This guidance is based on the Scottish Dental Clinical Effectiveness Programme guide to drug prescribing in dentistry.
To provide evidence for the guidance a literature review using Medline and Cochrane has been conducted, by Dr Joanne Hooker, up to October 2011 searching for Gingivitis; Antibiotics & dental abscess; Mucosal ulceration; Metronidazole; Oral Inflammation; Microbial flora & oral cavity; Oral hygiene; Oral microbial pathogens; Acute necrotising ulcerative gingivitis; Ludwig’s angina; Dentoalveolar abscess; Mucositis; Odontogenic infection; Antimicrobials & dentistry; Pericoronitis; Periodontal disease; Mouthwash/mouthrinse; Periodontitis; Chlorhexidine; Anti-plaque/anti-gingivival; Hydrogen peroxide; Antimicrobial susceptibility; Saline solution. The rationale was written by Dr Joanne Hooker under the guidance of Dr Cliodna McNulty and reviewed by stakeholders. Where only expert opinion was available, the guidance was based on the literature on the main pathogens and their antimicrobial susceptibility profiles in the UK.
Dosage of antimicrobials recommended in this guidance:
The Scottish Dental Clinical Effectiveness Programme 2011 recommends doses of 250mg amoxicillin or 200mg metronidazole when antimicrobials are appropriate. We recommend a higher dose of 500mg amoxicillin and 400mg metronidazole. The rationale for this is when antimicrobials are considered appropriate, it is important to have sufficient concentrations at the site of infection. For β-lactams such as amoxicillin this is time-dependent (i.e. the time period above the MIC) and 500mg TDS amoxicillin is more likely to attain this. For metronidazole, the killing effect is dose-dependent and the greater the concentrations above the MIC the better. AUC/MIC >70 is only attainable against Bacteroides fragilis with a 400mg dose.
An extensive literature search using Medline and Cochrane failed to find any robust clinical evidence on saline mouthwash. The recommendations are, therefore, based on expert opinion from the Scottish Dental Clinical Effectiveness Programme which recommends salt solution (half a teaspoon of salt dissolved in warm water) or compound sodium chloride mouthwash (prescribe 300ml) and dilute with an equal volume of water) as required until symptoms resolve. NB advise patient to spit out mouthwash after rinsing.
The Scottish Dental Clinical Effectiveness Programme (2011). Recommends chlorhexidine 0.2% mouthwash or chlorhexidine oromucosal solution, alcohol free 0.2% (300ml): rinse 10ml for one minute twice each day. Spit out mouthwash after use. Leave 30 minute interval between using chlorhexidine mouthrinse and using toothpaste due to staining of teeth and dilution of chlorhexidine. This recommendation is based on the trials outlined below in references 3 – 6.
Berchier CE, Slot DE, Van Der Weijden GA. The efficacy of 0.12% chlorhexidine mouthrinse compared with 0.2% on plaque accumulation and periodontal parameters: a systematic review. J Clin Periodontol, 2010;37: 829-39. (The Netherlands). This systematic review from the Netherlands aimed to evaluate the effects of 0.12% chlorhexidine versus 0.2% chlorhexidine in the management of gingival inflammation and plaque control. Medline, Pub-med and Cochrane were searched for randomised controlled trials and cohort studies. 409 titles and abstracts identified eight eligible publications. Overall there was no evidence for the benefit of 0.2% over 0.12% in the reduction of gingivitis however there was some evidence in favour of 0.2% regarding the reduction of plaque.
Lang NP, Hase JC, Grassi M, Hammerle CHF, Weigel C, Kelty E, Frutig F. Plaque formation and gingivitis after supervised mouthrinsing with 0.2% delmopinol hydrochloride, 0.2% chlorhexidine digluconate and placebo for 6 months. Oral Diseases, 1998;4;105-113 (Switzerland). Double-blind, randomised six month clinical trial. This study of 162 patients with gingivitis, based in Switzerland, compared the effects of 0.2% chlorhexidine mouthwash or 0.2% delmopinol mouthwash (which inhibits adhesion of oral micro-organisms to the tooth surface reducing plaque formation) to placebo on plaque formation and gingivitis.. Both were more effective than placebo, however, chlorhexidine was statistically significantly more effective (in relation to the clinical outcome parameters measured to quantify gingivitis and plaque formation). The trial also concluded that the long-term use of chlorhexidine was found to be less tolerated by the subjects.
Gunsolley JC. A meta-analysis of six-month studies of antiplaque and antigingivitis agents. A meta-analysis of the efficacy of anti-gingivitis and anti-plaque agents in sixth-month trials. J Am Dent Assoc 2006;137:1649-57. Seven studies, conducted between 1989 and 2005 (including 2258 subjects in total) looked at chlorhexidine 0.12% mouthwash and evaluated its efficacy at reducing gingival inflammation by using the Modified Gingival Index scoring system. Chlorhexidine had the most consistent results, demonstrating statistical significance in favour of its antigingivitis effects (P = 0.13). The Modified Gingival Index is a statistically sensitive scoring system that allows the non-invasive assessment of subtle signs of the severity and extent of gingival inflammation (Lobene, RR et al).
Lobene, RR; Weatherford, T; Ross, NM; Lamm, RA; Menaker, L. A modified gingival index for use in clinical trials. Clinical Preventative Dentistry. 1986 Vol 8 No.1 (USA)
Scottish Dental: Clinical Effectiveness Programme 2011. Formal expert opinion. Recommends 6% hydrogen peroxide (300ml): dilute 15ml in half a glass of warm water three times each day. Rinse for up to 3 minutes and spit out mouthwash after use. Continue until inflammation has resolved and normal oral hygiene measures can be resumed.
Hasturk H, Warbingon M, Van Dyke TE. Efficacy of a fluoridated hydrogen peroxide-based mouthrinse for the treatment of gingivitis: a randomised controlled clinical trial. J Peridontol 2004;75:57-65. This American placebo controlled trial in 99 patients looked at the effects of fluoridated hydrogen peroxide-based mouthrinse for the treatment of gingivitis (over 28 days) and teeth whitening (over 5 months). There was a statistically significant improvement in gingival inflammation in the mouthrinse group compared with placebo (p = 0.004).