hours, twice-daily mouthrinsing is required for a clinically and soft tissues and is the most effective chemotherapeutic for effective regimen. plaque control,50 it can be associated with increased calculus Regular rinsing in addition to brushing and flossing may formation, as well as brownish staining and temporary taste increase the chances of improved plaque removal — although disturbances that are reversed when use is discontinued. Due it is an additional step. If patients do not floss well or do not to these potential side effects, CHX is generally indicated for brush well, at least they will have the benefit of rinsing. short-term or intermittent short-term use except in special Based on a survey of dental hygienists, 70% of patients situations such as following head and neck irradiation. do not think that rinsing replaces flossing, indicating that Other chemotherapeutic mouthrinses available include patients see rinsing as an additional step rather than an al- cetylpyridinium chloride and zinc chloride. A recent study ternative.63 While intended and seen as an additional step comparing the use of 0.07% CPC mouthrinse and essential oil when noncompliance or partial compliance is already an mouthrinse twice daily for 21 days concluded that they had issue in a two-step procedure, and due to the ease and speed equivalent antiplaque and antigingivitis efficacy.51 In another of rinsing relative to brushing and flossing along with “fresh study, use of 0.07% CPC mouthrinse following brushing, breath” concerns, otherwise noncompliant patients may compared to brushing alone, reduced plaque coverage on nonetheless add rinsing to their regimen if recommended. teeth by 42%.52 In a third study, rinsing with 0.07% CPC Brushing alone, in the absence of chemotherapeutic agents, mouthrinse twice daily after brushing demonstrated plaque reduces and removes plaque purely by the mechanical reductions of 15.8% and a 33% reduction in gingival bleed- action of brushing. Plaque remaining on the teeth after ing versus negative control.53 In a study using 0.05% CPC brushing alone contains viable microbes that have not been mouthrinse, a 28% reduction in plaque and a 63% reduction subjected to bactericidal agents, allowing the plaque to con- in plaque severity indices as well as a 24% reduction in the tinue to grow and mature. Introducing a bactericidal rinse gingival index were found.54 In comparing 0.2% chlorhexi- into the regimen (including where chemotherapeutic pastes dine rinse with 0.12% chlorhexidine rinse containing 0.05% are used) may provide additional benefits for patients, es- CPC (the rinse times and dosage of CHX were adjusted for pecially interdentally in harder-to-reach areas. Patients who the different concentrations), no differences were found in brush well and floss daily may still benefit from adjunctive their ability to reduce plaque.55 Zinc chloride mouthrinse is rinsing to help prevent the development and initial matura- typically used for the prevention of calculus accumulation tion phase of fresh plaque, thereby reducing the presence www.ineedce.com 5 of acid-producing cariogenic bacteria associated with early 16. Lobene RR et al. Use of : Effect on plaque and plaque formation. In choosing a chemotherapeutic mouth- gingivitis. Clin Prev Dent 1982; 4(1):5–8. 17. Lamberts D et al. The effect of waxed and unwaxed dental floss rinse, considerations include the health status of the patient, on gingival health. J Periodontol 1982; 53(6):393–396. whether the rinse is intended for short-term or long-term 18. Kiger R et al. A comparison of proximal plaque removal use, efficacy, propensity for staining, lack of microbial resis- using floss and interdental cleaners. J Clin Periodontol 1991; tance, taste, and clinician and patient preferences. 18:681–684. 19. Schmage P, Platzer U, Nergiz I. Comparison between manual and mechanical methods of interproximal hygiene. Quintessence Summary Int. 1999 Aug; 30(8):535–9. The lack of compliance or poor results obtained by patients 20. Gordon JM, Frascella JA, Reardon RC. A clinical study of the who brush and floss are well documented and evident to safety and efficacy of a novel electric interdental cleaning device. J Clin Dent. 1996; 7(3 Spec No):70–3. dental professionals on a daily basis. Chemotherapeutic 21. Isaacs RL, Beiswanger BB, Crawford JL, Mau MS, Proskin rinses offer an opportunity to reduce plaque and gingivitis, H, Warren PR. Assessing the efficacy and safety of an electric incremental to the reductions obtained by brushing and interdental cleaning device. JADA 1999 Jan; 130(1):104–8. flossing alone. Rinsing is quicker and easier than flossing or 22. Cronin MJ, Dembling WZ, Cugini M, Thompson MC, Warren PR. A 30-day clinical comparison of a novel interdental cleaning use of another interdental aid, and while not a replacement device and dental floss in the reduction of plaque and gingivitis. for these activities, adding rinsing to the regimen might at J Clin Dent. 2005; 16(2):33–7. least help noncompliant patients reduce their plaque levels by 23. Walsh TF, Unsal E, et al. The effect of irrigation with means other than less than optimal interdental cleaning and chlorhexidine or saline on plaque vitality. J Clin Periodontol 1995; 22(3):262–264. toothbrushing. Given the importance of plaque reduction in 24. Hawkins B and Lainson P. Duration of toothbrushing for oral health and the oral-systemic health connection, measures effective plaque control. Periodontics 1986; 17(6):361–365. to reduce plaque and gingivitis are of increased importance. 25. Baehni PC. Takeuchi Y. Antiplaque agents in the prevention Patients’ use of a chemotherapeutic mouthrinse together with of biofilm-associated oral disease. Oral Diseases 2003; 9 (suppl):23–29. brushing and flossing as a three-step program may help to 26. Craig T and Montigue J. Family oral health survey. JADA 1976; reduce plaque accumulation, prevent the formation of mature 92:326–332. plaque, and delay the onset of diseases. 27. Ciancio S. Improving oral health: current considerations. J Clin Periodontol 2003; 30 (suppl) 5:4–6. 28. www.docere.com. HygieneTown Survey. July 2005. References 29. Lang W et al. The relation of preventive dental behaviors to 1. Center for Disease Control. Accessed June 2006. periodontal health status. J Clin Periodontol 1994; 21:194–198. 2. Epidemiology of Periodontal Diseases. J Periodontol 2005; 30. Stewart J and Wolfe G. The retention of newly acquired brushing 76:1406–1419. and flossing skills. J Clin Periodontol 1989; 16:331–332. 3. www.cdc.gov. Accessed July 2006. 31. Julien M. The effect of behavior modification techniques on oral 4. Parmly L. Practical guide to the management of the teeth. hygiene and gingival health of 10-year-old Canadian children. Philadelphia; Collins and Croft, 1819. Inter J Paediat Dent 1994; 4:3–11. 5. Bass C. The cause and prevention of the loss of teeth. New 32. Stewart J and Wolfe G. The retention of newly acquired brushing Orleans Med and Surg J 1940; 93:227–231. and flossing skills. J Clin Periodontol 1989; 16:331–332. 6. Smith T. Anatomic and physiologic conditions governing the 33. Panagakos FS, Volpe AR, et al. Advanced oral antibacterial/ use of the toothbrush. JADA 1940; 27:874. anti-inflammatory technology: A comprehensive review of the 7. Arnim S. 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Li J, Helmerhorst EJ, Leone CW, Troxler RF, Yaskell T, Haffajee plaque and gingivitis in man. J Periodont Res 1970; 5:79–83. AD, Socransky SS, Oppenheim FG. Identification of early 37. Loe H, van der Fehr FR, Schiott CR. Inhibition of experimental microbial colonizers in human dental biofilm. J Appl Microbiol. caries by plaque prevention. The effect of chlorhexidine 2004; 97(6):1311–8. mouthrinses. Scand J Dent Res 1972; 80:1–9. 12. Lang P et al. Toothbrushing frequency as it relates to plaque 38. Taller H. The effect of baking soda/ dentifrice development and gingival health. J Periodontol 1973; 44970; (Mentadent) and a 0.12 percent chlorhexidine mouthrinse 396–405. (Peridex) in reducing gingival bleeding J New Jersey Dent Ass 13. Wright G et al. The Dorchester dental flossing study: Final 1993; 23–26. report. Clin Prev Dent 1979; 1(3):23–26. 39. Pan P, Barnett ML, Coelho J, Brogdon C, Finnegan MB. 14. Wilkins EM. Clinical Practice of the Dental Hygienist. 8th ed. Determination of the in situ bactericidal activity of an essential Philadelphia: Lippincott Williams & Wilkins; 1999:372. oil mouthrinse using a vital stain method. J Clin Periodontol 15. Graves R et al. Comparative effectiveness of flossing and 2000 Apr; 27(4):256–61. brushing in reducing interproximal bleeding. J Periodontol 1989; 40. Whitaker EJ, Pham K, Feik D, Rams TE, Barnett ML, Pan P. 60(5):243–247. Effect of an essential oil containing antiseptic mouthrinse on

6 www.ineedce.com induction of platelet aggregation by oral bacteria in vitro. J Clin chlorhexidine mouthrinses. J Clin Periodontol 2005 Mar; Periodontol. 2000 May;27(5):370–3. 32(3):305–9. 41. Sekino S, Ramberg P. The effect of a mouth rinse containing 56. Charles CH, Cronin MJ, Conforti NJ, Dembling WZ, Petrone phenolic compounds on plaque formation and developing DM, McGuire JA. Anticalculus efficacy of an antiseptic gingivitis. J Clin Periodontol. 2005 Oct;32(10):1083–8. mouthrinse containing zinc chloride. J Am Dent Assoc 2001 Jan; 42. Esposito M, Worthington HV, Thomsen P, Coulthard P. 132(1):94–8. Interventions for replacing missing teeth: maintaining health 57. Giertsen E, Scheie AA, Rolla G. Dose-related effects of ZnCl2 around dental implants. Cochrane Database Syst Rev 2004; 3: on dental plaque formation and plaque acidogenicity in vivo. CD003069. Caries Res 1989; 23(4):272–7. 43. DePaola L et al. Chemotherapeutic inhibition of supragingival 58. Zaura-Arite E, van Marle J, ten Cate JM. Confocal microscopy dental plaque and gingivitis development. J Clin Periodontol study of undisturbed and chlorhexidine-treated dental biofilm. J 1989; 16:311–315. Dent Res 2001; 80:1436–1440. 44. Sharma N, Charles CH, Lynch MC, Qaqish J, McGuire JA, 59. Auschill TM, Arweiler NB, Netuschil L, Brecx M, Reich E, Galustians JG, Kumar LD. Adjunctive benefit of an essential Sculean A. Spatial distribution of vital and dead microorganisms oil-containing mouthrinse in reducing plaque and gingivitis in in dental biofilms. Arch Oral Biol 2001;46(5):471–476. patients who brush and floss regularly: a six-month study. J Am 60. Zaura-Arite E, van Marle J, ten Cate JM. Confocal microscopy Dent Assoc. 2004 Apr; 135(4):496–504. study of undisturbed and chlorhexidine-treated dental biofilm. J 45. Hennessy B, Joyce A. A survey of preprocedural antiseptic Dent Res 2001 May; 80(5):1436–40. mouthrinse use in army dental clinics. Mil Med. 2004 Aug; 61. Bonesvoll P. et al. A comparison between chlorhexidine with 169(8):600–3. regard to retention, salivary concentration and plaque-inhibiting 46. Ciancio S. Expanded and future uses of mouthrinses. J Am Dent effect in human mouth after mouthrinses. Arch Oral Biol 1978; Assoc. 1994 Aug; 125 (suppl) 2:29S–32S. 23:289–294. 47. Fine DH, Furgang D et al. Effect of an essential oil-containing 62. Sekino S, Ramberg P, Uzel NG, Socransky S, Lindhe J. The antiseptic mouthrinse on plaque and salivary Streptococcus effect of a chlorhexidine regimen on de novo plaque formation. mutans levels. J Clin Periodontol 2000; 27(3):157–161. J Clin Periodontol 2004 Aug; 31(8):609–614. 48. Ross NM, Charles CH, Dills SS. Long-term effect of Listerine 63. www.hygienetown.com. Survey, January 2005. antiseptic in dental plaque and gingivitis. J Clin Dent 1989; 1(4):92–95. 49. Kaplowitz GJ, Cortell M. Chlorhexidine: a multi-functional Author profile antimicrobial drug. ADTS 2005. Dr. Kaplowitz retired from the military 50. Baehni PC, Takeuchi Y. Anti-plaque agents in the prevention after serving as chief dental officer of the of biofilm-associated oral disease. Oral Diseases 2003; 9 US Coast Guard. He is a graduate of the (suppl):23–29. 51. Witt JJ, Walters P, Bsoul S, Gibb R, Dunavent J, Putt M. New York University College of Den- Comparative clinical trial of two antigingivitis mouthrinses. Am tistry and is a diplomate of the American J Dent. 2005 Jul; 18 Spec No:15A–17A. Board of General . He has 52. Kozak KM, Gibb R, Dunavent J, White DJ. Efficacy of a high published widely on dental materials and bioavailable cetylpyridinium chloride mouthrinse over a 24- hour period: a plaque imaging study. Am J Dent 2005 Jul; 18 clinical techniques. He is editor of OsseoNews.com and is in Spec No:18A–23A. private practice in York, Pennsylvania. 53. Mankodi S, Bauroth K, Witt JJ, Bsoul S, He T, Gibb R, Dunavent J, Hamilton A. A six-month clinical trial to study the effects of Disclaimer a cetylpyridinium chloride mouthrinse on gingivitis and plaque. Am J Dent 2005 Jul; 18 Spec No:9A–14A. The author of this course has no commercial ties with the 54. Allen DR, Davies R, Bradshaw B, Ellwood R, Simone AJ, sponsors or the providers of the unrestricted educational Robinson R, Mukerjee C, Petrone ME, Chaknis P, Volpe grant for this course. AR, Proskin HM. Efficacy of a mouthrinse containing 0.05% cetylpyridinium chloride for the control of plaque and gingivitis: a six-month clinical study in adults. Compend Contin Educ Reader Feedback Dent 1998; 19 (2 suppl):20–6. We encourage your comments on this or any PennWell course. 55. Van Strydonck DA, Timmerman MF, Van der Velden U, Van der For your convenience, an online feedback form is available at Weijden GA. Plaque inhibition of two commercially available www.ineedce.com.

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1. Gingivitis is present in a minimum of 11. One study found that brushing 21. Chlorhexidine mouthrinses are three to four teeth in what percentage and flossing resulted in a ___ a. Bactericidal, causing and cause bacterial cell walls of the US population? reduction in bleeding sites over a to rupture a. 20% three-week period. b. Bacteriostatic b. 30% a. 33% c. Effective in reducing plaque and gingivitis c. 50% b. 45% d. a and c d. 75% c. 67% d. 76% 22. Essential oil mouthrinse was first 2. Advanced periodontal disease introduced in affects what percentage of the 12. Studies comparing the oral hygiene a. 1856 US population? results achieved using different types b. 1896 a. 2%–5% of floss found that c. 1914 b. 5%–15% a. Waxed floss gave the best results d. 1930 b. Unwaxed floss gave the best results c. 25% c. No differences were found with waxed, unwaxed, d. 40% 23. Essential oil mouthrinses have been or flavored flosses d. Flavored floss gave the best results shown to be 3. Clinicians were recommending both a. Bactericidal brushing and flossing by 13. Most periodontal disease starts b. Bacteriostatic a. The mid-1800s a. Interdentally c. a and d b. The early 1900s b. Buccally d. Effective in reducing plaque and gingivitis c. The mid-1900s c. Lingually d. 1980 d. All of the above 24. When used as a subgingival irrigant, essential oil mouthrinse has been 4. The first floss-type oral hygiene aid 14. Issues in the attainment of good oral shown to in modern times was hygiene are a. Decrease anaerobic bacteria a. Cotton thread a. Patient compliance issues b. Decrease aerobic bacteria b. Waxed silk b. Dexterity issues c. Gauze c. Lack of ownership of a toothbrush c. a and b d. Thin string d. a and b d. None of the above 5. The first electric toothbrush was 15. Up to what percentage of patients 25. AntiCandida properties have been introduced in do not floss daily? found in a. 20% a. 1920 a. Chlorhexidine mouthrinse b. 30% b. 1950 b. Essential oil mouthrinse c. 55% c. a and b c. 1960 d. 90% d. 1975 d. None of the above 16. Based on the literature, 6. Regular removal of dental with concentrated educa- 26. Use of chlorhexidine mouthrinse plaque prevents tion and reinforcement can be associated with a. The formation of an anaerobic-rich a. Patients maintain good oral hygiene a. Staining subgingival plaque b. No improvement is seen, even short-term b. Temporary taste disturbances b. Bell’s palsy c. Patients brush less c. Increased calculus formation c. Trigeminal neuralgia d. Patients often revert to their previous oral hygiene d. All of the above d. All of the above habits over a short period of time 27. CPC mouthrinse has been found to 7. Until the third day of development, 17. Patients in the developed world have a. Be effective in reducing plaque and gingivitis dental plaque contains mainly been found to brush on average for b. Increase calculus formation a. Streptococci and rods a. 30 seconds c. a and b b. spirochetes b. One minute d. None of the above c. Anaerobic bacteria c. Three minutes d. Fungi d. Five minutes 28. Zinc chloride mouthrinse has been found to 8. Experimental gingivitis can be 18. The most widely used chemothera- peutic agent in oral care is a. Be Effective in reducing calculus formation induced by not brushing for b. Be Effective in combating a. 12 hours a. Fluoride b. Iodide c. Increase calculus formation b. 24 hours c. Chlorhexidine d. a and b c. 48 hours d. All of the above d. 72 hours 29. The substantivity of currently 19. Chemotherapeutic rinses targeting 9. According to the article, effective available mouthrinses is of plaque and gingivitis may contain brushing has been found to take up to a. Three hours’ duration a. Essential oils b. Less than five hours’ duration a. 3 minutes b. Cetylpyridinium chloride (CPC) c. Less than 12 hours’ duration b. 5 minutes c. Chlorhexidine d. 24 hours’ duration c. 7 minutes d. Any of the above d. None of the above 20. Chlorhexidine mouthrinses were 30. Rinsing in addition to brushing and 10. Brushing alone has been found to be first introduced flossing may help to a. Effective in reducing caries a. In Europe in the 1950s a. Reduce plaque b. Ineffective in reducing caries b. In Europe in the 1970s b. Reduce gingivitis c. Effective in removing interdental plaque c. In the US in 1899 c. Prevent the formation of mature plaque d. None of the above d. In both the US and Europe in 1986 d. All of the above

8 www.ineedce.com ANSWER SHEET Essential Elements of Oral Care

Name: Title: Specialty:

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City: State: ZIP:

Telephone: Home ( ) Office ( )

Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 4 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp.

Mail completed answer sheet to Educational Objectives Academy of Dental Therapeutics and Stomatology, 1. Understand the incidence of caries and gingivitis and preventive measures to use against these diseases. A Division of PennWell Corp. 2. Understand the various devices and techniques available for oral hygiene maintenance and their effectiveness. P.O. Box 116, Chesterland, OH 44026 or fax to: (440) 845-3447 3. Understand patient compliance issues related to brushing and flossing and the potential impact that lack of compliance has on oral health. For immediate results, go to www.ineedce.com 4. Understand the various chemotherapeutic rinses that are effective against plaque and gingivitis, the considerations and click on the button “Take Tests Online.” Answer sheets can be faxed with credit card payment to required in selecting a mouthrinse, and the benefits of mouthrinsing in addition to brushing and flossing. (440) 845-3447, (216) 398-7922, or (216) 255-6619. Payment of $59.00 is enclosed. (Checks and credit cards are accepted.) Course Evaluation If paying by credit card, please complete the Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. following: MC Visa AmEx Discover 1. Were the individual course objectives met? Objective #1: Yes No Objective #3: Yes No Acct. Number: ______Objective #2: Yes No Objective #4: Yes No Exp. Date: ______2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0 Charges on your statement will show up as PennWell

3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0

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9. Would you participate in a similar program on a different topic? Yes No

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PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.

AUTHOR DISCLAIMER INSTRUCTIONS COURSE CREDITS/COST RECORD KEEPING The author of this course has no commercial ties with the sponsors or the providers of All questions should have only one answer. Grading of this examination is done All participants scoring at least 70% (answering 21 or more questions correctly) on the PennWell maintains records of your successful completion of any exam. Please contact our the unrestricted educational grant for this course. manually. Participants will receive confirmation of passing by receipt of a verification examination will receive a verification form verifying 4 CE credits. The formal continuing offices for a copy of your continuing education credits report. This report, which will list form. Verification forms will be mailed within two weeks after taking an examination. education program of this sponsor is accepted by the AGD for Fellowship/Mastership all credits earned to date, will be generated and mailed to you within five business days SPONSOR/PROVIDER credit. Please contact PennWell for current term of acceptance. Participants are urged to of receipt. This course was made possible through an unrestricted educational grant. No EDUCATIONAL DISCLAIMER contact their state dental boards for continuing education requirements. PennWell is a manufacturer or third party has had any input into the development of course content. The opinions of efficacy or perceived value of any products or companies mentioned California Provider. The California Provider number is 3274. The cost for courses ranges CANCELLATION/REFUND POLICY All content has been derived from references listed, and or the opinions of clinicians. in this course and expressed herein are those of the author(s) of the course and do not from $49.00 to $110.00. Any participant who is not 100% satisfied with this course can request a full refund by Please direct all questions pertaining to PennWell or the administration of this course to necessarily reflect those of PennWell. contacting PennWell in writing. Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or [email protected]. Many PennWell self-study courses have been approved by the Dental Assisting National Completing a single continuing education course does not provide enough information Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet © 2008 by the Academy of Dental Therapeutics and Stomatology, a division COURSE EVALUATION and PARTICIPANT FEEDBACK to give the participant the feeling that s/he is an expert in the field related to the course DANB’s annual continuing education requirements. To find out if this course or any other of PennWell We encourage participant feedback pertaining to all courses. Please be sure to complete the topic. It is a combination of many educational courses and clinical experience that PennWell course has been approved by DANB, please contact DANB’s Recertification survey included with the course. Please e-mail all questions to: [email protected]. allows the participant to develop skills and expertise. Department at 1-800-FOR-DANB, ext. 445.

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