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Abstract

To establish the presence and quantify Ethanol in commercially available mouthwashes. Samples from twelve commercially available mouthwashes were tested for the presence of Ethanol followed by the estimation of percentage of Ethanol in five brands in Pakistan Council of Scientific and Industrial Research (P.C.S.I.R) and Husein Ebrahim Jamal (H.E.J.) labs, Karachi. Ten out of twelve brands of mouthwashes were found to be Ethanol positive. Alcohol (Ethanol) in the mouthwashes does not contribute to any therapeutic action. It is alarming to find the presence of alcohol in the mouthwashes which claim to contain no alcohol.
practitioner's own sexual orientation can enter into conflict
while dealing with such patients. Whether the patient wants to
maintain the orientation or request for treatment is another
question. Seeking treatment because of discrimination cannot
be successful and could only aggravate the distress for the
patient. Even when the patients presenting with psychiatric
problems are treated, the core issue remains unresolved that
could lead to multiple relapses over a time period.
There is little evidence about success in treatment for
homosexuality especially for those who are exclusively
homosexual. Empirical studies are not done on homosexuals in
Pakistan though some literature is available about
homosexuality and AIDS. How much are we trained to tackle
this issue in clinical practice? Do we need special training? Are
the psychiatrists aware of problem-specific psychotherapeutic
approaches? These questions need to be answered.
References
1- HIV Second Generation Surveillance in Pakistan, National Report Round2, in
National AIDS Control program Ministry of Health, Government of Pakistan
HIV?AIDS Surveillance Project; 2006-7.
2- No authours listed. Pakistan combats hidden AIDS menace. AIDS Wkly Plus
1996; 20: 16-7.
3- UNAIDS and WHO. AIDS epidemic update, UNAIDS, Geneva. [Online]
2006 (Cited 2008 Jan 28). Available from URL:
http://data.unaids.org/pub/EpiReport/2006/2006_EpiUpdate_en.pdf.
4- Facts about Homosexuality and Mental Health in 'Homosexuality and Mental
Health.' [Online] 2008. (Cited 2008 Sept 10). Available from URL:
http://psychology.ucdavis.edu/rainbow/HTML/facts_mental_health.HTML.
5- Cameron P. "The psychology of Homosexuality" [Online] 2006 (Cited 2008
Aug 27). Available from URL: http://www.familyresearchinst.org?FRI
_EduPamphlet6.html.
6. Fergusson DM, Horwood LJ, Beautrais AL. Is sexual orientation related to
mental health problems and suicidality in young people? Arch Gen Psychiatry,
1999; 56: 876-80.
7. Cochran SD, Mays MV, Sullivan JG. Prevalence of mental disorders,
psychological distress, and mental health services use among lesbian, gay, and
bisexual adults in the United States. J Consult Clin Psychol. 2003; 71: 53-61.
8. Hogg RS, Strathdee SA, O'Shaughnessy MV, Montaner JS, Schechter MT.
Modelling the impact of HIV disease on mortality in gay and bisexual men.
Internat J Epidemiol. 1997; 26: 657-61.
9. Huebner DM, Rebchook GM, Kegeles SM. Experiences of harassment,
discrimination, and physical violence among young gay and bisexual men.
Am J Public Health 2004; 94: 1200-3.
10. Paul JP, Catania J, Pollack L, Moskowitz J, Canchola J et al. Suicide attempts
among gay and bisexual men: lifetime prevalence and antecedents. Am J
Public Health 2002; 92: 1338-45.
11. Skegg K, Nada-Raja S, Dickson N, Paul C, Williams S. Sexual orientation and
self-harm in men and women. Am J Psychiatry 2003; 160: 541-6.
12. Remafedi G. Sexual orientation and youth suicide. JAMA; 1999; 282:1291-2.
13. Gilman SE, Cochran SD, Mays VM, Hughes M, Ostrow D, Kessler R. Risk
of psychiatric disorders among individuals reporting same-sex sexual partners
in the National Comorbidity Survey. Am J Public Health, 2001; 91: 933-9.
14. King M. Discrimination against homosexual people and their health. Student
BMJ 2007; 15: 257-92.
186 J Pak Med Assoc
Introduction
Mouthwashes are considered beneficial in the
prevention and treatment of variety of oral or orophryngeal
diseases such as gingivitis, periodontitis and other
inflammatory conditions. Apart from the various
therapeutically active ingredients in the mouthwashes such
as essential oils, Chlorhexidine, Fluoride, Potassium Nitrate
and Benzydamine, one ingredient that is present generally
in every mouthwash is "alcohol" (Ethanol, the term alcohol
and Ethanol are used interchangeably in this article) that is
in a concentration of 0-27% as compared to the alcohol
content in beer (4%) and wine (12%). Ethanol by virtue of
its structural configuration is bipolar that helps it dissolve
hydrophobic as well as hydrophilic components.
The concentration of alcohol used in the mouthwash
lags behind the optimum concentration of 50% to 70% at
which alcohol is able to exert its antiseptic effect, hence
except for its use as a solvent, alcohol in the mouthwash
does not contribute to any other therapeutic effect. Due to
this reason, alcohol free mouthwashes in the clinical trials
Students’ Corner
“Alcohol use in mouthwash and possible oral health concerns”
Muhammad Wasif Haq,1Mehwish Batool,2Syed Hammad Ahsan,3Navid Rashid Qureshi4
4th Prof B.D.S Students,1,2 Liaquat College of Medicine and Dentistry, Karachi.3,4
Abstract
Objective: To establish the presence and quantify Ethanol in commercially available mouthwashes.
Methods: Samples from twelve commercially available mouthwashes were tested for the presence of Ethanol
followed by the estimation of percentage of Ethanol in five brands in Pakistan Council of Scientific and Industrial
Research (P.C.S.I.R) and Husein Ebrahim Jamal (H.E.J.) labs, Karachi.
Results: Ten out of twelve brands of mouthwashes were found to be Ethanol positive.
Conclusion: Alcohol (Ethanol) in the mouthwashes does not contribute to any therapeutic action. It is alarming
to find the presence of alcohol in the mouthwashes which claim to contain no alcohol (JPMA 59:186; 2009).
have proven to be as effective as alcohol based
mouthwashes, with the former having lesser side effects.1
It has been postulated that alcohol in the mouthwash
in reference to its local effects and metabolism, acts
similarly to alcohol in the beverages.2As mouthwashes are
kept in contact with oral mucosa, there is absorption of
various ingredients including alcohol because of rich blood
supply and relatively high permeability of oral mucosa. This
has been measured by estimation of urinary excretion of
Ethyl glucoronide (product of Ethanol metabolism) in
concentration of as minimum as 50 ng/ml and as maximum
as 300ng/ml after rinsing with 12% Ethanol based
mouthwash.3Similarly alcohol has average oral fluid to
blood concentration ratio of 1.07 when compared with few
other drugs such as Barbiturates (0.3) and Diazepam (0.01-
0.02).4The breath analyzers (used for detection of alcohol
consumption) show positive readings after rinsing with
alcohol based mouthwashes implicating that effect of
alcohol in mouth is greater on rinsing than on swallowing.5
The metabolism of alcohol starts intra-orally by the
normal oral flora that results in the production of well
known toxic metabolite acetaldehyde.6Oral mucosa unlike
most tissues of body, lacks alcohol dehydrogenase due to
which acetaldehyde may be accumulated for a long duration
of time in the mouth before being cleared.
Research has shown the permeability of oral mucosa
to be directly proportional to the increase in concentration
of Ethanol such that the mucosal permeability being greater
at 15% Ethanol than at 5% Ethanol and sharply rises from
25% Ethanol to 50% Ethanol, beyond which no increase in
the permeability was observed (Figure).7Such an increase
in mucosal permeability has been evidenced to enhance the
penetration of carcinogens such as Nitrosnornicotine.8
Considering the above mentioned scientific data that
emphasizes on risks of high alcohol content in mouthwash,
we planned a study to determine the qualitative and
quantitative presence of Ethanol in commercially available
mouthwashes in Pakistan; products labeling alcohol and
those not labeling alcohol.
Material and Methods
Four samples each from twelve commercially
available mouthwashes were collected from three super
stores in Karachi. The batch number, manufacturing date
and expiry date of the samples were noted.
Atotal of four tests were performed. The tests were
divided into the qualitative tests used for the detection of
alcohol in the samples and the quantitative tests.
The qualitative/preliminary tests employed three
tests namely Iodoform test, Chromic Acid test and Nuclear
Magnetic Resonance (N.M.R.) spectroscopy.
In the Iodoform test , a standard volume of 5 ml of
the sample was taken and reacted with 2 ml of Iodine and
5% NaOH. Samples of twelve brands of mouthwashes were
tested using this reaction. The presence of Ethanol is
indicated by the formation of yellow precipitates of
Iodoform (Triiodomethane).9
The second test employed was Chromic Acid test in
which Potassium Dichromate oxidizes alcohol that was
indicated by the color change of Potassium Dichromate
from orange to green, this is the same reaction used in the
Breath Analyzers to measure concentration of alcohol. A
standard volume of 3 ml of every sample was taken and
reacted with few drops of concentrated Sulfuric acid.
Twelve samples were tested using this reaction.
After the two qualitative tests, two alcohol negative
samples were excluded while from remaining ten samples;
five mouthwashes were selected randomly (non-probability
sampling) for further confirmatory tests for the presence of
Ethanol followed by estimation of percentage of Ethanol in
the selected five samples.
In the third qualitative test, N.M.R. spectroscopy
was utilized. This technique detects radio frequency
absorbed by protons at applied magnetic fields denoting
chemical shifts on the recording paper. 3 ml of the sample
was taken. Five samples were submitted for this test.
In the fourth test, quantitative assessment of Ethanol
by Gas Chromatography (G.C.) was performed. To rule out
the element of bias and variability, two samples were
submitted in the lab of P.C.S.I.R and three samples were
submitted in H.E.J. labs.
Results
In the preliminary tests Iodoform and Chromic acid
test, twelve samples of mouthwashes namely Listerine,
Enziclor, Signal, Prodent, Niflam, Protect (Alcohol free),
Vol. 59, No. 3, March 2009 187
Figure: Increase in the permeability of oral mucosa in a stepwise pattern in relation
to increasing concentrations of Ethanol. Ethanol concentrations above 50% cause
no change in the permeability of oral mucosa.
Oral B (Alcohol free), Clinica, Neo-nexus, Hi-Paradent,
Pepsodent (Alcohol free) and Enliven (Alcohol free) were
tested. Except for two products; Oral B (Alcohol free) and
Enliven (Alcohol free), all the ten remaining samples gave
positive Ethanol reaction (Table-1). The samples that did
not contain alcohol were not subjected for further
confirmatory tests. In N.M.R. test, five samples namely
Listerine, Enziclor, Signal, Protect (Alcohol free) and
Pepsodent (Alcohol free) were selected and confirmed to be
Ethanol positive .In the quantitative assessment of Ethanol
in mouthwashes by G.C., the percentage of Ethanol was
determined in the selected five samples that were confirmed
to contain Ethanol by N.M.R., the percentage of alcohol
observed in these samples by P.C.S.I.R. and H.E.J. labs is
listed in Table 2.
Discussion
It is a matter of serious concern that alcohol is
present in many mouthwashes labeled as without alcohol
and in brands that do not mention any information regarding
presence of alcohol on the display panel of their products.
Such products are being sold over the counter without the
consumer knowing about it. The Drug Act, 1976 states that
in Pakistan companies require to mention their active
ingredients. Since alcohol is not an active ingredient
therapeutically, many companies defer from listing alcohol
in their list of ingredients.10 Only few brands such as
Listerine, Macleans, Colgate, Smokers and Signals are
currently mentioning alcohol in the ingredients with even
fewer brands mentioning the percentage of alcohol in the
product.
Although not therapeutically active, Ethanol in the
mouthwash has been proven to produce multiple other
effects many of which are not beneficial and un-necessary
for the user. These range from a characteristic burning
sensation upon contact with the oral mucosa by activation of
vanilloid receptor-1; a heat gated ion channel to a
dehydrating effect on the oral mucosa.11,12 Due to the
astringent action of ethanol, the use of high alcohol
mouthwashes in patients with radiation mucositis is not
recommended.13 Patients with Sjögren's syndrome should
avoid alcohol based mouthwash as it may aggravate
xerostomia, and with decreased salivary flow locally,
atrophic changes of oral epithelium may occur. Similarly
people on Alcohol Withdrawal therapy or patients on
Disulfiram therapy should also avoid using such
formulations. American Dental Association (ADA) advices
patients of burning mouth syndrome to avoid irritating
substances such as mouthwashes.14 Similarly alcohol is a
known cause of halitosis and mouthwashes only
temporarily relief the problem.15
Alcohol is an irritant to epithelium and in animal
studies; the topically applied alcohol was linked with
increased occurrence of tumours.16 Inflammatory changes
may also develop that may induce hyperkeratosis and
atrophy of mucosa. In a study that involved 40 hamsters,
two hamsters showed areas of hyper-parakeratinazation,
loss of cellular cohesion in basal cell layers with
mononuclear inflammatory cells when treated with 23%
Alcohol based mouthwash.17
Studies and case reports link such a high percentage
of alcohol in certain mouthwashes with development of
leukoplakia, the lesion was reversible when the mouthwash
was stopped.18 There has also been concern about the
correlation of high level of alcohol in the mouthwash with
increased susceptibility towards oral cancer.19 Although to
date, no scientific data establishes it as an etiological factor
but few cases have been documented in literature in which
alcohol containing mouthwashes are suspected, especially
of a patient who suffered from multiple recurrent oral
cancers, the patient gave a long history of using 14%
alcohol based mouthwash.18 However, it must be stated that
other local and systemic factors can aggravate the
susceptibility towards oral cancer.
The production of acetaldehyde intra-orally is also a
matter of grave concern. Acetaldehyde is a known
carcinogen and has been shown to cause hyperplastic and
188 J Pak Med Assoc
Table 1: Presence of Ethanol in samples by Iodoform,
Chromic Acid and N.M.R test.
Brand Name of Mouthwash Ethanol
Iodoform/Chronic Acid/NMR
1.Listerine* Positive
2.Enziclor* Positive
3.Signal* Positive
4.Prodent Positive
5.Niflam Positive
6.Protect (Alcohol free)* Positive
7.Oral B (Alcohol free) Negative
8.Clinica Positive
9.Neo-nexus Positive
10.Hi-Paradent Positive
11.Pepsodent (Alcohol free)* Positive
12.Enliven (Alcohol free) Negative
The marked (*) samples were tested by N.M.R. also and found to be Ethanol
positive.
Table 2: Results of percentage of Ethanol determined by G.C.
Brand Name of mouthwash Percentage of Ethanol
1.Listerine 24.5%
2.Protect (Alcohol free) 3.5%
3.Signal 13.8%
4.Enziclor 3.58%
5.Pepsodent (Alcohol free) 2.89%
The samples 1 and 2 were tested in P.C.S.I.R. labs while 3,4 and 5 in H.E.J. labs.
hyperproliferative changes in epithelium as well as it binds
to D.N.A. and proteins and destroys folate.20 This may lead
to decreased folic acid resulting in keratinzation
abnormalities leading to atrophy. Alcohol acts against
hepatic neo-antigens due to which tumour proliferation may
go unchecked and it also influences stem cell in the basal
cell layer by intracellular and intercellular pathway, a step
suggested to be of importance in development of oral
cancer.21
Stromyelysin 3; a gene involved in cancer metastasis
has been shown to be activated by acetaldehyde.22 In an
vitro study, acetaldehyde production from mouthwash was
proven to be cytotoxic for gingival fibroblasts.23 With
regards to cancer susceptibility from alcohol, Asian
population is more susceptible because of genetic
polymorphisms in Alcohol Dehydrogenase (ADH)
genotype that contributes to slower metabolism and
prolonged effects of ethanol metabolites.24
In relation to alcohol effect on composite
restorations, mouthwashes having high level of alcohol
have been studied to affect color and hardness of composite
restorations.25
FDA recommendations:
With raising concerns over safety of high alcohol
based mouthwashes, the Food and Drug Administration
(FDA) recommended following alcohol concentrations to
be used according to different age levels (Table 3).26
Currently most Chlorhexidine mouthwashes in
United States are formulated with maximum of 12% alcohol
while few others are entirely alcohol free. The U.S.
Consumer Product Safety Commission (CPSC) has
proposed child resistant packaging for mouthwashes having
3 grams or more Ethanol because of over eighteen thousand
cases of accidental ingestion by children over a period of
nine years resulting in coma, seizures and hypoglycemia
and two deaths reported so far.27,28 In case of hypoglycemia;
secondary to mouthwash ingestion, I/V glucose should be
given. Although FDA does not establish a causal relation
between alcohol in mouthwash and oral cancer, it suggests
further research to be carried out in this area. Furthermore,
American Cancer Society, National Cancer Institute (United
States) and Cancer Research Center UK discourage the use
of high alcohol based mouthwashes and categorize it as
possible risk factor.
Conclusion
In the present study, alcohol was present in all the
mouthwashes except for two products that were tested in
this study. It is a matter of serious concern to find the
presence of alcohol in the brands that claim to contain no
amount of alcohol, hence it is suggested that the regulatory
authorities of Pakistan and Pakistan Dental Association
(P.D.A.) in particular should play an active role and address
this issue. It is also recommended that the levels of alcohol
in the mouthwash need to be monitored and only the limit
necessary to dissolve active ingredients should be permitted
as well as making sure that all the brands should be obliged
to mention the exact percentage of alcohol as suggested by
F.D.A. thereby helping the consumer to choose any brand
depending upon the preferences. There is need for
development of child resistant packaging for mouthwashes
having high level of alcohol with instruction to keep out of
reach of children clearly written on the display panel to
avoid any accidental ingestion. We recommend that
depending on the different ingredients and their role in the
mouthwashes, these should be only prescribed when a
patient requires it in certain conditions. With regards to
susceptibility to increased risk towards oral cancer from
high alcohol based mouthwashes, definitive and conclusive
data is lacking and certainly there is a need for further
studies to be carried out to have a clear picture of any
association if at all from mouthwashes.
Acknowledgments
We would like to thank Liaquat College of Medicine
and Dentistry, Karachi for providing the funds and technical
support for the research project. We are also thankful to the
following people for their unlimited support and help;
Dr.Ali Farhan Razi, Prof.Naseer-ud-Din, Prof. Siraj-ud-
Daula, Prof.H.S.A. Athar, Dr.Bilal Abid, Dr. Mehwash
Kashif, Dr.Bahadur Ali, Dr.Ahmed Ali, Mr.Munawar,
Dr.Naheed Najmi, Col(R) Dr.Haq Nawaz, Dr.Imtiaz Ahmed
Lone, Prof Dr.Col (R) Sajjad Akbar, Dr.Iffat Khan, Rabia
Shafique and Miss.Humera Asif.
References
1. Bahna P, Hanna HA, Dvorak T, Vaporciyan A, Chambers M, Raad I.
Antiseptic effect of a novel alcohol free mouthwash: a convenient
prophylactic alternative for high-risk patients. Oral Oncol 2007; 43:159-64.
2. Scully C. Cancers of oral mucosa. [Online] 2009 [Cited 2007 Mar 25].
Available from URL: http://www.emedicine.com/derm/TOPIC565.HTM.
3. Beyer J, Gerostamoulos D, Drummer O, Costantino A. Comments on "The
effects of use of mouthwash on ethylglucuronide concentration in urine." J
Anal Toxicol 2007; 31:294-6.
4. Drummer OH. Drug testing in oral fluid. Clin Biochem Rev 2006; 27: 147-59.
5. Wigmore JG, Leslie GM. The effect of swallowing or rinsing alcohol solution
on the mouth alcohol effect and slope detection of the intoxilyzer 5000. J Anal
Toxicol 2001; 25:112-4.
Vol. 59, No. 3, March 2009 189
Table 3: Percentage of Alcohol for oral drug products
recommended by FDA.
Age limit % of Alcohol
1.Chilren under 6 Years Alcohol free, Otherwise 0.5% or less
2.Children between 6 to 12 Years 5% Alcohol
3.People over 12 Years Not more than 10% Alcohol
6. Muto M, Hitomi Y, Ohtsu A, Shimada H, Kashiwase Y, Sasaki H,et al.
Acetaldehyde production by non-pathogenic. Neisseria in human oral
microflora: implications for carcinogenesis in upper aerodigestive tract. Int J
Cancer 2000; 88:342-50.
7. Howie NM, Trigkas TK, Cruchley AT, Wertz PW, Squier CA, Williams DM.
Short-term exposure to alcohol increases the permeability of human oral
mucosa. Oral Dis 2001; 7:349-54.
8. Du X, Squier CA, Kremer MJ, Wertz PW Penetration of N-
nitrosnornicotine(NNN) across oral mucosa in the presence of ethanol and
nicotine.J Oral Pathol Med 2000; 29:80-5.
9. Vogel. Textbook of Practical Organic Chemistry. In: Vogel. Investigation and
characteristics of organic compounds. 5th ed. Delhi: Pearson 2005; pp 1220.
10. Ministry of Health. The Drug Act, 1976. [Online] 2003 [Cited 1976 May 11].
Available from URL: http://dcomoh.gov.pk/regulations/drugact1976.php.
11. Trevisani M, Smart D, Gunthorpe MJ, Tognetto M, Barbieri M, Campi B, et
al. Ethanol elicits and potentiates nociceptor responses via the vanilloid
receptor-1.Nat Neurosci 2002; 5: 546-51.
12. Burket. Oral Medicine. In: Epstein J, Wall IVD. Oral Cancer.11th ed. Ontario:
Elsevier 2008; pp 154.
13. Madan Kumar PD, Sequeira PS, Shenoy K, Shetty J. The effect of three
mouthwashes on radiation-induced oral mucositis in patients with head and
neck malignancies: Arandomized control trial. J Can Res Ther 2008; 4:3-8.
14. ADA. Division of Communications. Burning mouth syndrome. J Am Dent
Assoc 2005; 136: 1191.
15. No author. For the dental patient. What you should know about bad breath. J
Am Dent Assoc 2003; 134: 135.
16. Seitz HK, Pöschl G, Simanowski UA. Alcohol and Cancer. In: Galanter M.
Recent Developments in Alcoholism: The Consequences of Alcoholism. New
York, London: Plenum Press, 1998; 67-96.
17. Camila Lopes Cardoso, Renata Falchete do Prado, Luís Antônio de Assis
Taviera. Macroscopic and microscopic study of tissue response to oral
antiseptics and its influence on carcinogenesis. J Appl Oral Sci 2005;
13:286-90.
18. Weaver A, Fleming SM, Smith DB. Mouthwash and oral cancer: cariconogen
or conincidence? J Oral Surg 1979; 37:250-3.
19. Soames JV. Oral Pathology. In Soames JV: Oral epithelial tumors,
melanocytic naevi, and malignant melanoma. 4th ed. Karachi: Oxford
University Press 2005; pp 139.
20. Homann N, Kärkkäinen P, Koivisto T, Nosova T, Jokelainen K, Salasperso M.
Effects of acetaldehyde on cell regeneration and differentiation of the upper
gastrointestinal tract mucosa. J Natl Cancer Inst 1997; 89:1692-7.
21. Ogden GR. Alcohol and oral cancer. Alcohol 2005; 35: 169-73.
22. Timmons SR,Nwankwo JO, Domann FE. Acetaldehyde activates Jun/AP-1
expression and DNA binding activity in human oral keratinocytes.Oral Oncol
2002; 38:281-90.
23. Poggi P, Rodriguez y Baena R, Rizzo S, Rota MT. Mouthrinses with alcohol:
cytotoxic effects on human gingival fibroblasts in vitro. J Periodontol 2003;
74:623-9.
24. Bouchardy C, Hirvonen A, Coutelle C, Ward PJ, Dayer P, Benhamou S. Role
of alcohol dehydrogenase 3 and cytochrome P-4502E1 genotypes in
susceptibility to cancers of the upper aerodigestive tract. Int J Cancer 2000;
87: 734-40.
25. Settembrini L, Penugonda B, Scherer W, Strassler H, Hittelman E. Alcohol-
containing mouthwashes: effect on composite color. Oper Dent 1995; 20:14-7.
26. Over the counter drug products intended for oral ingestion that contain
Alcohol, pp13590-95. Food and Drug adminstration. Federal Register/Vol.60,
No.48/Monday, March13, 1995/Rules and Regulations.
27. Mrvos R, Krenzelok EP.Child-resistant closures for mouthwash: do they make
a difference? Pediatr Emerg Care 2007; 23:713-5.
28. Wade T, Gammon A. Ingestion of mouthwash by children. Child proof caps
are needed to prevent deaths. BMJ 1999; 318:1078.
190 J Pak Med Assoc
Madam, Communication and Interpersonal Skills
(CIPS) comprise an integral component of medical
professionalism.1-4 Effective CIPS augment quality health care
delivery, patient satisfaction, outcomes and physician's
confidence.1-3,5 Quite understandably, regulatory bodies such
as Accreditation Council for Graduate Medical Education
(USA), General Medical Council (UK) and College of
Physicians and Surgeons (Pakistan) have mandated their
incorporation into every residency programme.
Typically, the need for CIPS is considered equivalent to
the volume of direct patient interaction. Perhaps this is why
CIPS are not deemed priority training areas for radiologists.3
The neglect is reflected by the fact that radiology residents
perceive themselves inadequately skilled for communicating
with the patients and deem such situations stressful.1,2,6
Aradiologist carries the unique responsibility of
communicating with the patients, families, referring physicians
and other members of the health care team; there is potential
for loss of information at each interface.2,4,5 The routine
scenarios include discussing appropriateness of the requested
procedure, taking informed consent for it and sharing its
findings.4,6 At times, the situation may be more complex e.g.
when a patient inquires about the foetal well-being at the end
of a routine ultrasound exam during which foetal
anomaly/demise has been detected.4Aconsiderable proportion
of this communication is verbal, especially in acute care
setting. An accurate diagnosis may be rendered futile, with
possible ethical implications, if not communicated effectively,
in time, to the appropriate person.4,5 Added to it is the limited
duration of radiologist-patient interaction plus a lack of pre-
existing rapport2and the need for training "consultants of
consultants" in CIPS could not be any more obvious.4,6
This can be achieved through CIPS curricula
comprising of clearly defined objectives, effective learning
strategies such as role modeling or high fidelity simulations
and reliable techniques to gauge adequacy of these
attributes.1,2,5,6 The curriculum should emphasize long term
inculcation of basic principles of CIPS more than the amount
of knowledge attained.5,6
Currently, CIPS training for radiology residents in
Pakistan is limited to workshops organized by College of
Letter to the Editor
Communication & inter-personal skills? But I'm a radiologist…
... Alcohol added in mouthwash to function as a solvent for other active substances, preservatives, and antiseptics also harm the soft tissues of the oral cavity, such as an increased risk of ulcers and malignancies in the oral cavity, especially from the alcohol-containing mouthwashes. [15,16] The main action of using fluorine is to prevent dental caries by reducing the solubility of the enamel and thereby making it more resistant to an attack of dental caries. [17] Other factors that impact the surface roughness of restorative materials is the stiffness of toothbrush bristles, the effect of different toothbrush bristles' stiffness on the surface roughness of restorative materials showed that bristles have an abrasive effect on the composite resin. ...
... A total of 156 out of 287 participants did not prescribe alcohol mouthwash to patients with esthetic restorations and they agree with Munawar (2003) that alcohol-containing mouthwash was decreasing the surface hardness hybrid restorative material. Besides, Listerine contains alcohol it has a greater influence on the sorption rate of the composite restoration, especially on the hybrid and nanohybrid (Haq, Batool, et al. 2009). ...
Article
Full-text available
Objective: To evaluate the knowledge and attitude of dental students in Riyadh city toward the effect of mouthwash on surface roughness and color stability of some esthetic restorations. Materials and methods: This cross-sectional study is directed toward dental students in Riyadh city. The inclusion criteria include both undergraduate students and interns. The exclusion criteria include postgraduate dentist and those in the preparatory year. Also, dental students outside Riyadh are excluded, A questionnaire in English language was distributed through randomized selected participants in both social media (WhatsApp, Twitter) via link in a google sheet. The survey items were divided into two sections that include socio- demographic data and knowledge subscales. Results: A total of 455 dental students have filled the survey, among them 168 were excluded because they did not meet the inclusion criteria (they were preparatory year students), making the number of included responses 287. There was a significant difference between males in females when answering the questions related to 1) indication of mouthwash prescription (P = 0.044), 2) if mouthwashes increase surface roughness of esthetic restorations (P= 0.007) and 3) the type of toothbrush used with esthetic restoration (P= 0.016). Conclusion: there is high awareness and using of mouthwashes among dental students in Riyadh the correlation between mouthwashes and restorative materials needs more spot lightening in the dental education process.
... In the present study we used 70% alcohol (ethanol) to prepare the neem mouthwash. Haq MW (2009) 50 reported alcohol (Ethanol) in the mouthwashes does not contribute to any therapeutic action. Thus, the therapeutic effect of the solution could be totally attributed to neem. ...
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The aim of the present study is to evaluate the clinical efficacy of Azadirachta Indica (A. Indica)/ neem mouth rinse in conjunction with scaling and root planning in the treatment of chronic gingivitis and chronic periodontitis. Total of 50 patients who were diagnosed with generalized chronic gingivitis and chronic periodontitis were divided equally into 2 groups. In first group subgingival ultrasonic instrumentation was performed along with the 0.2% chlorhexidine mouth rinse and in the other group 10% A. indica-mouth rinse was used. Clinical parameters were recorded on the baseline, 7thday, 30th day and 90th-day post-therapy. The intra-group comparison showed a statistically significant difference in clinical parameters at different intervals post-therapy whereas in the inter-group comparison the difference in clinical parameters was statistically non-significant at various time intervals. Neem mouthwash as an irrigant during ultrasonic scaling enhances the benefits of scaling and root planing in the treatment of chronic gingivitis and chronic periodontitis and can be used as an effective alternative for chlorhexidine.
... Pandemi döneminde el hijyenini korumak amaçlı sık kullanılan kolonya ve alkol bazlı el dezenfektanlarının; trafik denetlemelerinde alkolmetre ile yapılan nefeste alkol ölçümlerinde hatalı sonuçlar vermeye neden olmakla suçlanmaları özellikle son zamanlarda gazete haberlerinde sıkça karşımıza çıkmaktadır. Bu konuda yapılan çalışmalarda nefes alkol testinde yanlış pozitif sonuca sebep olan bazı durumların olduğu, alkol bazlı el dezenfektanları, gargaralar, astım tedavisinde kullanılan inhaler ilaçlar, etanol içeren farmasötik preparatlar, ağız spreyleri, bazı kanser ilaçları ve homeopatik preparatların kullanımı sonrası nefes alkol düzeyinin pozitif çıkabileceği söylenmektedir (8)(9)(10)(11)(12). Etanol içerebilecek veya tüketimleri sonrası fermentasyon nedeniyle etanol oluşumuna neden olabilecek şalgam, şıra, kefir gibi gıda maddelerinin, enerji içeceklerinin, nefes tazeleyici tabletlerin ve nefeste alkol kokusuna neden olan bazı hastalıkların da nefes alkol testini etkileyebileceği düşünülmektedir (13,14). ...
... Ethanol is one of the main active ingredients in the majority of mouthwashes on the market as it is a food safe, cheap and readily available antiseptic. Some products even have ethanol concentrations as high as 27 % [141]. The use of such high concentrations of ethanol in these products will cause irritation to the oral cavity and dryness. ...
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This review explores the physical, chemical and structural properties of key components of oral care products, whilst looking at the challenges which need to be overcome to continue to improve the efficacy of oral care, and improve dental health. Oral care has been an essential part of all populations and cultures around the world for thousands of years. To maintain good oral health, dental plaque causing bacteria and malodour must be controlled whilst also strengthening and protecting the teeth to prevent dental caries. Advanced modern formulations need to provide controlled and extended release of ingredients vital for dental health. With modern day products such as toothpastes and mouthwashes, it has never been easier to maintain good oral hygiene and health, yet the incidence of dental caries is still on the rise. The complex formulations of modern toothpastes and mouthwashes makes them one of the most sophisticated pharmaceutical products on the market today. The demands of the consumer coupled with the complexity of the oral cavity make it one of the most challenging development processes.
... Avusturya, Avustralya, Kanada, Hırvatistan, İtalya, Makedonya, Yeni Zelanda, Slovenya, İspanya ve Amerika Bileşik Devletleri bu ülkelerdendir ve bu ülkelerde yaş sınırları veya deneme süreleri bulunduğundan, bu durumlarda daha düşük BAC seviyeleri uygulanmaktadır [14]. [16][17][18][19]. Etanol içermesi muhtemel şalgam, şıra, kefir gibi yiyecekler, enerji içecekleri, nefes tazeleyici tabletler ve gastroözofageal reflü hastalığının da nefes alkol testini etkileyebileceği düşünülmektedir [2,20]. ...
... Mouth rinse with alcohol as a base is prone for addiction for people consuming alcohol regularly. Excessive use of such mouth rinse regularly may cause harmful effect on the internal organs like lungs, kidneys, intestines and in certain cases the brain may also get affected 3,4 . ...
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A new Polyherbal Mouth Rinse was formulated comprising of polyherbal extracts of grapes peel, neem, clove, fennel and ginger based on their traditional applications. The extracts used in the formulation and polyherbal mouth rinse both were subjected for anti-bacterial activity separately. Phytochemical tests and spectral studies of the extracts have indicated the presence of polyphenolic compounds-mainly trans-resveratrol and the UV-Vis spectrum also shown the presence of trans-resveratrol at 260 nm. This compound is reported to have wide applications. Both the extracts and polyherbal mouth rinse have shown good sensitivity towards microorganisms like S. aureus, S. mutans and E. fecalis. These study results shows that the presence of compounds like glycosides, terpenoids, flavanoids and saponins which may be responsible for the antibacterial efficacy of the extracts and polyherbal mouth rinse against the these microorganisms which are mostly found responsible for bacterial infections in oral cavity. However further study is needed to confirm this.
... Alcohol added in mouthwash to be functioned as a solvent for other active substances, preservatives, and antiseptics. 3,4 In addition to the benefits provided, mouthwashes can also have an adverse effect on the soft tissues of the oral cavity, such as an increased risk of ulcers and malignancies in the oral cavity, especially from the alcohol-containing mouthwashe. 5,3 Research conducted by Asmussen in 1984 showed that not only its effects on the oral cavity, alcohol content in mouthwash can also affect the mechanical properties of resincontaining restorative material. ...
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Mouthwash is widely used by the community to maintain oral health. Beside the benefit provided, both alcohol-containing mouthwash and alcohol-free mouthwash have negative effects on the composite resin restorative materials, which can affect the surface hardness. One of composite types is hybrid type which is superior in physical and mechanical properties as a restorative material. The aim of this study was to determined the effect of alcohol-containing mouthwash and alcohol-free mouthwash towards the surface hardness of hybrid composite restorative material. This study used 15 disc-shaped specimens of hybrid composite with the size of 6 mm diameter and 4 mm thickness and divided into three treatment groups immersion, in the alcohol-containing mouthwash (A), alcohol-free mouthwash (B), and artificial saliva (C) as control for 12 hours, which surface hardness was further tested using Vickers hardness test. The mean of hardness values of group: A 24.9 VHN; B: 27.2 VHN; and C: 28.4 VHN. The results of statistical tests One-Way ANOVA showed there were significant differences in the hardness values among the three treatment groups (p<0,05). From this study concluded that both alcohol-containing mouthwash and alcohol-free mouthwash were decreasing the surface hardness of hybrid composite restorative material.
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Perception is an individual response about something that can be influenced by knowledge. Good individual knowledge of alcohol will affect their perception of alcohol-containing product. The MUI fatwa permits the use of alcohol in cosmetics. The purpose of this study was to observe the perception of alcohol content in cosmetics. The observation was carried out using a questionnaire technique with a nonprobability sampling technique with accidental sampling. The questionnaire was conducted by Pearson correlation test, validity test, reliability test, normality test, chi-square test, and description. In this study, using 98 respondents and get an average value of knowledge about cosmetics 6,73 with SD value of 0,49; knowledge of alcohol 4,54 with SD 1,17 and behavior with SD 1,46. There is a relationship between age with the level of cosmetic knowledge with p-value <0.05. As many as 46.94% stated, the halal label's urgency on cosmetics is very important and 39.80% is important, where the religion of the individual influences the urgency level of cosmetics halal. The urgency of halal labels on cosmetics is high in line with the behavior when buying cosmetics. The 81.63% of respondents stated that halal labels on cosmetic products affect the interest in buying cosmetics. As many as 61.24% of respondents have the perception that halal cosmetics do not contain alcohol. The Pearson halal label correlation test confirms this obtained a p-value value of 0.024 that the halal label influences respondents' perceptions. Individuals were having a perception that cosmetics with halal labels do not contain alcohol, which is influenced by halal labels' knowledge.
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Mouthwash is an additional mechanical oral cavity cleaning method which is known to reduce oral bacterias that causes plaque build ups. Mouthwash may and may not contain alcohol. The objective of this study was to determine the alterations on the oral cavity environment (salivary pH and plaque index) before and after gargling with alcohol and non-alcohol mouthwash, and to analyze which of the mouthwash is more effective. This study was an experimental study with one group pre test and post test experimental design. The subject of this study was 16 of University of Sumatera Utara’s female undergraduates whose age ranges from 18–23 years old and accorded to the inclusion and exclusion criteria. Subjects were divided in two groups, subjects were instructed to used the mouthwash twice a day for seven days, then salivary pH and plaque index were measured at third and seventh day of used. Repeated Annova test results shown a significant decreas on salivary pH and plaque index after gargled with mouthwash containing alcohol, in the non-alcohol mouthwash there was a significant decreased in plaque index but none on the salivary pH. Dependent T-test results shown that there were no difference in salivary pH and plaque index after gargled with alcohol containing and non-alcohol mouthwash. This study shows that non-alcohol mouthwash is better because there were a significant decrease in plaque index, without caused significant decreases in pH scores.
Thesis
L’éthylisme est responsable de nombreuses complications pour l’organisme. Son impact sur la santé se traduit par des dommages physiques, psychiques et sociaux, qui varient selon le mode et la fréquence de consommation, ainsi que les quantités ingérées. Les maladies parodontales et péri-implantaires sont des pathologies inflammatoires d’origine infectieuse, qui présentent une multitude de facteurs de risque. Les différents éléments de réponse trouvés dans les études mettent en évidence des effets contradictoires de l’éthylisme sur ces maladies ; les effets néfastes sont les plus prépondérants. Les résultats s’accordent pour dire qu’à partir d’un niveau de consommation élevée, les effets sont toxiques. L’utilisation d’alcool dans les bains de bouche ne constitue pas un risque pour la santé. La prescription de spécialité en contenant est à éviter chez les alcoolodépendants.
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Studies have related the action of alcohol on the oral mucosa as a promoter of carcinogenesis, once most oral antiseptics contain alcohol. Its utilization for mouthrinses from 30 to 60 seconds, as indicated on the labels, yields a longer-lasting topical action when compared to the intake of alcoholic beverages. This study aimed at conducting a macroscopic and microscopic analysis of the tissue response of tongue mucosa of hamsters to daily topical applications of antiseptics (Anapyon, Listerine, Oral B) during 13 and 20 weeks, following the methodology for carcinogenesis investigation developed by the Discipline of Pathology of Bauru Dental School, University of São Paulo. After sacrificing the animals, their tongues were removed and fixed on 10% formalin. Macroscopic examination did not reveal significant alterations, and the specimens were processed by routine histotechnical procedures for HE staining. Three serial sections of each tongue were evaluated, and characteristics related to epithelial hyperkeratinization, atrophy, hyperplasia and dysplasia were organized in tables. Despite the observation for moderate dysplasia in one case in the Anapyon 20 week group, the further results were very similar to the control group (saline solution), eliminating the need of comparative statistical tests. By means of such methodology for testing the carcinogenesis-initiating action, it was concluded that oral antiseptics are unable to trigger the development of neoplasms.
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The tumor-promoting effect of ethanol on cancer of the upper respiratory-digestive tract is not well understood. Although ethanol itself is not carcinogenic, the first product of ethanol metabolism-acetaldehyde is. Acetaldehyde can be produced from ethanol by oral bacteria, and high concentrations have been observed in human saliva after ethanol consumption. The purpose of this study was to investigate whether acetaldehyde administered orally to rats induces altered differentiation and proliferation in the animals' upper gastrointestinal tracts. Twenty Wistar rats were given either water containing acetaldehyde at a concentration of 120 mM or tap water to drink for 8 months. Tissue specimens were then taken from the tongue, epiglottis, and forestomach of each animal and immunohistochemically stained for markers of cellular proliferation (Ki67 nuclear antigen) or differentiation (cytokeratins 1, 4, 10, 11, 14, and 19). The mean epithelial thickness of each sample was measured via light microscopy, using an eyepiece containing grid lines. Differences between the control and acetaldehyde-treated groups were analyzed by use of the unpaired Student's t test. All reported P values are two-sided. Although no tumors were observed, staining for cytokeratins 4 and 14 revealed an enlarged basal layer of squamous epithelia in the rats receiving acetaldehyde. In these animals, cell proliferation was significantly greater than that observed in the control animals for samples from the tongue (P<.0001), epiglottis (P<.001), and forestomach (P<.0001). In addition, the epithelia from acetaldehyde-treated rats were significantly thicker than in epithelia from control animals (P<.05 for all three sites). Acetaldehyde, administered orally to rats, can cause hyperplastic and hyperproliferative changes in epithelia of the upper gastrointestinal tract. This finding suggests that microbially produced acetaldehyde in saliva may explain the tumor-promoting effect of ethanol on these epithelia.
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This study investigated whether commercially available mouthwashes could affect or change the color of a hybrid composite resin. Twenty-four disks were fabricated and divided into eight equal groups for testing. At baseline, six colorimetric recordings and color parameters (L*, a*, b*) were recorded for each grouping of disks using a Chroma Meter CR-300 in reflectance mode. The groups of disks were immersed in their respective mouthwashes for 2 minutes a day in a vibratory fashion over a 6-month period. At the end of 6 months, color differences, delta E, were calculated between the base line and test recordings. The results indicate that rinsing with mouthwashes for 6 months can cause a hybrid resin to undergo color variations. Except for one product the color variations were not clinically significant.
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