I would definitely NOT recommend long term use of any alcohol based mouthwash.

Oral hygiene is maintained primarily by regular tooth brushing and flossing, but adjunctive anti-bacterial chemicals are indeed necessary to remove biofilms from regions of periodontal destruction that complicate cleaning after therapy (Slots J. Periodontology 2000: 60, 110–137 2012). Yet the most commonly sold mouthwashes in the United States are made from mixtures of volatile aromatic compounds from plants that require 15 - 20% alcohol to remain soluble. Mixtures of these plant compounds possess a unique scent or essence and are commonly called “essential oil” mixtures. The antiseptic properties of these "essential oils" control the pathogenic (successor) microbiota, but the long-time daily use of any alcohol based mouthwash predisposes to oral cancer (McCullough MJ, Farah CS. Australian Dental Journal 2008; 53: 302–305). Less popular mouthwashes contain an antiseptic called chlorhexidine (Peridex) or a detergent that interferes with bacterial biofilm aggregation called delpolminol (Decapinol). Nevertheless, the prolonged use of ANY antiseptic or antibiotic mouthwash promotes bacterial resistance, upsets healthy microbial interactions (probiosis) and predispose the oral cavity to fungal and other oral infections (Addy M, Moran J, Newcombe RG. J Clin Periodontol 2007;34(1):58-65).

The next generation of drugs to supplement oral hygiene may interfere more specifically with one of four actions: (a) initial stages of bacterial attachment to teeth surfaces; (b) coaggregation of successor bacteria into a biofilm; (c) quorum sensing (bacterial agents that promote mutualistic bacterial growth in biofilms or liquid culture); and (d) lysine decarboxylase impairment of the epithelial attachment barrier to bacterial products. Most bacterial products induce inflammation in the gingiva by activating prokaryotic pattern-recognition receptors. Recent studies by the author suggest that immunological inhibition of E. corrodens lysine decarboxylase in beagle dogs (Peters JL, et al. Vaccine 30 (2012) 6706– 6712), or perhaps chemical inhibition of this enzyme in humans (Lohinai Z, et al. J Periodontol, 83 1048-1056) may retard gingivitis development and the eventual development of chronic periodontitis.

Very well said Martin, but i would like to focus your attention on the compliance of the mouthwash by the patient, as many a times patients become overwhelmed by the response of the m/w that they keep on using it without being prescribed bcoz most alcoholbased m/w are OTC drugs or sold in departmental stores.

Many patients if prescribed the mouthwashes keep on using it (unless it is strictly a prescription drug).

Too true - and oh how these mouthwashes are advertised!. Sale of alcohol-based mouthwashes make lots of money for the company but do little or nothing for biofilm accumulation or bad breath (halitosis) except to make the mouth feel good and remove the halitosis for an hour or so.

So just tell your patients that studies in Australia clearly indicate that these mouthwashes will predispose to oral cancers, if they keep on using them and that any statements to the contrary are simply not true.

Hi,

but: - who is recommending that? Do you have any data whether dentists ("we") are recommending alcohol based mouth washes for regular use? Your question is formulated as if every dentist would do that; and I can't imagine that this is true. At least Martin and me don't do that ;-)

You already mentioned yourself that the patient, who is bombed with advertisements, should be addressed, but the busy reader has in mind now from the headline that obviously these bad dentists are responsible for the misuse of the mouth-washes.

And yes, we should inform our patients about the risks, like Matin recommended, and therefore bringing up this topic is very important.

There are a lot of alcohol-free mouth-washes. Are there any studies whether or not they are different to the alcohol-based concerning the outcome (measured as bacterial load, taste, longevity of influence, predisposal for whatever disease)?

Yango

Hi Yango, your concern is good and ethically right. But may i ask one question on this platform that how many dental surgeons in this world of moneymaking are practising or researching ethically and obeying their conscience. I know about myself that i do both as my conscience allows. I am giving a link which has an article advocating the use of alcohol based mouthwashes.

http://www.ncbi.nlm.nih.gov/pubmed/19838548

If such is the level of confusion then we cannot directly blame our fraternity but only check the usage compliance.

I am against the use of such m/w but i come across many patients both from medium to high socioeconomic strata of society who are using these and want our support or recommendation for this.

Saurabh

The article you mention does not cite the detailed evidence for a link between the frequent use of alcohol mouthwashes and cancer reported in the Australian Dental J. We try to tell our students how to recognize good, comprehensive evidence, but that can be difficult to discern without a good scientific background which, alas, in the US seems to be disappearing. I do not deny that the essential oils may be helpful for controlling biofilm development, but they cannot be used indefinitely. The recent Slots paper lists a number of good non-alcoholic mouthwashes starting on page 118. And Yango, thanks for your comment.

Martin

I feel, only patients with xerostomia should be strictly on non-alcohol based mouthwash, cause it causes more dryness in oral cavity. Other than that, the concentration of alcohol is much less and there is no evidence to prove that these would lead to cancer. Yes, non-alcohol based mouthwash are also available in market, but i dont find any hard core evidence to completely rule out alcohol-based mouthwash from my practice.

Amit - As you feel, but please be sure that the alcohol based mouthwashes are not used daily for long periods. This especially applies to Listerine which has 20% alcohol (http://en.wikipedia.org/wiki/Listerine), or Scope which has close to 10% alcohol (http://www.pg.com/productsafety/msds/health_care/oral_care/Scope_Dual-Blast_Mouthwash_-_Fresh_Mint_Blast.pdf). As I wrote already, The Slots paper (PM:22909110) lists a number of good non-alcoholic mouthwashes starting on page 118.

Amit Sir, do you prescribe the alcohol-based m/w in your practice or verbally support the use of these by patients. Bcoz in both the cases the usage has to be discontinuous and periodic due to the ill effects of alcohol on the oral mucosa however minimal depending on the usage.

One more thing to notice here is that most of the patients use mouthwashes to mask the halitosis which may be due to local factors or systemic. One common local factor may be the use of tobacco or alcohol in their habits which gives added cytological stress to the oral mucosa.

Alcohol based mouthwashes have their own disadvantages if used for a long period of time time dry mouth, burning sensation and other major adverse effects. But used with caution i.e diluted to a good extent 1:1 or even better dilution ratio as in case of CHX where the effect of the mouthwash is at microgram against the microbes and has a good substantivity too. Use of Listerine with dilution for a short period of time is advisable post surgery or post instrumentation (after scaling). But this should be used only as an adjunct till the patient is able to adapt to your oral hygiene regimen. It is necessary to mechanically remove plaque.

Would like to draw your attention to Gandini et al Annals of Agricultural and Environmental Medicine 2012, Vol 19, No 2, 173-180 probably the most recent metaanalysis concluding no association of alcohol containing mouthrinses and oral cancer. Regarding efficacy of essential oil mouthrinses can also refer to Van Leeuwen et al J Periodontol 2011;82:174-194, Gunsolley JADA 2006;137(12):1649-57. Let the evidence speak.

Dear Christine Charles.

The paper you cite by Gandinin et al. did not reference the Australian paper that DID find good evidence for a link between frequent alcoholic mouthwash use and oral cancer. (McCullough MJ, Farah CS. Australian Dental Journal 2008; 53: 302–305). Let the complete evidence speak, not the evidence you select. The Gandini paper does in fact indicate a trend to cancer at p

The McCullough paper published in the Australian Dental Journal in 2008 was an abbreviated review. It included only a selective group of pre-existing data and did not present any new scientific research. The paper by Gandini et al 2012 is a meta-analysis of all published scientific studies on the topic. The articles were selected on the basis the usual inclusion criteria that the studies were case-controlled, cohort or cross-sectional studies published as an original article. Perhaps that is why the Australian paper was not included in the meta-analysis since it did not present any new or original science and did not accurately reflect the full body of credible scientific evidence on the subject.

Christine, Thank you for the reply and correction. Yes - Gandini indeed reviewed the major source study that resulted in the McCullough review. That study (Guha N, et al. Oral health and risk of squamous cell carcinoma of the head and neck and esophagus: results of two multicentric case–control studies. Am J Epidemiol. 2007; 166: 1159-73) appears to me to be the most extensive epidemiological study so far with over 2,000 subjects. And yes, the Gandini study also reported that the exact mouthwash used was not verified. Nevertheless, Gandini et al. appear a bit unconvinced with their findings. Their conclusion below is hardly a ringing endorsement of the safety of long-term daily use of an alcohol-based mouthwash.

"The role of mouthwash use in the etiology of oral carcinogenesis must be viewed in the wider context of the biology of the mouth, the biology of oral carcinogenesis,

and oral cancer epidemiology. Further evaluation of what has already been published would be valuable, in particular a re-analysis of existing studies, in order to properly control confounders, especially in older studies when statistical methods, such as logistic regression, were not widely available. Above all, there is a need to undertake studies in which more attention is given to the investigation of the effect of mouthwash use at different points throughout the life of subjects, with a focus on the reasons for using mouthwash and the particular types of mouthwash used."

I still think that patients should at least be advised to vary their mouthwash use if they like an essential oil high alcohol mouthwash.

As always the practitioner weighs the evidence, provides treatment options based on the individual, and of course risk - benefit for all recommendations. Thank you for the discussion.

Please refer to our letter to the editor with detailed criticism about the Gandini et al. paper: https://www.researchgate.net/publication/231609881_Alcohol-containing_mouthwash_and_oral_cancer_-_can_epidemiology_prove_the_absence_of_risk?ev=srch_pub

Article Alcohol-containing mouthwash and oral cancer - Can epidemiol...