“Alcohol Use In Mouthwash And Link To Oral Cancer” By: Wasif Haq Krona Daniel Rabia Shafique...

“Alcohol Use In Mouthwash And Link To Oral Cancer”

By:

Wasif Haq Krona DanielRabia Shafique Mehwish BatoolThird Prof B.D.S.Liaquat College Of Medicine And Dentistry.

Prologue:

Alcohol use is supported in Islam as derived from following Ayah:

“They question thee about strong drink and

games of chance. Say in both is great sin, and some utility for men but the sin of them is greater than the usefulness”.

(Ayah :219, Chapter of Cow, Parah No.2)

Aims And Objectives:

• Role of alcohol in the mouthwash after the advent of more effective agents.

• Determine whether there has been an increased risk observed with alcohol based mouthwash.

• Check the ratio of mouthwash usage between dental and non-dental community.

Introduction:• Many mouthwashes contain

high alcohol content(18%-26%)

• Increased risk towards oral cancer with high alcohol based mouthwashes

• A value higher than used in some wines and drugs:

WINE-(Merlot):11.5% Alcohol WINE-(Chardonnay):12.5%

Alcohol Diazepam:19% Alcohol.• The main mouthwash under

study is “Listerine” as it is most widely used.

Ethanol, Chemistry & Properties

Most of the mouthwashes contain two forms of Alcohols:

• Ethanol (Hygroscopic,Bi-polar molecule,reduces surface tension)

• Isopropyl Alcohol(Cleaner & Solvent,twice toxic than Ethanol)

Oral Absorption of Alcohol :

Metabolism of Alcohol :

Absorption by the oral mucous membrane.

Production of “Acetaldehyde” by two enzyme systems:

• Alcohol dehydrogenase• Microsomal ethanol oxidizing system

Higher blood concentration of Alcohol in women.

Myths Regarding Alcohol:

• Anti-septic action• Anesthetic effect• Soothing action• Prevents halitosis• Reduces plaque

level However none of

the effects are achieved at 25% concentration.

Squamous Cell Carcinoma:

Definition: “It is a malignant

neoplasm (cancer) of skin derived from epidermis”.

Also called as

“Epidermoid carcinoma”.

Etiological Factors Involved:

-Tobacco smoking: -Alcohols:

Pipes Spirits Cigars Wine and beer Cigarette Alcohol + Tobacco Bidis Reverse smoking -Diet and Nutrition:-Smokeless tobacco: Iron Deficiency Snuff dipping Vitamin A & C Deficiency Tobacco sachet Nutritional Deficiency Tobacco chewing Alcoholism-Betel chewing,betel quid, areca nut -Viruses:-Ultra violet light Herpes Simplex virus-Immunosupression Human papilloma virus-Chronic Infections: H.I.V. Syphilis -Dental Factors Candidosis -Occupation (Adapted by J.V. Soames, Oral Pathology,4th Edition)

The Real Picture:

Alcohol- - An inactive ingredient with no proven clinical benefit:

• Researches in Spain finds “No differences were seen between Alcohol rinse and Alcohol free rinse”.

• Alcohol free Chlorhexidine rinse as effective as one with Alcohol, except with increased cancer risk.

A Product Study—Listerine:

• Formulated by Dr.Lawrence and Jordan in 1879.

• Chemical Composition: The active ingredients listed on gold standard

version of Listerine bottle(120 ml) available in Pakistan are:

• Menthol USP 0.42% w/v• Thymol USP 0.063% w/v• Methyl salicylates USP 0.055% w/v• Eucalyptol N.F. 0.091% w/v• Benzoic acid USP 0.015% w/v• Alcohol 25% v/v

Role Of Different Constituents:

Role of different constituents in Listerine:

• Menthol—Local anesthetic• Thymol—Anti-septic• Methyl Salicylate—Cleaning agent• Eucalyptol—Anti-septic,anti-spasmdoic, local

anesthetic • Benzoic acid—Preservative.• Alcohol (Ethanol)—?

Role Of Alcohol:• Alcohol at 25% concentration ineffective

against bacteria and fungi.

• Alcohol’s dis-infection and anti-septic properties start at 50%-70% concentration.

• At 21%-25% concentration it acts as a good solvent.

Action Of Alcohol (Ethanol) In Mouthwash:

• As A Desiccant:

• Certain amount of moisture needed for maintenance of oral hygiene.

• Ethanol acts as a desiccant.Being hygroscopic, it absorbs moisture from environment.

Action Of Alcohol (Ethanol) In Listerine:

• Worsening bad breath(halitosis):

• Alcohol produces dehydration,favoring an-aerobic environment,increasing more episodes of bad breath and activities of an-aerobic bacteria e.g. Lactobacilli.


• Increased risk towards Oral cancer:

• A study from United states indicates elevated risk of mouth,tongue and throat cancers in mouthwash users with alcohol content greater than 25%.

• 60% higher risk of cancer in men and women had a 90% higher risk than people who didn’t use mouthwash.

(Research by the by the National Cancer, reported in

Working Mother, 230 Park Ave., New York 10169)


• Increased risk towards Oral cancer:

• Adapted from J.V. Soames,Oral Pathology,4th Edition


• Alcohol’s role in carcinogenesis:

• Irritation of epithelial lining of pharynx and mouth.

• “Acetaldehyde” generates free radicals.

• Oral mucous membrane atrophy.

• Solvent for other carcinogens.• Against hepatic neo-antigens.• Ethanol or it’s metabolite

“Acetaldehyde” acts as tumor promoter rather than direct carcinogen.


• Leukoplakia:

• Leukoplakia has been found more frequently in the oral cavities of those using high alcohol content mouthwash.


• Effect On Composite Restorations:

• Alcohol being a solvent, in some studies,it has been observed to dissolve and breakdown composite restorations.


• Systemic effects:• The American Association of Poison Control

Centers reported more than 10,000 calls concerning mouthwash ingestion by children, some actually involving deaths.

• Seizures, brain damage, and death in children.


• People who should not use Alcohol based mouthwashes:

• Alcohol dependency• Substance abusers • Organ and marrow

transplant patients• Pregnant women. • Some people with voice

problems should avoid mouthwashes that contain Alcohol or other irritating ingredient.

Anti-septic action:

Anti-septic action of an agent depends upon:

• Concentration • Time of contact • Temperature

Alcohols act a bactericidal agent at 70% concentration,at 300 C in 1-2 mins.

In A Nut Shell:

• Not an antiseptic at 25%• Anaesthetizing effect is by Menthol.• No soothing effect,rather lower alcohols

(Methanol and Ethanol) produce the burning sensation as experienced with Listerine.

• No anti bacterial effect at 25%, • Not recommended for halitosis.• Alcohol has no effect on plaque.

Actual Role Of Alcohol:

• Lowers the surface tension• Increases the solubility of

solution and is the “most cheapest pharmaceutical solvent”.....

• No beneficial use for the consumer.

Directions On The Bottle:

• Use for “specific condition”,

• “Not to be used regularly”

• “Use diluted”.

Food And Drug Recommendations:

• The limits for Alcohol in mouthwashes:

• Children under 6 years=Ideally Alcohol

free,Alcohol content 0.5% or less.• Children 6-12=0.5%-5% Alcohol content.• People over 12 years=5%-10% Alcohol

content. (Why FDA labels Listerine Safe and Effective?)

Sample Testing:

• To check the presence of Alcohol in the mouthwashes, two tests were conducted.

• The “Primary tests” were conducted at the Department of Biochemistry at Liaquat College Of Medicine And Dentistry.

Sample Testing:

• Iodoform Test: C2H5OH+4I2+6NaOH CHI3+ HCOONa+

5NaI+5H20

• The Iodoform test gives yellow precipitates if Ethanol is present in sample.

Sample Testing:

• Primary Tests:

1.Listerine2.Enziclor3.Flourocool4.Prodent5.NiFlam6.Protect (Alcohol Free)7.Benzirin8.Neo-nexus9.Hi-Paradent

Sample Testing:

• Results from primary tests:

Ethanol test positive in all samples except “Flurocool”.

Sample Testing:• Secondary Tests: The “Secondary tests” were conducted at Karachi

University labs, analysis for which four samples were sent:

1.Listerine 2.Enziclor 3.Protect 4.Clinica And the tests detected presence of Alcohol in all

the four samples.

Formation Of Esters:

• Esters are compounds formed by reaction of Alcohols with Carboxylic acid e.g Triacylglycerols.

• Alcohols reaction with Benzoic acid. (Endothermic reaction)

• Irritant to eyes,respiratory tract,skin & mucous membrane

Esters In Mouthwashes:

• Esters as artificial flavoring agents:

Esters

Flavors

AmylacetateBenzylacetateAmylbutyrate

Isobutyl formateEthyl ButyrateOctylacetate

Banana Jasmine Apricot Raspberry Pineapple Orange

CHX Products Better Than Alcohol Based Products:

Alternative Products: Side effects of CHX:• Staining of teeth.• Alteration in sensation of taste.• It worsen established radiomucositis. Other substitutes to lower surface

tension. Alternatively mixing 1 part of

hydrogen peroxide in 6 parts of warm water with a dash of salt,intra-orally swish this mixture for 2 to 4 minutes several times a day.

Survey:

• Do you use any mouthwash?• If yes,mention name,duration and frequency.• Any specific reason for use?• Was it prescribed by a dentist,doctor or self?• Preference of Alcohol based over non-Alcoholic

mouthwash?• Are you aware of Alcohol as a constituent of

mouthwash?• Would you prefer a mouthwash without Alcohol?• Are you aware of the fact that Alcohol may be

cytotoxic or pre-cancerous?• Do you think Alcohol based mouthwashes should be

available?

Statistics:

Conclusion:

• No definitive role of Alcohol in mouthwash.• Increased risk of oral cancer with prolonged

use of Alcohol based mouthwash.• Using CHX products that contain Alcohol

but in less quantity than 25% Alcohols can be regarded safe but again the mouthwash should not be used as a daily commodity.

• One should know what contents a product contains before taking it for regular use and especially Dentists need to know the benefits as well as hazards and prescribe mouthwashes only when needed.

Word Of Thanks:• Dr.Naveed Rashid (Principal)• Peridontology: Dr.Nadya Sultan Ali (B.D.S.,M.C.P.S.,F.I.C.C.D.E)• Chemistry: Dr.Iffat Khan (P.H.D. Chemistry) Mr.Munawar Siddique (M.S.C. Biochemistry) Saad Khawaja Farooq

• Pharmacology: Dr.Talea Hoor (M.B.B.S.)

• Oral Maxillofacial surgery: Dr.Mehwish Kashif (Residency in Oral Surgery) Dr.Atif Butt (B.D.S.)

Miscellaneous: Hassan Rasheed And to everyone who co-operated with us in each and every aspect.

Thank You:

Any Question,Suggesstions And Recommendations?:

“Alcohol Use In Mouthwash And Link To Oral Cancer” By: Wasif Haq Krona Daniel Rabia Shafique...

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