Should You Use a Mouthwash?

Dental Revelations Blog-1

Yes and no.

If you are a patient and you ask this question from two dentists there is a BIG chance that you will get two answers. The other shows you the green light and the other the red.

There is no consensus amongst the dental professionals about the recommendations. Even the professors in dentistry argue about the recommendations publicly. They give statements to the press for and against the mouthwashes after a new study about the risks of the mouthwashes is released. Some negate all the study’s conclusions.

So no wonder it leaves patients confused if us professionals are too.

Well Should You?

Generally no.

If you have a good oral hygiene – brushing twice a day and cleaning between the teeth most nights – and you use a fluoride toothpaste there’s no reason to use a mouthwash.

But there are exceptions – naturally!

If you suffer

  • from a gum disease you might be advised to use a mouthwash containing chlorhexidine (CHX) during and after a periodontal treatment. It is a very effective ingredient that kills bacteria. But remember to use it only as advised by a dental professional
  • from an extreme dryness of the mouth through an illness (e.g. Sjögren’s syndrome) you might be advised to use fluoride mouthwash regularly to prevent decay

Remember that in both of these cases you should choose the alcohol-free version.

Dangers of Using a Mouthwash

Oral cancer

If you use a mouthwash that has alcohol (ethanol, but I’m going to use the word alcohol instead) levels of 25% or higher and you have been using it since your teenage years the studies state that you have higher chances for getting an oral cancer.

One leading brand (the one that rhymes with word blistering) can have alcohol levels as high as 26% and this high level is thought to be toxic for gingival tissues when used in abusive amounts. But – and it is a big but – why do they add alcohol to the mouthwashes when it is a known fact that for alcohol to be toxic for bacteria it must be used at 40%? This means that there is no help from alcohol levels as low as 26% but it can still be harmful to the gingival tissues.

Discolorations

If you use a mouthwash containing CHX for a longer period of time it will stain your teeth. Stains can be removed but it will cost you of course.

In my professional life I have noticed that for some unknown reason the leading blistering-rhyming mouthwash stains the teeth with some patients eventhough it doesn’t contain the CHX. Actually the looks of the stains is different to those that build up from the CHX. After a thorough interview of the patient no other explanation was found to the stains than the mouthwash the patient had been using. The staining stopped once the patients stopped using the mouthwash.

Dry mouth and bad breath (halitosis)

Alcohol in mouthwashes can dry the mouth and the dry mouth is prone to halitosis. People often seek help from the mouthwash for the halitosis but it can actually make the matters worse.

Lichen planus

If you have been diagnosed with lichen planus you should not use any mouthwashes unless advised by a professional. But even in this case you should not use mouthwashes with alcohol.

WELL SHOULD I?

Wouldn’t it be the wisest thing to do if you DIDN’T use a mouthwash whilst us professionals argue about the health risks of the mouthwashes? It’s your health that is gravely at risk if the alcohol in mouthwashes is proven to be harmful.

I have seen patients who are going through the cancer treatments for oral cancer and I have seen the 50% of them who survived the cancer. I can tell you that it’s not a pretty sight. Not during the treatments or after surviving it.

Why would you play a Russian roulette over your health? I wouldn’t and therefore I am not using any mouthwashes.

If You Still Want to Use a Mouthwash

Always choose the alcohol-free fluoride mouthwash.

Remember

  • it can stain your teeth
  • it never replaces brushing or cleaning between the teeth
  • that in many countries the mouthwashes are considered as cosmetics by law. In some countries they are considered both cosmetics and drugs. But when considered as cosmetics they are not that highly regulated as drugs are. So what you could actually be rinsing in your mouth is a cocktail of chemicals that no-one knows (or cares) how they affect the health
  • that if you are also a heavy smoker it increases the risk of getting an oral cancer. If on top of that you are a high consumer of alcoholic drinks you are even at higher risk

Conclusion

I really don’t get it how we cannot decide if the mouthwashes containing alcohol should be recommended or not. It’s just ridiculous that even inside one dental practice opposite recommendations are given to the patients.

What all of us professionals agree is the fact that alcohol is an aldehyde and it is metabolised by the oral bacteria to acetaldehyde which is carcinogenic in humans. Carcinogens cause cancer! And yet we argue about the risks of using an alcohol containing mouthwash.

What are the reasons behind all this? Some have suggested that some of the dental professionals have financial commitments to the manufacturers of the mouthwashes. I must emphasise that this is a hearsay. But if you have read my previous post about the integrity amongst dental professional you understand that everything is possible.

If you are interested to read about groundbreaking study about the risks of using the alcohol containing mouthwashes (one that caused a mayhem amongst dental professionals) visit here.

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Where it all started

Dental Revelations Blog-2382
Do you know your dentist behind the mask?

There was whispering behind the reception desk when I arrived to work.
“Morning!” I said cheerfully and carried on downstairs to get changed to my uniform.

I was a dental student working as a trainee and was very happy that I was earning little extra on top of my student allowance. There wasn’t many dental practices who took in trainees on those days to work as nurses until they graduated.

I put the uniform on and went upstairs to the reception before setting up my surgery. There were two nurses and a receptionist still whispering as the reception was filling up with that morning’s first patients. I was a newbie but understood that something was going on. Something that made the nurses very annoyed. I heard a word Harry.

One word and I knew what was going on. Eventhough I had been working as a trainee only for a month, I knew almost all the secrets the practice had. Harry was a dentist and a partner of the practice which meant he had lots of freedom to decide how things were run. He was the one who paid our wages. Or to be precise, he made the money that paid our wages but it was the other partner of the practice, Sally who run the payroll. She had no dental education and dealt with all the finances of the practice.

Harry and Sally had been lovers on and off many years and had had this dental practice in the heart of the city for a long time. It was a very popular practice amongst celebrities who had extensive cosmetic treatment done by Harry. Veneers, crowns, implants… yes, implants as well eventhough he wasn’t an oral surgeon. He was a regular dentist who never attended any annual dental show case to revise. Worrying combination.

Now back to that one morning when Harry had once again done something to stir up feelings at the practice.

Harry had arrived to work drunk. Wasted. Pissed. Drunk as a skunk. And it wasn’t the first time. One would think that a dentist cannot work when drunk as they use various instruments that can cause serious damage to the patient, nurse and the dentist himself if used incorrectly. The drill for example, that is used for drilling through the enamel of your tooth – the high-pitched one – rotates up to 400 000 rpm. Imagine it in the hands of a drunkard. Scary as hell in my opinion.

Did Sally or Harry’s colleagues stop him from treating patients? No they didn’t. Neither did I but my excuse is that I was a newbie and didn’t have any say on anything really.

On this particular morning Harry was guided by his trusted nurse Tina from downstairs office which he shared with Sally to upstairs where the surgeries were. Half way up the stairs Tina realised that on her own she’s not able to prevent him from falling so she called help and another nurse came to her aid. Together they managed to steer Harry safely upstairs.

“Not that way!” I heard Tina whisper to Harry who was entering a wrong surgery. Tina pushed Harry from his shoulder to the direction of his surgery where the first patient was already in the dental chair with safety classes and a bib on. Tina sat Harry down to his chair and put a face mask on.

This is as much as I could see what was happening. The patient was treated and she left without complaints. So did the next one. No-one ever complained that the dentist was drunk. Didn’t they notice? They must have as the smell was obvious.

Why didn’t Tina say anything? She had worked with Harry for ages and had seen everything that is going on. How did she put up with this kind of behaviour and malpractice? I got an answer to this question couple of years later (already after I had left the practice) when I found out that Tina was Harry’s mistress. Love is blind, it sure is in many ways.

One day Tina was off sick and I was told to replace her as Harry’s nurse. I soon realised that the nurse was expected to do much more than what nurses normally do. And that was probably how Harry could carry on as he did. When Harry wasn’t able to do the treatment, Tina did it. Thankfully Harry realised that I wouldn’t be able to replace Tina fully. I wouldn’t use turbine (the high speed drill). So he was only hungover on the day when I was working with him. Phew!

What I saw that day, I never forget.

Patient one.

A 70 year-old man who had had two implants done to replace lower front teeth. The plan was to have an implant supported bridge done once the implants were fully integrated to the bone. He came in to complain odd feeling and appearance of the area where the implants were done.

The patient had a very low alveolar bone and the mucogingival junction was almost on top of the alveolar bone. The alveolar mucosa had probably pulled the area where the surgery was performed and opened up the incision. As a result the alveolar bone was exposed.

“Should it be like this?” the patient asked.
“Well it shouldn’t!” I thought.
Harry examined the area quickly and slurred something vague. Then he sent the patient home until the next scheduled appointment. My eyes were as wide as saucers but of course Harry didn’t see them as he was out of the surgery already before the patient was.

Patient two.

A 50 something year old lady who had started a restorative treatment for her lower teeth. The plan was to restore the bite by two rather long bridge. The bridges were going to be cemented today.

Harry fitted the bridges. He had difficulties in getting them in place and he had to use a drill to file away some of the metal of the bridge. Eventually the bridges went in and the patient was asked to bite the teeth together only to notice she wasn’t able to. Only the very back teeth were in contact leaving the mouth quite open. Harry took the high speed drill and started to file away the ceramic.

He drilled off a large area of ceramic and part of the metal structure underneath. I wanted to close my eyes as he was destroying the beautifully shaped cusps of the bridge but then the mouth of the patient would have flooded. So I carried on watching this mad man’s way of cutting corners.

Once Harry was done, he cemented the bridges into their places.

“The bite does not feel right…” the patient said.
“It will feel odd at first. It needs some getting used to.” Harry replied and left the surgery.

The patient left the practice with horrid looking bridges and bite that was not anywhere close being balanced.

I was in shock after that day. I knew this wasn’t going to be my future work place. Not a chance. And it wasn’t.

 

If you are interested to read more on the subject in another blog, visit here.

Alcohol – The Feared Subject

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About 60 year-old man came to see me one morning and complained that every once in a while a layer of skin comes off inside his mouth and no-one has been able to tell why. He was concerned and felt that it was happening at that very moment as well.

I took a look at the soft tissues before the treatment and asked if he had used a mouthwash the same morning or the night before. Negative. I asked if he had drank wine last night. The patient’s face went serious and he said he had been drinking whiskey last night. I went on telling without any judgement how alcohol effects the mouth and body – the risks in mouth and the age related risks. He looked like he had eureka moment and was very happy but also shaken as he realised that his alcohol use could be damaging his health in more ways than just one.

Now, this blog post is full of information for dental professionals but there are links that are useful for the patients as well. I will give advice to the patients at the end of this post so move on over there if you want to skip the professional part.

Fear of Asking

Us professionals seem to find it hard to discuss about patient’s alcohol consumption. For some reason we think that alcohol consumption is too personal question to ask. Sometimes also the patients think the same which makes it even more difficult question to ask. But we ask about illnesses, smoking, diet and oral hygiene habits. Why not about alcohol?

Everyone knows that smoking can cause oral cancer. But not so many know that alcohol does the same. And even fewer knows that alcohol and cigarettes combined raise the risk of developing oral cancer many times higher. So dental professionals are on the frontline of preventing oral cancer. This means that asking about alcohol consumption should be a routine thing to do and I’m going to help you with that.

  1. When interviewing the patient about his medical history, oral hygiene routines and smoking, continue without hesitation How about alcohol? Do you use alcohol? Keep the same tone of voice as if you were asking did you watch the footie last night?

This is how the conversation continues:

Patient: Yes, sometimes.
You: How often would you say you drink per week?
P: When we go out after work.
Y: How often did you go out last week?
P: Last week we went out almost every night.
Y: What do you normally drink?
P: Beer.
Y: How many do you drink on your regular night out?
P: Normally 3 or 4 pints and on weekends it can be a lot more…

When you engage patient into discussing about alcohol consumption you are kind of evaluating the patient’s attitude towards the subject. Is he co-operative or defensive? If the latter, you need to advance with very small steps. A piece of information here, a piece there. Whenever the patient is ready to take in information about alcohol.

If the patient is co-operative (you would be surprised how many are!), you can move on to sum up the alcohol units the patient consumed the last week and then give information about how it affects his health. Before you can do this you need to know the facts.

2. Learn the numbers and facts behind the risks of excessive alcohol consumption

The recommended low risk (of developing an alcohol related illnesses) daily units are:

healthy women 0-1 units
healthy men 0-2 units
65+ year-olds no more than 0-2 units (no more than 7 per week)

Learn these by heart or print them out (please note, that the recommendations can vary in different countries).

The oral cancer’s death rate is nearly 50%.

Alcohol is an aldehyde and it is metabolised by oral bacteria to acetaldehyde which is carcinogenic in humans.

This is very short but effective list. With this little information you can have a significant impact on patient’s alcohol consumption.

3. Be a therapist if needed

More than once I have been in a situation with a patient when the patient opens up about his life when we discuss about alcohol. There have been patients who have thought by themselves that they are drinking too much. Some tell the reasons behind them. All they need at this point is that someone listens.

But if you feel like the patient needs more advice and guidance, remember to ask
Do you mind me giving you an advice?

People generally respect you more if you don’t offer advice without asking. Especially when it is about alcohol. Have phone numbers at hand for local AA and offer them if needed.

4. If you didn’t ask about alcohol consumption

Do ask about alcohol every time when

  • there is no improvement on oral hygiene routine despite a great effort, especially if there is lot of plaque every time
  • the soft tissues are bright red and the patient is not using mouthwashes (and even if he is, mention also that alcohol can irritate the soft tissues no matter how it enters the mouth)
  • the mouth is very dry and no other reason is found for it

Reminder to All Dental Professionals

Do check the soft tissues and tongue every time you see the patient. It doesn’t take long and you might be saving somebody’s life. No matter if you are a nurse, hygienist or dentist. All of us can tell if something is normal or not and it doesn’t matter who points out the abnormality in the first place.

Have a dental camera or DSLR with macro lens at hand. Learn to use them so that when you see something suspicious, you are able to take a photo of it and compare it the next time.

This is an area in our profession that is too often neglected.

Information for the Patients

You are in good hands when you are interviewed thoroughly on your very first visit and  and every time when you have your check-up done. If you only needed to fill in a medical history form and no-one asks further questions, it’s not a very good sign. The professionals treating you are not looking after you very well.

Please do take our questions as they are. They are questions for your best interest and health and for good quality of treatment. We need to repeat these questions over and over again every time you come in for your regular check-up.

We will ask about subjects (like alcohol consumption) you would rather not discuss with anyone but please do not hide anything or lie. Most often we can see from the patient’s mouth if we were not told the truth about certain subjects like:

smoking
alcohol consumption
how often you clean between the teeth
do you brush your teeth regularly
certain illnesses

So be honest and don’t be afraid of a judgement. It is not our job to do.


Please click here to see the repost of this same post. It includes forewords worth reading.