a critical review of the literature on mouthwashes

A CRITICAL REVIEW OF T H E LITERATURE ON MOUTHWASHES

Jess McCormick

University of Alabama School of Dentistry The Children’s Hospital, Birmingham, Ala.

INTRODUCTION

This conference emphasizes the importance of the immediate invironment of the tooth and gingival surfaces, and is concerned with means of regulating the environment so that a healthy condition is maintained. This is important because both caries and periodontal disease are primarily surface lesions in the beginning. Periodontal disease usually starts as superficial gingivitis, and caries is initiated in the outer 30 microns of the enamel surface.

The teeth and soft tissues are bathed by saliva and other oral liquids, and ultimately all chemical agents that prevent dental caries must be in liquid form in order to function. A therapeutic dentifrice-gum, troche, lozenge, chewable or effervescent tablet, spray, mouthwash or topical application- must release the agent in the mouth so that it can be incorporated into the fluid bathing the surface to be treated. Since most mouthwashes do not have abrasives or binders to interfere with the active agent, the mouthwash has a theoretical advantage over other vehicles.

This review of the literature on mouthwashes includes historical aspects of the subject and then considers the various types of mouthwashes that have been used in the prevention of oral disease. Because of the volume of material, and because there are several excellent reviews of topical dental this subject is not included in this review.

HISTORICAL ASPECTS

Mouthwashes have been used by man for thousands of years. Apparently, they originated either as a requirement of a religious code or as a special concoction that had curative properties (TABLE 1). For example, the Oriental Code of Manu required all Indians to rinse the mouth after meals.4 Similarly, Jewish Law directed: “When a man marries, it is understood that his wife is physically well and if it turns out that her breath is bad the marriage could be dis~olved.”~

The Chinese had two favorite mouthwashes that, in a modified form, are still being used today.’ An early nostrum was made of infant’s urine, which is related to the carbamide or ammoniated mouthwashes and dentifrices of the present era. Also, 4,000 years ago the Chinese used calcium phosphate preparations in the form of powered bones of small animals. This form resembles the remineralizing pastes and mouthwashes of the twentieth century. The

3 74

McCormick: A Review of Literature on Mouthwashes 375

Composition Year Purpose 3,000 B.C.

2,000 B.C. 1,000 B.C.

1,000 B.C.

ammoniac, Peruvian bark, charcoal, burned bread and honey once a week. Cool wine and water after each meal. Eau de cologne every morning.

Acidic mouthwash (Wallace) Ammoniated mouthwashes (Grove) Mineralizing mouthwash (Andresen)

400 B.C.

500 A.D.

1752 1869

deodorizing

Stimulation of saliva Precipitation of saliva Mineralization of the

enamel

1912 192 1 1926

Powdered bones of small animals suspension

Infants’ urine Code of Manu (religious edict)

“All Indians must rinse after meals” Jewish Traditional Laws: Marriage im-

plies physical fitness . . . “If bad breath, marriage could be dissolved.”

Hippocrates advocated a concoction of castorium and pepper

Public cisterns for urine mouthwashes

Calcium and phosphate abrasives

Plaque control? Mechanical cleaning

Importance of hygiene and “Swish and swallow”

health

I Hygiene and health I Plaaue control? (Pliny ) ! -

Tolver recommended warm water 1 Mechanical cleaning

Greeks valued a mixture of pepper and catorium, which was recommended by Hippocrates;6 later, Pliny7 noted that the public cisterns were used in Greece to provide urine used for mouthwashing.

A reawakening of interest in mouthwashes in the seventeenth and eight- eenth centuries is seen in the writings of Tolver’ and Hayes.’ Tolver recom- mened that warm water be used to “wash away those parts which would stick to the gums and the teeth.” Hayes, in his physiology text, stated: “AS for the teeth, . . . . a mixture of water and alcohol, with a few grains of solammoniac, may be very beneficially employed; and the powder of Peruvian bark, or charcoal, or burnt bread, incorporated with honey, compose a n electuary which is very suitable for whitening the teeth, removing the tartar tha t en- crusts them and thereby preserving them from attacks of caries. The electuary ought to be used at least once a week; and it is right to rinse the mouth after each meal, with cool wine and water; and to do the same thing every morning with water containing a portion of some one of the liquid dentifrices or merely a little eau de cologne.”

Until the nineteenth century, only religion, hygiene, esthetics, or halitosis were advanced as reasons to employ mouthwashes, but the discovery of bacteria and the advent of antisepsis brought new types of mouthwashes into use. Until then, society had tried to control uncleanliness and disease on an unscientific basis. Pasteur’s demonstration that bacteria caused disease re- sulted in the formulation of mouthwashes that would kill bacteria. This was based on Lister’s discovery that carbolic acid was of value in the sterilization

376 Annals New Y ork Academy of Sciences

of operating rooms, and for incisions. This approach to the control of oral disease fitted in well with Miller’s new chemicoparasitic theory, and for several years thereafter various writers’0’’’ advocated either the bacterial control of oral disease or the chemical approach. According to Wallace,” an acidic mouthwash would be best for the removal of plaque, rather than the alkaline mouthwashes that were customarily used; on the other hand, Morgan13 thought that acid and alkaline mouthwashes should be alternated. Up to the present time, the relative advantages of acid, neutral, or alkaline topical agents are a matter of lively discussion.

Briefly, there was a surge of interest in the use of nascent oxygen for the control of oral disease. The mechanical cleansing effect of the bubbling gas and its supposed ability to destroy the bacteria, particularly the anaerobes, were attractive concepts. Each investigator designed a mouthwash to support his hypothesis as to the best way to clean the mouth. However, despite the continued clinical interest in some of these mouthwashes, they are still used mainly on an empirical basis.

A change in the direction of preventive dentistry occurred through the writing of Gottleib14 and Andre~en . ’~ These workers placed emphasis on building up the resistance of the tooth or repairing defects that occurred in the tooth surface. Gottleib believed that the “inroads” of initial caries could be sealed off with the use of alkaline mouthwashes that stimulate the precipitation of calcium salts from the saliva. This may be considered, along with Andresen’s work, the beginning of the “remineralization” concept.

Grovel3 expanded the concept of caries prevention by the urea type of mouthwash. He claimed that, in addition to its time honored role, an ammoniated mouthwash could cleanse the teeth, “influence the caries attack rate,” inhibit acidogenic micro-organisms, dissolve mucins, and thereby prevent the formation of dental plaque. Goodfriend’s report16 of a urea- containing mouthwash seems to note the last time that the urea or ammonia mouthwash was used to control oral disease.

The literature on mouthwashes before 1939 was dominated by “clinical authorities.” With very little evidence, one could get a mouthwash listed in the National Formulary, and this became proof of efficacy. One finds the following quotes in the literature: “We die slowly due to the loss of the alkaline reserve. Acid is the cause of all troubles including caries. Halitosis whether due to indigestion, acidosis or constipation is due to fermentation. For thick ropy saliva an alkaline saline laxative should be used once or twice a week.””

I t is no wonder that the Council on Therapeutics of the American Dental Association eventually adopted the policy that mouthwashes should be advocated only for cleaning the teeth. Until recently, no “over-the-counter” mouthwashes have been approved as having therapeutic action, but recent studies to be discussed in this paper have opened up new avenues for mouthwash research.

McCormick: A Review of Literature on Mouthwashes

CURRENT USES OF MOUTHWASHES

377

There are now two main types of mouthwashes: a ) the antibacterial and b) the fluoride or remineralizing mouthwashes.

Antibacterial mouthwashes are used to inhibit or prevent caries or periodontal disease by affecting plaque formation and the growth of calculus. They also are used before and after oral surgery and have been widely advertised as a preventive or curative remedy for bad breath. Fluoride or remineralizing mouthwashes are reputed to prevent and arrest caries and have been reported to reduce sensitivity a t the necks of the teeth.”

Antibacterial Mouthwashes

Pasteur, Lister, Miller,” and others established the relationship of bacteria, cleanliness, fermentation, odor, and oral disease. Today, the bulk of mouthwash sales involve antibacterial mouthwashes with advertising aimed a t the basic fears the customer may have of “bad breath” and “germs by the millions.” It has been stated that psychologists and trade motivational researchers utilize the individual’s desire to “wash away guilt feelings.””

This general review of the current status of antibacterial mouthwashes indicates that some of the claims are not without basis. The oral flora can be depressed briefly by mouthwashes, and breath odor arising from the mouth can be temporarily improved.”’*’ These effects may be of value, and there is no doubt that even a temporary masking of bad breath is desirable in many situations. This is analogous to washing the body. One does not expect to sterilize the skin; rather, the objective is to reduce the numbers of resident bacteria and clear away dead tissue and debris that cause body odor.

Breath odor can arise from the mouth, respiratory passages, lungs, and stomach. It is not reasonable to expect a mouthwash to improve odor that does not arise in the mouth. An interesting study by Stephens” showed that the odor from garlic, chewed but not swallowed, disappeared in less than one hour. Garlic given by stomach tube was not noticed on the breath until absorption took place in the stomach. In the lungs, the odor remained for one or two days. They also studied normal and constipated patients to end a centuries-old tradition, and showed that constipation does not cause breath odor. In sum- mary, it seems generally accepted that odor arising from the mouth can be temporarily masked or reduced by mouthwashing. A similar effect is produced by tooth brushing with a dentifrice, but in either event, it would be undesirable to have a patient or the public lulled into believing that oral or general health is improved merely because bad breath has been masked.24 Antiseptic and antibiotic mouthwashes are probably more harmful than helpful by alter- ing the balance of the oral flora in an indiscriminating way. Unfortunately, the general public can easily be misled into believing than an antibacterial mouthwash is a panacea. Therefore, the manufacturers have the responsibility to


protect the public by careful advertising and continued research for better products.

Studies of the effects of antibacterial mouthwashes on the oral flora have generally overlooked the fact that the salivary bacteria and plaque bacteria may be different in numbers and type. Krassez5 has shown that salivary bacterial samples are different from bacterial samples taken from pits, plaque, and periodontal pockets. More than 1,000 strains of oral bacteria have been isolated and identified, but in most cases it is not known which bacteria are saprophytic and which are pathogenic under usual conditions. Thus, a study that shows that salivary bacteria are reduced in number by a mouthwash cannot predict whether or not there will be an accompanying change in dental caries or periodontal disease. Brown” was able to reduce the number of bacteria with antiseptic mouthwashes such as hexylresorcinol, or hydrogen peroxide, but often with unpleasant effects on taste or irritation of the oral soft tissues. He noted that the process of eating reduced the number of bacteria, but he was unable to reduce the number of oral bacteria by rinsing with distilled water. Recently, Alderman” studied the oral flora of 25 dental students for several weeks. Thirteen used dequalinium acetate and cetylpyri- dium chloride mouthwashes, while twelve used tap water. He showed that the antiseptic mouthwash could reduce the number of salivary bacteria for several weeks. He recommended that a different antiseptic be used after six weeks, in order to avoid adaptation. Here, again, it is not clear if this reduction in the number of bacteria would be beneficial to oral health.

In the area of presurgical and postsurgical care, mouthwashes have been shown to be of value. Keosian” claimed that an iodine mouthwash was effective in preventing postextraction bacteremia when no profuse infiltrating infection was present. Simring” showed that hexetidine hastened healing and reduced odor following periodontal surgery in 108 patients who were compared to 112 saline controls. Sackler and coworkers also used an antiseptic mouthwash in conjunction with surgery, and reported that his patients had improved breath odor and reduced bleeding. BlumZg used a phenolic-salt mouthwash to relieve pain postoperatively by producing topical anesthesia. Relief was reported in 97% of the patients. As expected, the placebo group were relieved in 35% of cases. Pinson and S t a n b a ~ k , ~ ’ using the same mouthwash, reported success in 95% of his treatment group and 69%- success in the placebo group.

Air pollution produced by the coolant spray during dental-cavity prepara- tion can be a serious hazard to the patient and to the staff near the operation, and mouth rinses used preoperatively by patients reduced the number of airborn bacteria.31 More studies are indicated on this subject.

Fluoride and Remineralizing Mouthwashes

28

The history of fluoride mouthwashes is summarized in TABLE 2. In 1939, the direction of mouthwash research was changed when it became evident


Shannon

Torell

H

Year

Use as rinse instead of conventional

2 x month or daily more effective topical.

than topicals or dentifrices.

1939

1940

1944 1944 1945 1946 1948

1959 1960

1960 1964

1964

1964

1964

1965

1965

Lundstam

McCormick

Brudevold

TABLE 2 TORICAL DEVELOPMENT OF THE FLUORIDE MOUTHWASH

2 x month 36% reduction in 9

Reduced interproximal caries 40%.

Reduced caries 70%.

months, 2,400 children.

Mouthwash Solution

NaF radioisotopes

NaF

NaF 1,000 ppm NaF 4 ppm SnFz 12-22 ppm NaF 100 ppm Acidulated

NaF 100 ppm 1,000 ppm SnFz NaF 1,000 ppm

radioactive NaF 0.25% SnF2 500 pprn

SnFz 5,000 ppm + NaCl

NaF, KF, FeFz (209 ppm- 500 ppm)

NaF 2,000 ppm

NaF 3-40 ppm + Ca and Po4

NaF 10,300 ppm + acid

Principal Investigator Volker

Bibby

Epstine Atkins Van Huysen Bibby Roberts

Konig Hellstrom

Demonstration

1) Fluoride makes enamel less

2) Fluoride absorbed on the surface

Fluoride inhibits acid formation by

Not toxic to gingiva after 6 months. Decreased lactobacillus count. Reduced enamel solubility. No reduction in caries in adults. Increase in caries, 30%.

Decreased rat caries. Retained 6% of dose, equivalent to

water fluoridation.

soluble.

of enamel.

mouth bacteria.

I

that teeth could be made more resistant to caries by topical fluoride treatment. Volker and colleagues showed tha t fluoride was adsorbed by, or reacted with, the surface of enamel, and made it less s o l ~ b l e . ~ ~ ’ ~ ~ About the same time, Bibby and Van Kesteren showed tha t fluoride inhibited acid formation by

laid the mouth bacteria.34 These fundamental observations and others groundwork for clinical studies of fluorides as mouthwashes, dentifrices, and solutions applied topically in the dental office.

Although i t was apparent that fluoride mouthwashes were not irritating to the mouth3’ and tha t the lactobacillus count could be reduced3’ along with the increased acid-resistance of the enamel,*” the first clinical results were disappointing. Bibby and coworkers41 were unable to show a clinical effect with 0.01% NaF mouthwash. They stated that this was probably because adult dental students were used as experimental subjects, and insufficient time was allotted for the study. Subsequently, Roberts and coworkers4’ found that an acidulated fluoride mouthwash actually caused a 30% increase in caries in sixth-grade children. Despite these early disappointments, investigators continued to conduct studies with fluoride mouthwashes by changing

11.35-37


the concentration, pH, type of fluoride, frequency of application, and age of the subjects.

New solutions were tested in animal studies, and clinical researchers eventually established the effectiveness of fluoride mouthwashes. we is^^^ reported up to 90% reduction in caries in children using a home-treatment mouthwash containing 0.25% NaF. He was also able to lower the lactobacillus count with fluoride mouthwashes. An interesting observation made by Weisz as well as Knutson and A r m ~ t r o n g ~ ~ is that a few caries-free subjects experienced an increase in caries as well as an increase in lactobacillus counts following fluoride therapy. Weisz also found that the earlier the teeth were exposed posteruptively to the mouthwash, the greater the caries reduction.

Shannon is evaluating the stability and safety of stannous fluoride mouthwashes for a military p~pulat ion.~’ He added sodium chloride as an emetic to render safe the high concentration of fluoride used in the 1.0% mouthwash. A prescription mouthwash for home use contained 473 mg of stannous fluoride per 16 fluid ounces. The preliminary in uitro experiments indicate that a “stannous fluoride mouthwash may be safe and effective in protecting the teeth against caries.” However, no specific data on caries reductions have been reported with these stannous fluoride mouthwashes. Shannon has also recommended a stannous fluoride mouthwash to reduce root sensitivity. Patients are given the mouth rinses in the dental office a t each visit and after prophylaxis, in lieu of “paint-on’’ techniques. No specific data in support of this technic are available. Lilienthal,“ using SnFz mouthwashes, showed that the oral acid-forming systems were inhibited. He attributed this to the antien- zymatic effect of fluoride.

Torell has been a very active investigator in the fluoride mouthwash field.4’ He has varied the concentration, the type of fluoride, and the frequency of application. His examining technique is unconventional in that he uses the mean number of new fillings per child rather than the number or DMFT or DMFS. This may have more practical significance, but it does not lend itself to comparison with the results of other investigators.

F jae~tad-Seger~~ showed that when a 0.2% NaF mouthwash was used monthly, the children in six school districts had a 0.66 mean number of restorations per child less than the nontreated children. In this study, a mouthwash with NaF seemed to be more effective than KF. He also showed that mouthwashes containing FeF3 were as effective as NaF in reducing caries. When he combined the NaF and FeF3 groups and compared them to a no- treatment group, he obtained a 60-70% reduction in new restorations.

Tore114’ has advocated fortnightly applications of 0.2% NaF as well as daily applications by means of home mouthwashes (0.05% NaF). Since 1960, 35,000 school children have received mouthwashes in the public schools of Norway. In comparing various procedures, Torell found that a daily mouthwash of 0.05% NaF was more effective than a 0.2% NaF mouthwash used once every two weeks. Torell believes that his preventive program with the mouthwashes

McCormick: A Review of Literature on Mouthwashes 38 1

is more effective than the standard techniques of topical 2% NaF or 10% SnF2, or dentifrices containing stannous fluoride, sodium fluoride, or sodium mono- fluorophosphate. In a parallel study, Lundstam5’ utilized dental health nurses to administer a 0.2% NaF mouthwash twice a month to school children, and a 36% reduction of caries was noted a t the end of nine months in the 2,400 children treated.

Wellock and Brudevold5’ have shown that acidulated fluoride phosphate is absorbed on the tooth surface three times more than stannous fluoride and two times more than neutral sodium fluoride. Clinical studies using 1.23% fluoride as a mouth rinse that is then swallowed are under current study.

A different and promising approach to the use of mouthwashes with which we have been associated in clinical trials is the new development in the use of a “remineralizing” mouthwash. The rationale for this mouthwash is based on the evidence that softened enamel can be rehardened by solutions of calcium and phosphorus, and that the process is accelerated by small amounts of f l ~ o r i d e . ~ ” ~ ~ We have shown in a comprehensive, long-term studys4 that the remineralizing mouthwash is capable of reducing caries on the mesial surface of the first permanent molar by 40 percent. I t is possible that other surfaces that usually are not subjected to such an intense caries attack as this surface might benefit even more. An interesting finding was that a demineral- ized water control rinse showed no reduction of caries when compared to the no-treatment group. This tends to throw doubt on the “swish and swallow” recommendation so widely advertised by the American Dental Association.

From the preceding, it is evident that mouthwashes as anticaries agents may offer a method of reducing caries that can be made available to large groups, with little or no professional supervision. If confirmed by other investigators, Torell’s studies show that by increasing the frequency of exposure to fluorides, the concentration of the mouthwash can be kept within safe levels. Thus, fluoride mouthwashes seem likely to play an important future role in effective home-care programs.

MISCELLANEOUS USES OF MOUTHWASHES An interesting mouthwash development in Europe by Palrna55 and others

is the physicai therapy approach to the treatment of periodontal disease. Balneotherapy involves the use of appliances to irrigate and cleanse the mouth with various solutions a t 1-2 atmospheres of pressure and temperatures between 44‘ and 46OC. Clinical improvement is reported after 10 days of 20-minute treatments. This resembles the water irrigating devices which are gaining popularity in this country.

A 30-second rinse of the mouth is centrifuged and the sediment is smeared and inspected for cancerous cells. Most authorities consider the scraping or swab technique superior to the mouthwash test.

Mouthwash testing to detect early oral cancer is under continuing

382 Annals New York Academy of Sciences

Antibiotic mouthwashes are not usually recommended, bu t a terramycin mouthwash gave “satisfactory” cures in a study by Stout” of 50 patients with acute gingivostomatitis. The easier and more dependable systemic approach to infection is used by most clinicians. More studies are needed in which both topical and systemic drugs are used. Burnett5’ arrived at this conclusion following a study tha t showed that systemic administration was more reliable than topical application, but that “appropriate hygienic measures and topical antibiotic therapy still hold a place.”

MUhleman~~’~ was able to increase and decrease the rate of calculus formation with an antibacterial mouthwash. He stated tha t this is of academic interest, and tha t long-term usage may have undesirable side effects. Thei- lade6’ also was able to depress calculus formation with an antibiotic (ery- thromycin). Antiseptic mouthwashes and antibiotics were used by Weinstein‘l unsuccessfully to control calculus formation. Likewise, Schroeder used various “calculus-plaque inhibitors” in the form of antiseptic mouthwashes to retard plaque and calculus formation, bu t was successful only with toxic doses that caused gingival inflammation.

Before the Vietnamese were conquered by the Chinese in 111 B.C., a custom was started of applying a black enamel to the teeth. A recent (1965) survey showed that black-enameled teeth were 50% less carious. The technique consists of cleaning by rubbing with coral powder, and painting on several successive days with a mixture of honey, animal black, and aloes wood. This is the earliest reference found of topical application to the tooth surface, and it was interesting to note tha t it did reduce caries.

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REFERENCES

CALDWELL. R. C. 1967. The application of chemical agents for the control of dental

MANDEL, I. D. & R. J. CAGAN. 1965. Pharmaceutical agents for preventing caries-A

MERCER, V. H. & C. W . GISH. 1966. Stannous fluoride versus sodium fluoride and

LUFK1N.A. W . 1948. History of Dentistry. 2nd edit. Lea and Febiger. Philadel-

THE BIBLE. Deuteronomy, Old Testament. Ch. 24. Last injunctions of Moses. HUNTER, J . 1839. A Practical Treatise on Disease of the Teeth. J. Jonson. London,

FOX, J. 1806. History and Treatment of the Diseases of the Teeth. Tomas Cox.

TOLVER. A. 1752. A treatise on the teeth. Lockyer, Davis. London, England. HAYES, A. H. 1869. Woman. : 244. Peabody Med. Inst. Boston, Mass. HEFELMANN, R. 1912. On the effects of mouthwashes upon the substance of the

BLACK, C. V. 1924. Operative Dentistry. 4th edit. Medico-Dental Publishing Co.

WALLACE, J. S. 1912. The Prevention of Dental Caries. 2nd edit. The Dental

canes. Advances in Chemistry. (In press.)

review. 2. Topical application procedures. J. Oral Ther. 2 128-144.

acid phosphate as a topical agent. J. Indiana Dent. Ass. 45 15-18.

phia, Pa.

England.

London, England.

teeth. Brit. J. Dent. Sci. 55: 4-13.

Chicago, Ill.

Record. London, England.


GOTTLIEB, B. 1947. Dental caries: Its Etiology, Pathology, Clinical Aspects, and

GOTTLIEB, B. 1949. Use of alkaline dentifrices and alkaline mouthwash for caries

ANDRESEN, V. 1926. The Physiological and Artificial Mineralization of the Enamel.

GOODFRIEND, D. J. 1948. Practical method for prevention of dental caries. J. Amer.

PALEY, B. 1930. Practical dental therapeutics. Dentifrices-Mouth Washes. Dent.

SHANNON, I. L. 1963. Evaluation of prophylaxis pastes and topical applications prepared with X-14 stannous fluoride solution. Techn. Docum. Rep. SAM-TDR- 63-103. US Air Force Electron Syst. Div. 1-7.

MILLER, W. D. 1890. Micro-organisms of the human mouth. S. S. White Dental Mfg. Co. Philadelphia, Pa.

CONSUMERS UNION. 1961. Mount Vernon, N.Y. From Chemical Week. Consumer Rep. 26.

SIMRING, M. 1963. Deodorization and healing: hexetidine in periodontal surgery. Oral Surg. 16 1432-1442.

ALDERMAN, JR., E. J. 1965. An in-viw study of the effect of prolonged use of a specific mouthwash on the oral flora. Chron. Omaha Dent. SOC. 28 284.

STEPHENS, D. W. 1966. Finding the hidden cause of bad breath. Today’s Health 44 4.

UNION CALENDAR No. 1122.1958. False and misleading advertising. House Rept. No. 2667.

KRASSE, B. 1965. The effect of caries-inducing streptococci in hamsters fed diets with sucrose or glucose. Arch. Oral Biol. 1 0 223-226.

BROWN, E. A. 1946. Effects of glycerite of hydrogen peroxide on the type and number of oral organisms. Tufts Dent. Outlook 20 17-23.

KEOSIAN, J., I. WEINMAN & S. RAFEL. 1956. The effect of aqueous diatomic iodine mouthwashes on the incidence of postextraction bacteremia. Oral Surg. 9 1337- 1341.

SACKLER, A. M., S. C. ROCKOFF & H. S. ROCKOFF. 1956. Evaluation of clorpactin WCS 60 as an adjunct in periodontal therapy. New York J. Dent. 26: 199-201.

BLUM, B. 1960. Clinical evaluation of an anesthetic mouthwash. New York Dent. J.

PINSON, T. J . & J. STANBACK. 1964. Evaluation of Chloraseptic solution as an anesthetic mouthwash. Quart. Nat. Dent. Ass. 22: 49-52.

MOHAMMED, C. I., J. H. MANHOLD & B. S. MANHOLD. 1964. Efficacy of preopera- tive oral rinsing to reduce air contamination during use of air turbine handpieces. J. Amer. Dent. Ass. 69 715-718.

VOLKER, J. F., H. C. HODGE, H. J. WILSON & S. M. VAN VOOCHIS. 1940. The adsorption of fluorides by enamel, dentin, bone, and hydroxyapatite as shown by the radioactive isotope. J. Biol. Chem. 134 543-548.

VOLKER, J. F., R. F. SOGNNAES & B. G. BIBBY. 1941. Studies on the distribution of radioactive fluoride in the bones and teeth of experimental animals. Amer. J. Physiol. 132 707-712.

BIBBY, B. G. & M. VAN KESTEREN. 1940. Effect of fluoride on mouth bacteria. J. Dent. Res. 19 391-401.

DEAN, H. T. 1938. Endemic fluorosis and its relation to dental caries. Public Health Rep. 5 3 1443-1452.

MILLER, B. F. 1938. Inhibition of experimental dental caries in the rat by fluoride and iodoacetic acid. Proc. SOC. Exp. Biol. Med. 39 389-393.

HODGE, H. C. & S. B. FINN. 1939. Reduction in experimental rat caries by fluorine. Proc. SOC. Exp. Biol. Med. 42 318-320.

EPSTEIN, S. & H. M. SCHAMP. 1944. Sodium fluoride in mouth rinse: Report of two cases. J. Amer. Dent. Ass. 31: 1233-1234.

Prophylaxis. Lea and Febiger. Philadelphia, Pa.

reduction. Texas Dent. J. 67: 48-51.

Dancke. Oslo, Norway.

Dent. Ass. 37: 511-518.

Outlook. 17: 507-512.

26 419-421.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

35.

36.

37.

38.


39. 40.

41.

42.

43.

44.

45.

46.

47.

48.

49.

50.

51.

52.

53.

54.

55.

56.

57.

58.

59.

60.

61.

62.

63.

ATKINS, A. P. 1944. Practical caries control. J. Amer. Dent. Ass. 31: 353-357. VAN HUYSEN, G. & G . B. DIEFENBACK. 1944. Reducing substances in expectorated

stimulated saliva. (abst.) J. Dent. Res. 23: 191. BIBBY, B. G., H. A. ZANDER, M. McKELLEGET & B. LABUNSKY. 1946. Preliminary

reports on the effect on dental caries of the use of sodium fluoride in a prophylactic cleaning mixture and in a mouthwash. J. Dent. Res. 25: 207-211.

ROBERTS, J. F., B. G. BIBBY & W. D. WELLOCK. 1948. The effect of an acidulated fluoride mouthwash on dental caries. J. Dent. Res. 27: 497-500.

WEISZ, W. S. 1960. The reduction of dental caries through use of a sodium fluoride mouthwash. J. Amer. Dent. Ass. 60 438.

KNUTSON, J. W. & W. D. ARMSTRONG. 1943. Effect of topically applied sodium fluoride on dental caries experience. Pub. Health Rep. 58 1701-1715.

SHANNON, I. L. 1964. Laboratory studies in the development of a stannous fluoride mouthwash. J. Southern Calif. Dent. Ass. 3 2 167-172.

LILIENTHAL, B. 1956. Effect of a stannous fluoride mouthwash on acid formation in the mouth and some observations on the mechanism of inhibition. Aust. Dent.

TORELL, P. & A. SIBERG. 1962. Mouthwash with sodium fluoride and potassium fluoride. Odont. Rev (Malmo) 13: 62-72.

FJAESTAD-SEGER, M., K. NORSTEDT-LARSSON & P. TORELL. 1961. Forsok med enkla metoder for klinisk fluorapplikation. Svensk. Tand1akt.-Forb. Tidn. 53: 169.

TORELL. P. & Y. ERICCSON. 1965. Two-year clinical tests with different methods of local caries-preventive fluorine application in Swedish school-children. Acta Odont. Scand. 23 287-322.

LUNDSTAM, R. 1964. Teachers administering mouthwash with fluorides in Jamt- land, Sweden. Sverig. Tandlakarforb. Tidn. 56 681-682.

WELLOCK, W. D. & F. BRUDEVOLD. 1963. A study of acidulated fluoride solutions. 11. The caries inhibiting effect of single annual topical applications of an acidic fluoride and phosphate solution. A two year experience. Arch. Oral Biol. 8 179- 182.

KOULOURIDES, T., H. CUETO & W. PIGMAN. 1961. Rehardening of softened enamel surfaces of human teeth by solutions of calcium phosphates. Nature 189 226-227.

KOULOURIDES, T. & J. L. REED, JR. 1964. The effects of calcium, phosphate and fluoride ions on the rate of softening and dissolution of tooth enamel. Arch. Oral Biol. 9 585-594.

McCORMICK, J . & T. KOULOURIDES. 1965. A study of neutral calcium, phosphate, and fluoride remineralizing mouthwashes. Inter. Ass. Dent. Res. July. 43rd Meet., p. 138. (abstract)

PARMA, C. & I. J. SKLENAR. 1963. Balneotechnics in oral irrigation. Parodonto-

HELSPER, J. T., G. S. SHARP & W. K. BULLOCK. 1966. Experiences with the tissue culture solution mouthwash method for the early detection of oral cancer: an interim report. Acta Cytol. 10 179-181.

STOUT, W. C. 1957. Treatment of infectious gingivostomatitis and membranous stomatitis with terramycin mouthwash. J. Periodont. 28 314-315.

BURNETT, J . W. 1963. The route of antibiotic administration in superficial impetigo. New Eng. J . Med. 268 72-15.

MUHLEMANN, H. R. 81 H. E. SCHROEDER. 1964. Dynamics of supragingival calculus formation. Advances Oral Biol. 1: 175-203.

THEILADE,J., R. J. FITZGERALD, D. B. SCOTT & M. U. NYLEN. 1964. Electron microscopic observations of dental calculus in germfree and conventional rats. Arch. Oral Biol. 9 97-100.

WEINSTEIN, E. & I. D. MANDEL. 1964. The present status of anti-calculus agents. J. Oral Ther. 1: 327-334.

T . M. MARTHALER, H. E. SCHROEDER & H. R. MUHLEMANN. 1962. Effects of some potential inhibitors on early calculus formation. Helv. Odont Acta. 6 6-9.

RUSSELL, A. L., E. C. LEATHERWOOD, L. VAN HIEN & R. V. REEN. 1965. Dental caries and nutrition in South Vietnam. J. Dent. Res. 44: 102-111.

J. 1: 221-227.

logic 17: 131-144.


64.

65.

WEATHERELL, J. A. & J . A. HARGREAVES. 1966. The fluoride content of surface enamel from permanent and deciduous teeth. Advances Fluorine Res. 4 181-191.

ISAAC, S., F. BRUDEVOLD, F. A. SMITH & D. E. GARDNER. 1958. The relation of fluoride in the drinking water to the distribution of fluoride in the enamel. J. Dent. Res. 37: 318-325.

66. SILVERMAN, S. L. 1915. Dentifrices and mouthwashes. Cosmos 57: 691-694. 67. BIBBY, B. G. 1966. Do we tell the truth about preventing caries. J. Dent. Child.

33 269-279.

a critical review of the literature on mouthwashes

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