Randomized controlled trial on mouth rinse and flossing efficacy on interproximal gingivitis and dental plaque

Quantitative analysis of the effects of brushing, flossing, and mouthrinsing on supragingival and subgingival plaque microbiota: 12-week clinical trial

BACKGROUND

Translational microbiome research using next-generation DNA sequencing is challenging due to the semi-qualitative nature of relative abundance data. A novel method for quantitative analysis was applied in this 12-week clinical trial to understand the mechanical vs. chemotherapeutic actions of brushing, flossing, and mouthrinsing against the supragingival dental plaque microbiome. Enumeration of viable bacteria using vPCR was also applied on supragingival plaque for validation and on subgingival plaque to evaluate interventional effects below the gingival margin.

METHODS

Subjects with gingivitis were enrolled in a single center, examiner-blind, virtually supervised, parallel group controlled clinical trial. Subjects with gingivitis were randomized into brushing only (B); brushing and flossing (BF); brushing and rinsing with Listerine® Cool Mint® Antiseptic (BA); brushing and rinsing with Listerine® Cool Mint® Zero (BZ); or brushing, flossing, and rinsing with Listerine® Cool Mint® Zero (BFZ). All subjects brushed twice daily for 1 min with a sodium monofluorophosphate toothpaste and a soft-bristled toothbrush. Subjects who flossed used unflavored waxed dental floss once daily. Subjects assigned to mouthrinses rinsed twice daily. Plaque specimens were collected at the baseline visit and after 4 and 12 weeks of intervention. Bacterial cell number quantification was achieved by adding reference amounts of DNA controls to plaque samples prior to DNA extraction, followed by shallow shotgun metagenome sequencing.

RESULTS

286 subjects completed the trial. The metagenomic data for supragingival plaque showed significant reductions in Shannon-Weaver diversity, species richness, and total and categorical bacterial abundances (commensal, gingivitis, and malodor) after 4 and 12 weeks for the BA, BZ, and BFZ groups compared to the B group, while no significant differences were observed between the B and BF groups. Supragingival plaque vPCR further validated these results, and subgingival plaque vPCR demonstrated significant efficacy for the BFZ intervention only.

CONCLUSIONS

This publication reports on a successful application of a quantitative method of microbiome analysis in a clinical trial demonstrating the sustained and superior efficacy of essential oil mouthrinses at controlling dental plaque compared to mechanical methods. The quantitative microbiological data in this trial also reinforce the safety and mechanism of action of EO mouthrinses against plaque microbial ecology and highlights the importance of elevating EO mouthrinsing as an integral part of an oral hygiene regimen.

TRIAL REGISTRATION

The trial was registered on ClinicalTrials.gov on 31/10/2022. The registration number is NCT05600231.

Efficacy of flossing and mouth rinsing regimens on plaque and gingivitis: a randomized clinical trial

BACKGROUND

To investigate the effects of combinations of mechanical (brushing and flossing) and chemotherapeutic regimens which included essential oils (EO) non-alcohol and alcohol-containing mouthrinses compared to brushing only in the prevention and reduction of plaque, gingivitis, and gingival bleeding.

METHODS

This was a randomized, virtually supervised, examiner blind, controlled clinical trial. Following informed consent and screening, subjects (N = 270) with gingivitis were randomly assigned to one of the following regimens: (1) Brush Only (B, n = 54); (2) Brush/Rinse (EO alcohol-containing mouthrinse) (BA, n = 54); (3) Brush/Rinse (EO non-alcohol containing mouthrinse) (BZ, n = 54); (4) Brush/Floss (BF, n = 54); (5) Brush/Floss/Rinse (EO non-alcohol containing mouthrinse) (BFZ, n = 54). Unflavored waxed dental floss (REACH unflavored waxed dental floss), and fluoridated toothpaste (Colgate Cavity Protection) were used. Examinations included oral hard and soft tissue, plaque, gingivitis, gingival bleeding, probing depth and bleeding on probing.

RESULTS

After 12 weeks, both BA and BZ and the BFZ group were superior in reducing interproximal plaque (30.8%, 18.2%, 16.0%, respectively), gingivitis (39.0%, 36.9%, 36.1%, respectively), and bleeding (67.8%, 73.6%, 79.8%, respectively) compared to B. The BF group did not provide significant reductions in interproximal plaque but did reduce interproximal gingivitis (5.1%, p = 0.041) at Week 4 and bleeding at Weeks 4 and 12 (34.6%, 31.4%, p < 0.001 respectively) compared to B. The BFZ group did not significantly reduce interproximal plaque, gingivitis or bleeding compared to BZ.

CONCLUSIONS

This study demonstrated that the addition of EO non-alcohol containing mouthrinse to the manual toothbrushing and flossing regimen further reduces plaque, gingivitis and bleeding showing that addition of EO mouthrinses (alcohol or non-alcohol containing) to the oral hygiene regimen provides sustained reductions in plaque to help maintain gingival health after a dental prophylaxis. Dental professional recommendation of the addition of an EO non-alcohol containing mouthrinse to daily oral hygiene routines of brushing or brushing and flossing should be considered to aid supragingival plaque control and improve gingivitis prevention.

STUDY REGISTRY NUMBER

NCT05600231.

Clinical investigation of gingival papilla recession after orthodontic treatment in adults

OBJECTIVE

To investigate the incidence, severity, susceptibility sites of gingival papillary recession (GPR) in adults after orthodontic treatment and the clinical impact of tooth extraction on GPR.

METHODS

A total of 82 adult patients were recruited and then divided into extraction and non-extraction groups according to whether the orthodontic teeth were extracted (teeth that needed to be extracted when performing orthodontic treatment). The gingival conditions of the two groups of patients before and after treatment were recorded using intraoral photos, and the incidence, severity and predilection sites of GPR after correction were investigated.

RESULTS

The results indicated that GPR occurred in 29 patients after correction, with an incidence rate of 35.4%. A total of 1648 gingival papillae were recorded among the 82 patients after correction, of which 67 exhibited atrophy, with an incidence of 4.1%. All occurrences of GPR were classified as papilla presence index 2 (PPI 2) (mild). The condition is most likely to occur in the anterior tooth area, especially in the lower incisor area. The results indicated that the incidence of GPR was substantially higher in the extraction group than in the non-extraction group, with the difference statistically significant.

CONCLUSION

Following orthodontic treatment, adult patients will have a certain proportion of mild GPR, which is more common in the anterior tooth area, especially the lower anterior tooth area.

Potential Application of the Plant-Derived Essential Oils for Atherosclerosis Treatment: Molecular Mechanisms and Therapeutic Potential

Essential oils (EOs) are complex secondary metabolites identified in many plant species. Plant-derived EOs have been widely used in traditional medicine for centuries for their health-beneficial effects. Some EOs and their active ingredients have been reported to improve the cardiovascular system, in particular to provide an anti-atherosclerotic effect. The objective of this review is to highlight the recent research investigating the anti-inflammatory, anti-oxidative and lipid-lowering properties of plant-derived EOs and discuss their mechanisms of action. Also, recent clinical trials exploring anti-inflammatory and anti-oxidative activities of EOs are discussed. Future research on EOs has the potential to identify new bioactive compounds and invent new effective agents for treatment of atherosclerosis and related diseases such as diabetes, metabolic syndrome and obesity.

Supportive Home Remedies for Orofacial Pain during the Coronavirus Disease 2019 Pandemic: Their Value and Limitations

Background

The coronavirus disease 2019 (COVID-19) pandemic has impeded access to timely dental care, and there is an urgent need for adjuvant therapies that can reduce orofacial pain in emergencies.

Aims

To provide information on the benefits and limitations of eight representative home remedies as palliative care for orofacial pain during the coronavirus disease 2019 (COVID-19) pandemic.

Methods

PubMed and Medline were electronically searched for eight home remedies for orofacial pain that can be used in COVID-19. Papers published in English in the past 30 years were considered. Among the published studies suitable for the research purpose, those in which the abstract and body text were confirmed were targeted, and duplicate studies were excluded. Finally, 86 studies were included.

Results

There is extensive and high-level scientific evidence for the application of tooth brushing and flossing, mouth rinsing with chlorhexidine, use of over-the-counter pain medication, and application of cryotherapy in emergencies. Gargling with salt water, brushing with bamboo salt, gargling with garlic juice, and oil pulling are traditional methods used for centuries. The use of natural products for orofacial pain has a significant empirical effect but has weak scientific evidence.

Conclusions

Knowing the correct application method, effects, and side effects is desirable to use these methods appropriately in emergencies. However, scientific evidence is unclear and generally lacking for home remedies to be the main treatment strategy, and there are clear limitations to their use as a single main treatment.

Does flossing before or after brushing influence the reduction in the plaque index? A systematic review and meta-analysis

OBJECTIVES

The purpose of this systematic review was to assess whether flossing before or after influences plaque index reduction.

METHODS

This systematic review was conducted according to the guidelines of the preferred reporting items for systematic reviews and meta-analyses and registered with the International prospective register of systematic reviews under number CRD42019126239. The PICO question was, 'does flossing before or after brushing have any effect on reducing dental plaque?'. An electronic search was performed until April 2020 in the following databases: PubMed/MEDLINE, Scopus Web of Science and Cochrane Library. The initial database search resulted in 9679 references, and after detailed analysis of the titles and abstracts of the selected studies, the inclusion/exclusion criteria were applied, and 06 complete articles were downloaded and selected for further analysis. After the complete 02 articles were selected, 60 patients with a mean age of 23.1 years were studied and compared dental flossing before or after dental brushing.

RESULTS

The results showed that there was no statistical difference between brush-floss and floss-brush in reducing plaque index (p = 0.91, RR: 0.01, 95% CI: -0.16, 0.18).

CONCLUSIONS

Flossing before or after brushing has no significant effect on reducing dental plaque index. However, more clinical studies should be conducted.

Efficacy of adjunctive therapies in patients with gingival inflammation: A systematic review and meta-analysis

AIM

To evaluate the efficacy of adjunctive therapies in reducing gingivitis and plaque by means of a systematic review of randomized clinical trials (RCTs).

MATERIAL AND METHODS

A search protocol was designed to identify 6-month RCTs that investigated the efficacy of adjuncts to mechanical plaque control on gingivitis and plaque. Following screening, relevant information was extracted, and quality and potential risk of bias were estimated. Mean treatment differences were calculated to obtain standardized mean differences and weighted mean differences (SMD and WMD) as appropriate.

RESULTS

Meta-analyses included 70 studies of adjunctive antiseptics. Compared with mechanical plaque control alone, adjuncts yielded statistically significant reductions in gingival index (n = 72; SMD = -1.268; 95% CI [-1.489; -1.047]; p < .001; I²  = 96.2%), bleeding (%) (n = 26, WMD=-14.62%; 95% CI [-18.01%; -11.23%]; p < .001; I²  = 95.1%), plaque index (n = 93, SMD = -1.017; 95% CI [-1.194; -0.840]; p < .001; I²  = 95.3%) and plaque (%) (n = 23; WMD = -18.20%; 95% CI [-24.00%; -12.50%]; p < .001; I²  = 96.9%). Mouthrinses resulted in greater reductions in per cent plaque compared with dentifrices (meta-regression, coefficient = 13.80%; 95% CI [2.40%; 25.10%]; p = .020). The antiseptic agents were similarly effective in reducing gingivitis and plaque in patients with dental plaque-induced gingivitis (intact periodontium) or previously treated periodontitis with gingival inflammation.

CONCLUSION

Adjunctive antiseptics in mouthrinses and dentifrices provide statistically significant reductions in gingival, bleeding and plaque indices.

Effectiveness of Alcohol-free Mouth Rinse Containing Essential Oils and Fluoride as an Oral Hygiene Adjunct among Pregnant Thai Women: A Randomized Clinical Trial

Aim:

This 3-month, double-blind, two-center, parallel, randomized controlled clinical trial compared the improvement of oral hygiene status from alcohol-free essential oils (EO) with 0.05% fluoride mouthwash to the control (0.05% fluoride mouthwash).

Materials and Methods:

One hundred and fifty-four pregnant women were clinically examined to determine Modified Gingival Index (MGI), Plaque Index (PI), and Winkel Tongue Coating Index (WTCI) at baseline, 2 weeks, and 3 months by calibrated examiners. After supragingival scaling and provision of a tooth brushing method, participants were randomly assigned to daily use of alcohol-free EO or the control rinse for 30s at bedtime. Repeated measures of analysis of variance (ANOVA) were performed to assess the effectiveness of alcohol-free EO with 0.05% fluoride mouthwash on MGI, PI, and WTCI scores.

Results:

One hundred and forty subjects completed the study. The dropout rate of 9.1% (n = 14) was mainly due to loss of follow-up. At baseline, no significant differences were observed between the intervention and the control groups for MGI (1.19±0.57 vs. 1.11±0.48, P = 0.371), PI (1.53±0.56 vs. 1.47±0.48, P = 0.439), and WTCI (0.88±0.48 vs. 0.88±0.50, P = 0.990). There was a statistically significant reduction of MGI, PI, and WTCI scores over time (P < 0.001). However, no significant differences were observed for between-group comparisons for all measured indices at any time point. No adverse effect was reported in either group.

Conclusion:

At the end of 3-month period, improvement of oral hygiene of pregnancy women in this study was evidence. However, the use of alcohol-free EO mouthwash as supplements to the daily oral hygiene did not provide a significant improvement in terms of plaque, gingival, and tongue coating indices.

Anti-inflammatory effect of salt water and chlorhexidine 0.12% mouthrinse after periodontal surgery: a randomized prospective clinical study

OBJECTIVES

The purpose of this study was to compare the anti-inflammatory efficacy of sodium chloride- and a 0.12% chlorhexidine mouth rinses in patients undergoing minimal invasive periodontal surgery.

MATERIALS AND METHODS

Forty-seven patients with a diagnosis of periodontitis and indication for access flap procedure were randomly selected. Group A: a sodium chloride (salt)water-based mouth rinse (test group) or group B: a 0.12% chlorhexidine mouth rinse (control group) administered after surgery. Gingival Index (GI) were evaluated in the whole mouth and in the surgical site at baseline (T1), a week later (T2), and 12 weeks (T3) after the treatment. Total MMP activity was measured in GCF using a commercial kit and plate reader. Medians of total MMP activity and GI were compared for time intervals T1 vs. T2, T1 vs. T3, and T2 vs T3 using Friedman tests and Wilcoxon signed rank tests, and were also compared between test and control using Mann-WhitneyU tests at each timepoint.

RESULTS

The average GI values showed significant differences between baseline and T2 (p = 0.0005) and baseline and T3 (p = 0.003) in the test group.

CONCLUSION

The sodium chloride-mouth rinse use after periodontal surgery seems to have similar anti-inflammatory properties as CHX mouth rinse and can be used regularly postoperatively after periodontal surgical procedures.

CLINICAL RELEVANCE

The use of salt water mouthwash showed an anti-inflammatory effect similar to CHX 0.12% after minimal invasive periodontal surgery. Salt water mouthwash is accessible to the world population and can contribute on the healing process after periodontal surgery.

Clinical periodontal, bacterial, and immunological outcomes of antimicrobial photodynamic therapy in orthodontic treatment-induced gingival enlargement

AIM

The aim of the present clinical trial is to evaluate the clinical, bacterial, and immunological outcomes of photodynamic therapy (PDT) in adolescent patients with orthodontic treatment-induced gingival enlargement (OTGE).

MATERIALS AND METHODS

A total of 26 adolescent patients, 16 girls and 10 boys, of mean age 16.8 years, undergoing fixed orthodontic treatment for at least 6 months (mean duration in months, 8.3 ± 1.9) and presenting with GE were included in the clinical trial. All patients undergoing fixed orthodontic treatment with clinical diagnosis of OTGE were divided into two groups: Patients receiving full-mouth periodontal debridement (FMPD) 'Group-FMPD' and 'Group-PDT' included participants receiving methylene blue-assisted PDT in the selected area along with FMPD. Clinical periodontal assessments included the evaluation of plaque scores (PS), bleeding on probing (BOP), probing depth (PD) and hyperplastic index (HI). The total bacterial counts of Porphyromonas gingivalis (P. gingivalis), Treponema denticola (T. denticola), and Tannerella forsythia (T. forsythia) were estimated and expressed as log CFU/mL of each bacteria. Cytokines including interleukin (IL)-1β and IL-6 were analyzed using enzyme-linked immunosorbent assay (ELISA) kit.

RESULTS

The mean percentage of PS and BOP statistically significantly reduced with both FMPD and PDT from baseline to 4 weeks (p < 0.05). Although mean PD significantly reduced in both the groups at all time points, there was significantly higher reduction with PDT as compared to FMPD at 2 weeks post treatment (p < 0.05). Inter-group comparison showed PDT demonstrated significantly higher HI at 2- and 4-weeks post treatment (p < 0.05). The mean log CFU/mL of P. gingivalis and T. forsythia showed statistically significantly higher reduction with PDT than FMPD (p < 0.05) at both 2-and 4-weeks follow-up. T. denticola reported significantly reduced levels at 2 weeks follow-up period only with PDT (p < 0.05). No statistically significant difference appeared when both treatment modalities were compared with one another (p > 0.05). Four weeks after periodontal treatment, IL-6 significantly reduced with PDT compared to FMPD (p < 0.05).

CONCLUSION

PDT assisted in reducing bacterial counts and improving hyperplastic index in OTGE.