| Abstract|| |
Denture stomatitis, periodontitis, and peri-implantitis are the growing problems in restorative dentistry. Chemicals play an important role as an adjuvant to mechanical cleaning of teeth, implants, surrounding tissues, and prostheses. Current mouth rinses are reported to affect the tissues and prostheses if used on a long-term basis. Sodium bicarbonate, the common baking soda, has been reported to be versatile. A search of the resources through Medline and Google Scholar was made to understand the current status of the mouth rinses and the use of sodium bicarbonate. Different MeSH and search criteria were used for the different search engines. Baking soda, being a common household item, with its ready availability, safety, minimal abrasivity, and bactericidal property makes it a patient-friendly mouthwash, component in the dentifrice, or chewing gum, which can be used on a long-term basis as an adjunct virtually free of any side effects.
Keywords: Denture cleanser, denture stomatitis, diabetes, mouth rinse, mucositis, peri-implantitis, sodium bicarbonate
|How to cite this article:|
Madeswaran S, Jayachandran S. Sodium bicarbonate: A review and its uses in dentistry. Indian J Dent Res 2018;29:672-7
| Introduction|| |
Advances in preventive and restorative dentistry have contributed to the global decline in the proportion of edentulous patients., On the other hand, there is an increase in the number of denture wearers, especially with implant restorations., Raising standard of living and dental awareness have increased patient expectations toward dental treatment. This demands the dentist to provide the best care with an assurance for long-term success. However, the successful treatment outcomes depend on the regular maintenance of hard and soft tissues around the teeth and the prostheses. Communicating with patients about the current status, pre- and post-treatment responsibilities for both the dentist and the patients, becomes a key to success. Therefore, dental practitioners should be competent in addressing the maintenance issues before and after treatment. This goes beyond the technical competencies during the provision of optimal care.
Simple, noninvasive methods to stop the disease such as caries control and to improve the current periodontal health and maintenance may play an important role in general dental practice. These include mechanical and chemical methods. The mechanical methods include oral prophylaxis, motivating patients to use brushing and interdental cleaning aids, etc. These methods work better if supplemented with the use of chemicals such as chlorhexidine and fluorides.
The aim of this article is to discuss the role of a chemical which is readily available and can act as both chemical and mechanical agent. It is sodium bicarbonate which is nothing but the common household baking soda.
Chemistry of sodium bicarbonate
Sodium (Na+) and bicarbonate (HCO3−) ions are normal constituents in the human body. Bicarbonate is the principal buffer of extracellular fluid (plasma and interstitial fluid) and saliva. Fermentation of carbohydrates in the mouth produces the acids and in turn lowers the pH. This increased concentration of H+ is neutralized by salivary HCO3− to form water and carbon dioxide.
Similarly, when sodium bicarbonate is dissolved in water, it ionizes and forms HCO3− ions which then react with H+ ions from the acids. The mild alkalinity along with the mild abrasiveness makes sodium bicarbonate a versatile product. It is also classified as “generally a safe food product” worldwide.,
Versatile uses of sodium bicarbonate
Various general and medical uses of sodium bicarbonates are listed in [Table 1]. Their use in food industry is because of their nature to react with acids such as vinegar, lemon juice, cream of tartar, and bacterial acids forming carbon dioxide, thus aerating the batter to give the end product a greater volume. Similarly, they neutralize the odoriferous fatty acids produced by the action of bacteria on sweat.,
Metabolic acidosis is the condition when the pH of body fluids drops. This is the usual complication of diabetic keto-acidosis, salicylate poisoning, and tricyclic antidepressant overdosage., As a mucolytic agent, it reduces the viscosity of the mucous by weakening the chemical bond within the mucin molecules. Use of 2% sodium bicarbonate for direct tracheal irrigation or as a spray to remove the secretions and for cleaning the sticky secretions of the inner cannula of tracheotomy tubes has been reported. Sodium bicarbonate is also available as over-the-counter antacid to treat acid reflux, for example, ENO® GlaskoSmithKline.
Sodium bicarbonate can be used as a regular oral care product, a preventive regimen, and also as a medicine to treat disease. The uses are discussed as follows:
Prevention of dental caries
Dental caries is a time-dependent demineralization of the enamel and dentine due to bacterial acids. Streptococcus mutans and Lactobacilli are the main bacteria related to dental caries as they can produce acids by breaking dietary saccharides and maintain the acidity for a prolonged period. Cariogenicity of these bacteria has been found to be reduced when the pH increases to neutral and above. In addition to the acid-neutralizing property, sodium bicarbonate has also been reported to be bactericidal against cariogenic bacteria. Studies have compared sodium chloride and sodium bicarbonate and ruled out the role of sodium ions in the bactericidal activity. In addition, the bicarbonates are also available in chewing gums to enhance salivary flow to wash away the food debris.
Prevention of dental erosion
Erosion is a form of tooth surface loss resulting from pathologic, chemical dissolution of the organic and inorganic components of tooth structure by acids without bacterial involvement. Normally, the acid can be either dietary such as from acidic food and drinks or gastric due to gastro-esophageal reflex and frequent vomiting. Reports suggest that tooth demineralization can start when the pH drops below 5.5. The acid attacks can lower the pH further even to around 1.0. In addition, the pH remains low because of the residual acid in the mouth.
The effects can be from simple erosive facets on the enamel surfaces to severe sensitivity. Teeth enamel then becomes more prone to other forms of tooth surface losses such as attrition and abrasion. Careful diagnosis and management will be needed depending on the severity of tooth surface loss, the detail of which is beyond the scope of this article. However, prevention needs to be looked at carefully, and priority should be given to minimize further enamel loss. This will involve dietary counseling to avoid acidic food and drinks and medical or psychological management of gastric regurgitation. Delaying brushing for at least half an hour after acid exposure and the use of neutralizing oral rinses such as sodium bicarbonate or Milk of Magnesia have been reported to be effective., Overnight smearing of sodium bicarbonate gel has also been reported to be effective to neutralize the acid regurgitated during sleep.,,
Control of periodontal disease
The prevalence of periodontal diseases remains high, and peri-implant diseases are on the rise worldwide., The main factor is the microbial colonization, which includes Gram-negative, anaerobic organisms such as Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Tannerella forsythia, Prevotella intermedia, and Treponema denticola. These bacteria release a variety of chemicals such as proteases, lipopolysaccharides, hydrogen sulphide, ammonia, and short-chain fatty acids such as butyric acid and propionic acid. These virulent factors then induce both micro- and macro-level tissue destruction. Sodium bicarbonate has been found to neutralize the butyric acid and therefore hinder the inflammation. Sodium bicarbonate in the periodontal pocket has been reported to aid in the healing of periodontal tissues along with mechanical debridement. The minimal bactericidal concentration of sodium bicarbonate against major periodontal pathogens has been found to be 2.5%–5%. Subgingival irrigation with sodium bicarbonate has also been advocated for nonsurgical management of aggressive periodontitis.
Component of dentifrice
Mechanical cleaning of the hard and soft tissues of the oral cavity is the focus of oral hygiene. However, over enthusiastic use of the mechanical aids can result in abrasive damage to the tissues. Patients should be advised to use tooth brushes with soft-to-medium bristles and to be gentle with their brushing techniques. From the dentists' perspective, the abrasiveness of the dentifrice becomes important, especially with respect to dental implants.
The abrasiveness of dentifrices is measured in terms of relative dentine abrasiveness (RDA). The normal RDA of commercially available dentifrices ranges from 70 to 110. High solubility and low intrinsic hardness of sodium bicarbonate reduce the RDA to 30–40. Therefore, bicarbonates can safely be used on the dentine surface. However, bicarbonate, as any other dentifrices, has been found to abrade the dentine when used on dry surfaces. The alkalinity with the pH of 8.3 along with the bactericidal property makes sodium bicarbonate a friendly cleanser around teeth, implant surfaces, and soft tissues around them. Smith et al. have shown that the chemical action of bicarbonate ions dominates the actual mechanical cleaning action.,
Component of denture cleansers
Poor maintenance of even well-made prostheses can lead to failure. This can be from frustration due to stains and bad odor to major issues such as denture stomatitis and peri-implantitis. Denture cleansers are important as adjunct to mechanical cleaning of the prostheses. Their use becomes vital where mechanical cleansing is compromised, such as aging or physical dependence.
Commercial denture cleaners are available in the form of powder, tablet, and soaking solutions. The major components of the denture cleaning powder are sodium bicarbonate, sodium perborate, or hypochlorite. These cleansers effervesce when mixed with water and mechanically disintegrate the biofilm on the denture surface. Sodium perborate–sodium bicarbonate denture cleansers have been found to have lesser effect on the surface properties of the dentures and elastic properties of the implant attachments when compared to hypochlorite-based denture cleansers. Denture cleansers based on sodium bicarbonate have been reported to be safer on metal components and resin surfaces than the perborate-based cleansers. Household baking soda and plain vinegar have been suggested for use by patients who do not have access to commercial denture cleansers., However, vinegar being a dilute acid was found to corrode the metallic components of the prostheses.
Denture stomatitis is associated with poor denture hygiene and candida infection. Soaking heat-activated acrylic resin in a solution of 5% sodium bicarbonate has been proven to be successful in controlling the adherence of Candida albicans. Therefore, sodium bicarbonate solution can be an effective denture hygiene measure, in patients suffering from denture stomatitis.
Role in mucositis patients
The treatment for oral cancer is multimodality involving surgery, radiation, and chemotherapy. Mucositis is the most common stressful consequence of head and neck radiation therapy and chemotherapy. Mucositis results in edematous, erythematous, and friable mucosa. Salivary production is impaired resulting in xerostomia which leads to decreased buffering and flushing action and increased plaque accumulation. Saliva becomes thick and ropy, as serous acini are affected prior to mucinous acini. The resulting lack of lubrication can make the food stick to the palate and make swallowing difficult. This becomes a distressing situation to the patients. In addition, radiation-induced muscular fibrosis leads to trismus, making it difficult in using regular oral hygiene measures such as brushing and flossing. These compromised oral conditions necessitate meticulous oral hygiene to prevent the opportunistic infections and caries. Sodium bicarbonate rinses have been reported to protect inflamed and sensitive mucosa, buffer the intraoral pH, and lubricate and clear the mouth of viscous salivary secretions, even to an extent to decrease the treatment-related morbidity.,
Oral examination and impression making
Visualization of hard and soft tissues is important for a thorough examination. Presence of thick and ropy saliva can make the diagnosis of mucosal lesions difficult. Nearly 1%–1.5% of sodium bicarbonate oral rinses have been reported to improve visualization of tissues by removing the viscous saliva. In addition, mucous saliva secreted by palatal glands can interfere with the accuracy of the impressions which in turn affects the quality of the prostheses. Sodium bicarbonate mouth wash prior to impression procedure has been proved to minimize impression distortion, even though it may not entirely remove ropy strands of mucus.
Causes of oral malodor can be local or systemic. Dry mouth and accumulation of plaque due to inadequate oral hygiene are the most common causes for the increased bacterial load. The microbes act on sulfur-containing proteinaceous substrates present in debris and plaque and produce volatile sulfur compounds which cause the malodor. Sodium bicarbonate transforms volatile sulfur compounds to a nonvolatile state. In addition, their antimicrobial property has also been discussed earlier. The deodorizing effect of sodium bicarbonate lasts up to 3 h when dentifrices containing >20% sodium bicarbonate are used.
Role in implant osseointegration
Osseointegration is the direct structural and functional connection between ordered, living bone and the surface of a load-carrying implant. This interaction can be influenced by the implant surface topography, hydrophilicity, wettability, and surface energy. These factors enhance complete wetting of the implant surface by the blood and adherence of the blood proteins to the implant surface, thereby initiating the osseointegration. Surface treatment with sodium hydroxide and sodium bicarbonates has been reported to enhance the hydrophilicity and protein adsorption of titanium surfaces. Being a milder alkali, sodium bicarbonates (pH 8.3) have been suggested to be a better alternative to sodium hydroxide (pH 12.7).
Tooth whitening is a fast-growing aspect of esthetic dentistry. Teeth discoloration can be extrinsic or intrinsic. Extrinsic stains are due to the use of tobacco, coffee, tea, red wine, etc., Commercially available bleaching systems are effective against these stains. These are dispensed as gels, strips, paint on materials, tooth pastes, and chewing gums. Common ingredients of the bleaching systems are hydrogen peroxide and carbamide peroxide, which work by chemical bleaching and mild polishing.
The nonbleaching whitening systems include sodium fluoride, hydrated silica, sodium mono fluorophosphate, sodium pyrophosphate, sodium tripolyphosphate, and sodium bicarbonate. Sodium bicarbonate is used in many commercial teeth-whitening formulations as the main active ingredient with or without hydrogen peroxide. Kleber et al. have reported that baking soda-containing teeth-whitening systems were more effective in removing intrinsic stains also than systems that did not contain baking soda.
Removal of extrinsic stains by regular scaling and polishing can be laborious in esthetic dentistry. A less time-consuming and effective method can be air polishing. The stains are removed when warm water mixed with prophylactic paste is sprayed under pressure using a specific handpiece. Sodium bicarbonate (particle size of 74 μ)-based powder is the main ingredient of the prophylactic paste. Other ingredients available in the market include glycine, calcium hydroxide, and aluminum trihydroxide. With the prior understanding of the solubility and low intrinsic hardness, sodium bicarbonate is considered safe on enamel, amalgam, gold, porcelain, and orthodontic bracket and bands. However, it should not be used on composites, glass ionomer, and luting cements.
Air polishing with bicarbonates has been found to be safe and effective in removing plaque and subgingival biofilm even around titanium surfaces. This could be a step forward in the prevention and management of peri-implantitis, which is one of the growing concerns of a restorative dentist.
| Discussion|| |
Sodium bicarbonate or the common baking soda has been recognized to have a versatile nature and application in different areas in dentistry.
Different uses of bicarbonates have been identified as listed in the article. The properties discussed are pH restoration, wetting action, and mechanical cleansing. The author would like to stress on two important areas that can be benefitted by the use of bicarbonates. The first one is diabetes mellitus, a metabolic disorder characterized by hyperglycemia due to defective insulin secretion or its absorption or both. The second one, the salivary output is reduced resulting in dry mucosal surface, oral burning sensation, and decrease of pH and alteration in the flora of the oral cavity, with greater predominance of Candida albicans.
The second condition is denture stomatitis, where there is inflammation of denture-bearing mucosa associated with prolonged denture wearing. This condition is often associated with candida infection and predisposed by diabetes, xerostomia, high carbohydrate diet, smoking, and other immunocompromised conditions. The management normally involves maintenance of meticulous oral and denture hygiene and appropriate denture-wearing practice.
Sodium bicarbonate oral rinses up to 4 times a day can be an effective adjuvant in these cases.
Traces of dental materials and oral health-care products entering the systemic stream and posing problems have been reported., Therefore, the safety of sodium bicarbonates has to be considered, especially in relation to plasma sodium level. Hypernatremia is the condition where serum sodium ion concentration raises above 150 mmol/L. This can occur due to dehydration or excess ingestion of sodium. Normal plasma volumes of sodium ions and bicarbonate ions are 142 mmol/L and 26 mmol/L, respectively. Correlating the above plasma values, 1% sodium bicarbonate oral rinse may not cause hypernatremia, unless ingested. In addition, absorption of dietary sodium is normally in the small intestine and colon, and the evidence for sodium absorption in the oral cavity is lacking. However, for patients with hypertension and on restricted sodium diet, use of sodium bicarbonate oral rinse may have a caution. Further studies are required to determine the concentration and duration required for its bactericidal action without any detrimental effect to the oral mucosa.
Recommended formulation of bicarbonate mouth rinse
Sodium bicarbonate is isotonic at the concentration of 1.26% solution. Half a teaspoon (2.5 g) of sodium bicarbonate in 250 ml of water makes approximately 1% (W/V) solution which can be swished in the mouth for 1 min 3–4 times a day., This formulation is slightly hypotonic and can be used as a bland rinse frequently to neutralize the pH, moisturize, deodorize, and decrease the microbial load of the oral cavity.
However, active disease state such as periodontitis or denture stomatitis may warrant a mouth rinse with bactericidal activity. A hypertonic solution of sodium bicarbonate can facilitate osmotic movement of water from bacterial cells, resulting in shrinkage, plasmolysis, and ultimately the bacterial cell death.
| Conclusion|| |
Most of the oral rinses available in the market contain alcohol, preservatives, artificial colors, and flavoring agents. They are generally used to address specific needs on a short-term basis, such as disinfection of surgical sites, to facilitate a sterile environment for wound healing, mouth ulcers, gingivitis, and periodontitis. Alcohol is used as a solvent for the active ingredients in the mouth rinse. Alcohol being an astringent can exacerbate the dryness of mouth. Prolonged use of these products might also lead to taste disturbance, staining of hard and soft tissues, allergic reactions, and even may be carcinogenic.
Baking soda, being a common household item, is readily available, safe, and minimally abrasive. The bactericidal property makes it a patient-friendly mouthwash, and a component in dentifrice or chewing gum, all of which can be used on a long-term basis as an adjunct virtually free of any side effects.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Sivakumar Jayachandran
Birmingham Dental Hospital, Mill Pool Way, Birmingham B57EG
Source of Support: None, Conflict of Interest: None