The Efficacy of Populus euphratica and Myrtus communis Herbal Mouthwash on Gingivitis in Pediatric Patients Diagnosed Clinically and with Photometric CIELab Analysis: An In Vivo Randomized Double-blind Clinical Study

Background

Children are more prone to develop gingivitis as a result of deficient oral hygiene, morphological variance, and a diet that encourages the growth of pathogenic oral bacteria.

Aim

The purpose of this randomized, double-blind clinical study is to compare the therapeutic effect of an herbal mouthwash made of decoction and ethanolic extract of Populus euphratica and Myrtus communis to that of chlorhexidine (CHX) mouthrinse.

Materials and methods

In this study, 60 patients aged between 8 and 10 years were divided into four groups, each with 15 patients. The first group was treated with a mouthwash made of ethanolic herbal extract, the second group was treated with a mouthwash made of herbal decoction, the third group was treated with CHX mouthwash (0.12%) (positive control), and the fourth group was treated with a placebo made with colored distilled water (negative control). Clinical parameters gingival index (GI) and plaque index (PI) were evaluated at the start, 1, and 2 weeks from ensuing the treatment. Preoperative and postoperative photographs of the maxillary anterior sextant were recorded to evaluate CIELab coordinates to monitor color changes.

Statistical analysis

One-way analysis of variance (ANOVA) with Tukey's honest significant difference (HSD) post hoc tests were used for data assessment.

Results

Significant reductions in GI and PI were found among the tested groups (p < 0.05). A significant reduction in a* value was observed, while L* value showed a significant increase between baseline and posttreatment (p < 0.05).

Conclusion

Herbal-based mouthwash of Populus euphratica and Myrtus communis, whether prepared by boiling or ethanolic extraction, reduced gingival inflammation significantly and has a lot of potential for treating and preventing periodontal disease in young children. Digital photography is a reliable supplementary approach for diagnosing and monitoring gingival inflammation in pediatric patients.

How to cite this article

Mohamed-Ali SF, Jasim AA, Mahmood MAK, et al. The Efficacy of Populus euphratica and Myrtus communis Herbal Mouthwash on Gingivitis in Pediatric Patients Diagnosed Clinically and with Photometric CIELab Analysis: An In Vivo Randomized Double-blind Clinical Study. Int J Clin Pediatr Dent 2024;17(8):918-924.

Aloe vera mouthwashes can be a natural alternative to chemically formulated ones - A randomized-controlled trial

Objectives

To evaluate the antiplaque and antibacterial efficacy of commercially available mouthwashes containing aloe vera (AV), hydrogen peroxide (HP), and cetylpyridinium chloride (CPC) in a 4-day plaque regrowth study.

Methods

Plaque score and salivary samples were assessed (Day-0 and Day-4) in 96 participants in a randomised, double-blind prospective parallel-arm 4-day plaque regrowth study. Participants were divided into five groups who refrained from engaging in regular oral hygiene measures during the study period and used commercially available mouthwashes containing AV, HP, and CPC as test products with distilled water (DW) and chlorhexidine (CHX) mouthwash as negative and positive controls, respectively. Salivary bacterial count was expressed as colony-forming units (CFU) (culture method).

Results

There was a significant difference both in plaque score (p < 0.001) and in CFU (p < 0.001) among the study mouthwashes at Day-4. The plaque score and CFU of AV were significantly higher and lower than those of CHX and DW, respectively. The plaque score of HP was significantly higher than that of AV (p = 0.016) and CPC (p < 0.001). No significant difference was observed between AV and CPC (p = 0.70). Moreover, the CFU of HP was significantly higher than that of CPC (p = 0.04). There was no statistically significant difference between the CFU of mouthwashes containing AV and HP (p = 0.912) or AV and CPC (p = 0.280). No significant difference was seen in the inhibition of plaque and salivary bacterial count between AV, HP, and CPC.

Conclusion

The antiplaque and antibacterial efficacy of commercially available AV mouthwash was similar to that of CPC and significantly better than that of HP mouthwash and can be a natural alternative to chemically formulated mouthwashes.

Differences in chlorhexidine mouthrinses formulations influence the quantitative and qualitative changes in in-vitro oral biofilms

OBJECTIVE

Chlorhexidine mouthrinses are marketed in different formulations. This study aimed at investigating qualitative and quantitative changes in in-vitro multispecies oral biofilms, induced by different chlorhexidine-containing mouthrinses.

BACKGROUND DATA

Earlier studies comparing chlorhexidine mouthrinses are either clinical studies or in-vitro studies assessing the antimicrobial efficacy of the mouthrinses. However, no clear investigations are available regarding ecological impact of different chlorhexidine formulations on in-vitro multispecies oral biofilms after rinsing with different chlorhexidine formulations.

METHODS

Nine commercially available chlorhexidine mouthrinses were selected. Multispecies oral communities (14 species) were grown for 48 h in a Biostat-B Twin bioreactor. After that, they were used to develop biofilms on the surface of hydroxyapatite disks in 24-well pates for 48 h. Biofilms were then rinsed once or multiple times with the corresponding mouthrinse. Biofilms were collected before starting the rinsing experiment and every 24 h for 3 days and vitality quantitative PCR was performed. The experiment was repeated 3 independent times on 3 different days and the results were analyzed using a linear mixed model.

RESULTS

The mouthrinses provoked different effects in terms of change in total viable bacterial load (VBL), ecology, and community structure of the multispecies biofilms. There was no relation between chlorhexidine concentrations, presence, or absence of cetylpyridinium chloride and/or alcohol, and the observed effects. Some tested chlorhexidine mouthrinses (MC, HG, HH, and HI) strongly lowered the total VBL (≈10⁰⁷ Geq/ml), but disrupted biofilm symbiosis (≥40% of the biofilms communities are pathobionts). On the other hand, other tested chlorhexidine mouthrinses (MD, ME, and HF) had limited impact on total VBL (≥10¹⁰ Geq/ml), but improved the biofilm ecology and community structure (≤10% of the biofilms communities are pathobionts).

CONCLUSION

Not all chlorhexidine mouthrinses have the same effect on oral biofilms. Their effect seems to be strongly product dependent and vary according to their compositions and formulations.

[Prevention of complications in patients with cleft lip and palate combined with teeth crowding receiving long-term orthodontic treatment]

This study aim was to improve the effectiveness of treatment of patients with cleft lip and palate in combination with crowding of teeth receiving long-term orthodontic treatment. The study involved 30 patients divided in 3 groups in which chlorhexidine-containing medication was included in the individual prevention and treatment program. The effectiveness of using 0.2% CG gel was assessed after 6 months to control the development of inflammatory phenomena in periodontal tissues during long-term orthodontic treatment. The obtained clinical and laboratory data indicate the normalization of the cytokine profile and oral hygiene indices as a result of using a CG-containing preparation for effective control of the biofilm etiological factor.

Chlorhexidine Gluconate - The Solution for Dental Problems

Rarely is a chemical agent so effective with so few contra-indications as is chlorhexidine. It has many oral applications, the main ones being the control of plaque and gingivitis. Due to the constraints on oral hygiene in animals, its benefits and indications are especially appropriate to veterinary dental cases. Its full potential is not being realised.

Novel Chlorhexidine-Loaded Polymeric Nanoparticles for Root Canal Treatment

Persistence of microorganisms in dentinal tubules after root canal chemo-mechanical preparation has been well documented. The complex anatomy of the root canal and dentinal buffering ability make delivery of antimicrobial agents difficult. This work explores the use of a novel trilayered nanoparticle (TNP) drug delivery system that encapsulates chlorhexidine digluconate, which is aimed at improving the disinfection of the root canal system. Chlorhexidine digluconate was encapsulated inside polymeric self-assembled TNPs. These were self-assembled through water-in-oil emulsion from poly(ethylene glycol)-b-poly(lactic acid) (PEG-b-PLA), a di-block copolymer, with one hydrophilic segment and another hydrophobic. The resulting TNPs were physicochemically characterized and their antimicrobial effectiveness was evaluated against Enterococcus faecalis using a broth inhibition method. The hydrophilic interior of the TNPs successfully entrapped chlorhexidine digluconate. The resulting TNPs had particle size ranging from 140–295 nm, with adequate encapsulation efficiency, and maintained inhibition of bacteria over 21 days. The delivery of antibacterial irrigants throughout the dentinal matrix by employing the TNP system described in this work may be an effective alternative to improve root canal disinfection.

Chlorhexidine mouthrinse as an adjunctive treatment for gingival health

BACKGROUND

Dental plaque associated gingivitis is a reversible inflammatory condition caused by accumulation and persistence of microbial biofilms (dental plaque) on the teeth. It is characterised by redness and swelling of the gingivae (gums) and a tendency for the gingivae to bleed easily. In susceptible individuals, gingivitis may lead to periodontitis and loss of the soft tissue and bony support for the tooth. It is thought that chlorhexidine mouthrinse may reduce the build-up of plaque thereby reducing gingivitis.

OBJECTIVES

To assess the effectiveness of chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for the control of gingivitis and plaque compared to mechanical oral hygiene procedures alone or mechanical oral hygiene procedures plus placebo/control mouthrinse. Mechanical oral hygiene procedures were toothbrushing with/without the use of dental floss or interdental cleaning aids and could include professional tooth cleaning/periodontal treatment.To determine whether the effect of chlorhexidine mouthrinse is influenced by chlorhexidine concentration, or frequency of rinsing (once/day versus twice/day).To report and describe any adverse effects associated with chlorhexidine mouthrinse use from included trials.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 28 September 2016); the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8) in the Cochrane Library (searched 28 September 2016); MEDLINE Ovid (1946 to 28 September 2016); Embase Ovid (1980 to 28 September 2016); and CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to 28 September 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included randomised controlled trials assessing the effects of chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for at least 4 weeks on gingivitis in children and adults. Mechanical oral hygiene procedures were toothbrushing with/without use of dental floss or interdental cleaning aids and could include professional tooth cleaning/periodontal treatment. We included trials where participants had gingivitis or periodontitis, where participants were healthy and where some or all participants had medical conditions or special care needs.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the search results extracted data and assessed the risk of bias of the included studies. We attempted to contact study authors for missing data or clarification where feasible. For continuous outcomes, we used means and standard deviations to obtain the mean difference (MD) and 95% confidence interval (CI). We combined MDs where studies used the same scale and standardised mean differences (SMDs) where studies used different scales. For dichotomous outcomes, we reported risk ratios (RR) and 95% CIs. Due to anticipated heterogeneity we used random-effects models for all meta-analyses.

MAIN RESULTS

We included 51 studies that analysed a total of 5345 participants. One study was assessed as being at unclear risk of bias, with the remaining 50 being at high risk of bias, however, this did not affect the quality assessments for gingivitis and plaque as we believe that further research is very unlikely to change our confidence in the estimate of effect. Gingivitis After 4 to 6 weeks of use, chlorhexidine mouthrinse reduced gingivitis (Gingival Index (GI) 0 to 3 scale) by 0.21 (95% CI 0.11 to 0.31) compared to placebo, control or no mouthrinse (10 trials, 805 participants with mild gingival inflammation (mean score 1 on the GI scale) analysed, high-quality evidence). A similar effect size was found for reducing gingivitis at 6 months. There were insufficient data to determine the reduction in gingivitis associated with chlorhexidine mouthrinse use in individuals with mean GI scores of 1.1 to 3 (moderate or severe levels of gingival inflammation). Plaque Plaque was measured by different indices and the SMD at 4 to 6 weeks was 1.45 (95% CI 1.00 to 1.90) standard deviations lower in the chlorhexidine group (12 trials, 950 participants analysed, high-quality evidence), indicating a large reduction in plaque. A similar large reduction was found for chlorhexidine mouthrinse use at 6 months. Extrinsic tooth staining There was a large increase in extrinsic tooth staining in participants using chlorhexidine mouthrinse at 4 to 6 weeks. The SMD was 1.07 (95% CI 0.80 to 1.34) standard deviations higher (eight trials, 415 participants analysed, moderate-quality evidence) in the chlorhexidine mouthrinse group. There was also a large increase in extrinsic tooth staining in participants using chlorhexidine mouthrinse at 7 to 12 weeks and 6 months. Calculus Results for the effect of chlorhexidine mouthrinse on calculus formation were inconclusive. Effect of concentration and frequency of rinsing There were insufficient data to determine whether there was a difference in effect for either chlorhexidine concentration or frequency of rinsing. Other adverse effects The adverse effects most commonly reported in the included studies were taste disturbance/alteration (reported in 11 studies), effects on the oral mucosa including soreness, irritation, mild desquamation and mucosal ulceration/erosions (reported in 13 studies) and a general burning sensation or a burning tongue or both (reported in nine studies).

AUTHORS' CONCLUSIONS

There is high-quality evidence from studies that reported the Löe and Silness Gingival Index of a reduction in gingivitis in individuals with mild gingival inflammation on average (mean score of 1 on the 0 to 3 GI scale) that was not considered to be clinically relevant. There is high-quality evidence of a large reduction in dental plaque with chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for 4 to 6 weeks and 6 months. There is no evidence that one concentration of chlorhexidine rinse is more effective than another. There is insufficient evidence to determine the reduction in gingivitis associated with chlorhexidine mouthrinse use in individuals with mean GI scores of 1.1 to 3 indicating moderate or severe levels of gingival inflammation. Rinsing with chlorhexidine mouthrinse for 4 weeks or longer causes extrinsic tooth staining. In addition, other adverse effects such as calculus build up, transient taste disturbance and effects on the oral mucosa were reported in the included studies.

A randomised clinical trial to evaluate the effect of a 67 % sodium bicarbonate-containing dentifrice on 0.2 % chlorhexidine digluconate mouthwash tooth staining

Background

Gingivitis can develop as a reaction to dental plaque. It can be limited by curtailing plaque build-up through actions including tooth brushing and the use of medicinal mouthwashes, such as those containing chlorhexidine digluconate (CHX), that can reach parts of the mouth that may be missed when brushing. This study aimed to compare dental stain control of twice-daily brushing with a sodium fluoride (NaF) dentifrice containing 67 % sodium bicarbonate (NaHCO₃) or a commercially available NaF silica dentifrice without NaHCO_3, while using a mouthwash containing 0.2 % CHX.

Methods

This was a 6-week, randomised, two-site, examiner-blind, parallel-group study in healthy subjects with at least ‘mild’ stain levels on the facial surfaces of ≥4 teeth and ≥15 bleeding sites. Assessment was via modified Lobene Stain Index (MLSI), the score being the mean of stain intensity multiplied by area (MLSI [IxA]).

Results

One hundred and fifty of 160 randomised subjects completed the study. There were no significant differences in Overall (facial and lingual) MLSI (IxA) scores between dentifrices. The Facial MLSI (IxA) was statistically significant at 6 weeks, favouring the 67 % NaHCO₃ dentifrice (p = 0.0404). Post-hoc analysis, conducted due to a significant site interaction, found significant differences for all MLSI scores in favour of the 67 % NaHCO₃ dentifrice at Site 1 (both weeks) but not Site 2.

Conclusions

No overall significant differences were found between a 67 and 0 % NaHCO₃ dentifrice in controlling CHX stain; a significant difference on facial surfaces suggests advantage of the former on more accessible surfaces.

Trial registration

This study was registered at ClinicalTrials.gov (NCT01962493) on 10 October 2013 and was funded by GSK Consumer Healthcare.

Inhibition of de novo plaque growth by a new 0.03 % chlorhexidine mouth rinse formulation applying a non-brushing model: a randomized, double blind clinical trial

OBJECTIVES

The aim of this study was to investigate the plaque inhibitory effect of a new 0.03 % chlorhexidine digluconate (CHX) and 0.05 % cetylpyridinium chloride (CPC) mouthrinse formulation and to explore patients' experience and side effects after its use.

MATERIALS AND METHODS

This short-term, randomized, double blind, parallel, clinical trial enrolled 150 periodontally healthy patients. These volunteers were randomly allocated to one of following mouthrinse groups (n = 50/group): 0.12 % CHX + 0.05 % CPC (Perio-Aid® Treatment alcohol-free), 0.03 % CHX + 0.05 % CPC new test formulation or to the placebo group. Clinical parameters (plaque, gingival, and stain indexes) and microbiological samples were taken at baseline, before supragingival cleaning, and after 4 days of undisturbed plaque growth, rinsing twice/day with one of the mouthrinses.

RESULTS

Plaque reduction was similar for the 0.12 % CHX (-0.52 ± 0.55) and 0.03 % CHX (-0.47 ± 0.49) groups. Both showed significant reductions in plaque accumulation compared to the placebo (p < 0.001). The new formulation had less of a negative impact on taste perception when compared to the 0.12 % CHX solution. The new CHX mouthrinse was also able to control bacterial loads and reduce some periodontopathogens.

CONCLUSIONS

This study indicated that the new 0.03 % CHX + 0.05 % CPC formulation exerted clinical efficacy similar to that achieved by an already-marketed 0.12 % CHX + 0.05 % CPC mouthrinse, but with slightly fewer side effects.

CLINICAL RELEVANCE

Lower CHX mouthrinse formulations could be effective in the inhibition of plaque regrowth with reduced unpleasant subjective side effects.

Efficacy of triphala mouth rinse (aqueous extracts) on dental plaque and gingivitis in children

AIM

The aim of the present study was to evaluate the efficacy of triphala mouth rinse (aqueous) in the reduction of plaque and gingivitis among children.

METHODS

The study was a randomized, double-blinded, controlled trial, with a total of 60 school children (n = 30 in each group; triphala and chlorhexidine groups). Plaque and gingival indices were used to evaluate baseline and follow-up plaque and gingivitis.

RESULTS

A total of 57 children completed the study. Both chlorhexidine and triphala groups showed significantly lower mean gingival and plaque index scores at follow up than baseline (P < 0.001). There was no significant difference in the percentage change in the mean gingival index between the two groups (P = 0.826). The percentage change in the mean plaque index was significantly higher in the chlorhexidine group compared to the triphala group (P = 0.048).

CONCLUSION

The effectiveness of triphala in the reduction of plaque and gingivitis was comparable to chlorhexidine, and can be used for short-term purposes without potential side-effects. It is a cost-effective alternative in reducing plaque and gingivitis.

The effect of Triphala and Chlorhexidine mouthwash on dental plaque, gingival inflammation, and microbial growth

The objective of this study was to ascertain the effects of a mouthwash prepared with Triphala on dental plaque, gingival inflammation, and microbial growth and compare it with commercially available Chlorhexidine mouthwash. This study was conducted after ethics committee approval and written consent from guardians (and assent from the children) were obtained. A total of 1431 students in the age group 8–12 years, belonging to classes fourth to seventh, were the subjects for this study. The Knowledge, Attitude and Practice (KAP) of the subjects was determined using a questionnaire. The students were divided into three groups namely, Group I (n = 457) using Triphala mouthwash (0.6%), Group II (n = 440) using Chlorhexidine mouthwash (0.1%) (positive control), and Group III (n = 412) using distilled water (negative control). The assessment was carried out on the basis of plaque scores, gingival scores, and the microbiological analysis (Streptococcus and lactobacilli counts). Statistical analysis for plaque and gingival scores was conducted using the paired sample t-test (for intragroup) and the Tukey's test (for intergroup conducted along with analysis of variance test). For the Streptococcus mutans and Lactobacillus counts, Wilcoxon and Mann–Whitney test were applied for intragroup and intergroup comparison, respectively. All the tests were carried out using the SPSS software. Both the Group I and Group II showed progressive decrease in plaque scores from baseline to the end of 9 months; however, for Group III increase in plaque scores from the baseline to the end of 9 months was noted. Both Group I and Group II showed similar effect on gingival health. There was inhibitory effect on microbial counts except Lactobacillus where Triphala had shown better results than Chlorhexidine. It was concluded that there was no significant difference between the Triphala and the Chlorhexidine mouthwash.

Effect of a chlorhexidine mouthrinse on plaque, gingival inflammation and staining in gingivitis patients: a systematic review

AIM

To systematically evaluate the efficacy of chlorhexidine (CHX) mouthrinses on plaque, gingival inflammation and staining in gingivitis patients.

MATERIAL & METHODS

Medline, EMBASE and Cochrane Central Register of Controlled Trials were searched through April 2011. Randomized controlled clinical trials comparing CHX to placebo/control mouthrinses or oral hygiene (OH) ≥ 4 weeks were included.

RESULTS

Among 1355 titles, 30 publications fulfilled the selection criteria. Meta-analysis (MA) showed significant weighted mean differences (WMD) favouring CHX. This was -0.39 [95% CI: -0.70; -0.08] for the Plaque Index Silness & Löe, -0.67 [95% CI: -0.82; -0.52] for the Plaque-Index Quigley & Hein (PIQH), -0.32 [95% CI: -0.42; -0.23] for the Gingival Index (GI), -0.08 [95% CI: -0.10; -0.05] for the bleeding aspect of the GI, -0.21 [95% CI: -0.37; -0.04] for the Papillary BIeeding Index, -0.16 [95% CI: -0.26; -0.07] for Bleeding on Marginal Probing and 0.91 [95% CI: 0.12;1.70] for the Lobene Stain Index. MA of studies with a low risk of author-estimated bias showed a WMD of -0.68 [95% CI: -0.85; -0.51] for the PIQH and -0.24 [95% CI: -0.29; -0.20] for the GI in favour of CHX. Relative to control, the reduction with CHX for plaque was 33% and for gingivitis 26%. CHX rinsing groups demonstrated significantly more staining.

CONCLUSIONS

In gingivitis patients, CHX mouthrinses together with OH versus placebo- or control mouthrinse provide significant reductions in plaque and gingivitis scores, but a significant increase in staining score.

Prospective clinical study evaluating the long-time adjunctive use of chlorhexidine after one-stage full-mouth SRP

OBJECTIVES

Scaling and root planing are the causal procedure in the treatment of periodontitis. Many attempts have been made to improve the outcome. The aim of this study was to verify the influence of the extended use of chlorhexidine after one-stage full-mouth (FM) SRP in patients with chronic periodontitis on the clinical outcome after 3 months.

METHODS

Eighty-one patients with pockets > or =5 mm were treated by FM. All patients rinsed additionally with 0.2% chlorhexidine (CHX) twice daily over 3 months. Plaque index, bleeding on probing, probing depth (PD) and clinical attachment level (CAL) were recorded at baseline and after 1 and 3 months.

RESULTS

In the test group, all variables were significantly improved after 1 and 3 months. Mean reduction of PD and CAL gain was 2.25 +/- 1.08 and 1.67 +/- 1.08 after 1 and 2.99 +/- 1.11 and 2.33 +/- 1.31 after 3 months respectively.

CONCLUSIONS

Over 3 months of extended use of CHX mouth rinse after SRP showed slightly but statistically significant better results.

A comparison of two chlorhexidine gel brushing regimens and a conventional toothpaste brushing regimen for the development of tooth staining over a 6-week period

AIMS

A single-centre, randomized single-blind parallel study was undertaken to compare staining seen with three brushing regimens and to determine subject perception of side effects such as staining and effects on taste.

METHODS

This 6-week parallel study used 157 volunteers who were randomized into one of three treatment groups: (i) brushing in the morning and evening with a normal dose of a 1% chlorhexidine gel, (ii) brushing with a low dose of chlorhexidine gel in the evening and a whitening dentifrice in the morning, and (iii) brushing with a standard fluoride paste in the morning and evening. Following home usage of their allocated products, the study volunteers returned after 3 and 6 weeks to record the amount of stain present. After the 6-week period, subject perception of taste and stain acceptability was determined using a questionnaire.

RESULTS

After 6 weeks of use of the low-dose chlorhexidine gel and whitening dentifrice, significantly more stain was seen compared with the use of a standard dentifrice (P<0.0001). Similarly, significantly more stain was seen with use of the normal-dose chlorhexidine gel compared with the low-dose gel and whitening dentifrice (P=0.0007). Approximately 30% of individuals on the low-dose chlorhexidine gel regimen found the amount of stain unacceptable and 10% noted an effect on their taste perception.

CONCLUSIONS

The use of low dose of chlorhexidine gel at night and a whitening paste in the morning produced a significant amount of stain that 30% of subjects considered unacceptable.

The Effects of Antimicrobial Sprays and Mouthrinses on Supragingival Plaque Regrowth: A Comparative Study

BACKGROUND

Due to the side effects of chlorhexidine digluconate (CHX) mouthrinsing, a spray has been proposed as an alternative method of CHX delivery to the oral cavity. The aim of this study was to investigate the plaque inhibitory effects of CHX, cetylpyridinium chloride (CPC), and triclosan (TRN) delivered by sprays and mouthrinses.

METHODS

The study was an observer-masked, randomized cross-over design balanced for carryover effects, involving 15 healthy volunteers in a 4-day plaque regrowth model. Products being tested (0.2% CHX, 0.12% CHX, 0.05% CPC, and 0.03% TRN) were used both as sprays and mouthrinses. A saline solution served as a negative control. On day 1, subjects received professional prophylaxis, suspended oral hygiene measures, and commenced using their allocated products. On day 5, subjects were scored for disclosed plaque.

RESULTS

CHX sprays (P<0.01) were the most effective sprays in preventing plaque regrowth, without significant differences between the two concentrations tested (P>0.05). TRN spray showed a significant inhibition of plaque regrowth in comparison to the negative control (P<0.05). CPC spray did not differ from saline spray (P>0.05). A similar trend of efficacy was detected for rinses. Although the effect on plaque regrowth observed with CHX rinses was superior to that of CHX sprays (P<0.0003), the latter did not cause side effects (P>0.2).

CONCLUSIONS

These findings, together with those from clinical trials, suggest that the CHX-containing sprays may represent an effective alternative to CHX rinses when mechanical oral hygiene has to be avoided in restricted areas. On the contrary, the TRN and CPC sprays showed little or no plaque inhibitory effects.

The Effects of Three Oral Sprays on Plaque and Gingival Inflammation

BACKGROUND

The aim of this clinical trial was to compare the effects of three oral sprays containing chlorhexidine (CHX), benzydamine hydrochloride (B-HCl), and CHX plus B-HCl (CHX/B-HCl) on plaque and gingivitis.

METHODS

Fifty-one periodontally healthy volunteers, randomly divided into three spray groups, refrained from all mechanical oral hygiene measures for 7 days and, instead, used one of the randomly assigned sprays twice daily. The plaque index (PI), gingival index (GI), and gingival bleeding time index (GBTI) were assessed at days 0 and 7. Side effects were also evaluated.

RESULTS

In all groups, PI, GI, and GBTI showed significant increases from the baseline to day 7. There were no significant side effects for B-HCl spray and CHX spray at day 7, but, for CHX/B-HCl, burning sensation significantly increased from the baseline. For all parameters, there were significant differences between B-HCl and CHX/B-HCl and between B-HCl and CHX, but no significant differences were observed between CHX/B-HCl and CHX. In addition, a significant difference was found between CHX/B-HCl and CHX with regard to burning sensation.

CONCLUSIONS

These results indicate that both CHX and CHX/B-HCl sprays have equal clinical effectiveness, but only B-HCl spray has less anti-plaque and anti-gingivitis effects. Furthermore, CHX/B-HCl spray causes more side effects.

Influence of Additional Active Ingredients on the Effectiveness of Non-Alcoholic Chlorhexidine Mouthwashes: A Randomized Controlled Trial

BACKGROUND

Non-alcoholic chlorhexidine mouthwashes are equally effective and have fewer potential risks than hydroalcoholic solutions. Nowadays, other active ingredients are added to these mouthwashes in an attempt to improve their effectiveness and reduce side effects. Following an experimental gingivitis model, this study examined three non-alcoholic commercial mouthwashes having 0.12% chlorhexidine digluconate (CHX) in common.

METHODS

Using a double masked, cross-over design, 30 subjects underwent three consecutive experimental phases with three mouthwashes: CHX, CHX + 0.05% sodium fluoride (CHXNaF), and CHX + 0.05% cetylpyridinium chloride (CHX-CPC). In each one of these 21-day phases, the subjects discontinued all oral hygiene measures and were treated exclusively with the experimental mouthwash randomly assigned (an oral rinse twice a day). Each experimental phase was preceded by a 14-day washout period. Levels of gingivitis, dental plaque, supragingival calculus, and dental staining were assessed at baseline and end (day 21) of experimental phases.

RESULTS

The evolution of gingival and dental staining indices did not show statistically significant differences between the treatments. Differences were noticed in the plaque index (P = 0.0002), with CHX-NaF the treatment with the greatest increase. Differences were also observed in the supragingival calculus index (P = 0.0136), with CHX-CPC showing a smaller increase. Tongue staining was more frequent with CHX-CPC (P = 0.0141).

CONCLUSION

In non-alcoholic 0.12% chlorhexidine mouthwashes, the addition of other active ingredients does not produce beneficial effects, but may even reduce the antiplaque effectiveness or increase tongue staining.

Optimal rinsing time for intra-oral distribution (spread) of mouthwashes

AIM

To investigate the intra-oral spread of an erythrosine mouthwash in relation to the rinsing period.

MATERIAL AND METHODS

Thirty subjects were randomly divided into two equal groups and asked to rinse with 10 ml erythrosine mouthwash for cumulative periods of 15, 30 and 60 s (Group I) and 30, 60 and 90 s (Group II). Each rinsing session was followed by new plaque measurements. After rinsing plaque was finally assessed using the erythrosine mouthwash applied by means of a cotton swab.

RESULTS

In Group I there was a difference observed between the 15 s rinsing period and those of 30 and 60 s. Explorative analysis for Group I suggested that differences in both jaws and approximal sites on both vestibular and lingual surfaces appeared to have contributed to the overall difference seen between 15 and 30 s rinsing periods. Also, pre-molars and front teeth seem to have contributed to this observed difference. No differences were noted between rinsing sessions and cotton swab application for Group II or Groups I+II combined.

CONCLUSIONS

Rinsing for 30 s appeared to be sufficient for all plaque-covered surfaces of the dentition to come into contact with the mouthwash.

Plaque inhibition of two commercially available chlorhexidine mouthrinses

BACKGROUND

Chlorhexidine (CHX) 0.2% solution is still "the leading oral antiseptic" for controlling gingivitis. Side effects, however, limit the acceptability to users and the long-term employment of a 0.2% CHX antiseptic in preventive dentistry. This stimulated the development of new formulations. The aim of the present study was to assess the effect on plaque inhibition and taste perception of two commercially available mouthrinses (0.12% CHX non-alcohol base with 0.05% cetyl pyridinium chloride (Cpc) versus 0.2% CHX alcohol base).

METHODS

The study was designed as a single-blind, randomized two group parallel experiment, to compare two different commercially available mouthrinses, during a 3-day plaque accumulation model. Forty healthy volunteers were enrolled in the study and received a thorough dental prophylaxis at the beginning of the test period. Over a 72-h experimental non-brushing period, during which subjects abstained from all forms of mechanical oral hygiene, one group (test) used a 15 ml alcohol free 0.12% CHX (=18 mg) mouthrinse on a Cpc base (Perioaid), CHX plus sign in circleCpc), twice daily for 30 s. The other group (control) used a 10 ml 0.2% CHX (=20 mg) mouthrinse on an 11.8% ethanol alcohol base (Corsodyl), CHX plus sign in circleAlc), twice daily for 60 s. After 72 h of plaque formation, the amount of plaque was evaluated. By the use of visual analogue scale, the subjects were asked for their appreciation of the taste of the mouthrinse they had used.

RESULTS

The mean plaque index for the CHX plus sign in circleCpc group was 0.97 and for the CHX plus sign in circleAlc group 0.78. After 72 h of non-brushing, there was no significant difference in plaque accumulation between the two groups. The answers to the questions (taste perception and after-taste) showed a statistically significant difference between the two groups. The mean visual analogue scale (VAS) scores for taste appreciation on a scale from very bad to very good taste (0-10) were 5.92 for the CHX plus sign in circleCpc group and 4.10 for the CHX plus sign in circleAlc group (p=0.02). The mean visual analogue scale (VAS) scores for the after-taste on a scale from very short to very long (0-10) were 7.24 for the CHX plus sign in circleCpc group and 5.38 for the CHX plus sign in circleAlc group.

CONCLUSIONS

Within the limitations of the present study design, it can be concluded that rinsing with a 0.12% CHX mouthrinse on a non-alcohol base with 0.05% Cpc (Perio-Aid) is not significantly different from rinsing with a 0.2% CHX mouthrinse on an alcohol base (Corsodyl). It appears that the subjects appreciated the taste of the non-alcohol CHX solution better but the after-taste of the rinse remained longer in the mouth.

Chlorhexidine with an Anti Discoloration System. A comparative study

Correct oral hygiene is believed to be the basis of primary and secondary prevention. Sometimes, using a toothbrush or other mechanical instruments for oral hygiene may be difficult and it may become necessary to use an antiseptic. Chlorhexidine is an essential component in many available preparations on sale, because of its marked antiseptic qualities. One of the most frequent side-effects is the appearance of stains on the teeth and mucous membranes, which particularly disturbs the patient. A new mouthwash containing chlorhexidine has recently become available, besides maintaining its antiseptic qualities, also avoids the side-effect of staining.

OBJECTIVES

The aim of this study was to check the capacity of the new mouthwash, which contains chlorhexidine and Anti Discoloration System (ADS), not only to prevent plaque formation like the other mouthwashes containing chlorhexidine but also to avoid staining that is one of the most frequent side-effects.

STUDY DESIGN

The comparative study was carried out on a sample of 15 patients treated with two mouthwashes both containing 0.2% chlorhexidine, but different in that the first does not contain ADS, which is instead present in the second, a new product. The results obtained show that in the 15 patients treated, there is no statistically significant difference in the ability of the mouthwash to prevent bacterial plaque, however evidence of the stain was much less with the new mouthwash.

Comparison of 2 commercially available chlorhexidine mouthrinses

BACKGROUND

It has been shown that lowering the concentration of chlorhexidine (CHX) in mouthrinses from 0.2% to 0.12% does not adversely affect inhibition of plaque accumulation. The aim of this study was to evaluate the inhibition of plaque growth by 2 commercially available mouthrinses used according to the manufacturers' instructions, one with a 30-second and one with a 60-second rinsing time.

METHODS

The clinical investigation was a single-blind, randomized study involving 80 volunteers (40 female, 40 male; mean age 25.7 years). At the start of the trial, all participants received a dental prophylaxis to remove all plaque deposits. Subjects refrained from all mechanical oral hygiene procedures, but rinsed twice a day with the allocated CHX mouthrinse over a period of 72 hours. The chlorhexidine preparations compared were a 0.12% concentration used at a 15 ml dose for a rinsing time of 30 seconds and a 0.2% concentration used at a dose of 10 ml for 60 seconds. After 72 hours, the plaque index (PI) from all volunteers was recorded at 6 sites per tooth. All participants received a questionnaire to evaluate their perception of the mouthrinses.

RESULTS

After 72 hours, the 15 ml/30 second/0.12% CHX group had a mean whole mouth PI of 1.65 (SD 0.31) compared with a mean PI of 1.60 (SD 0.40) for the 10 ml/60 second/0.2% CHX group. The difference in plaque scores between the groups was not statistically significant. Results from the questionnaire showed no significant difference between the groups for taste perception, duration of taste, alteration in taste, or perceived plaque reduction; however, the panelists preferred the shorter rinsing time of 30 seconds and, for this parameter, the difference was statistically significant (P = 0.048).

CONCLUSIONS

The results of this short-term study showed that there was no statistically significant difference between both commercially available CHX mouthrinses with respect to plaque inhibition, although both differed in concentration and rinsing time. The subject preference phase of the study indicated that the shorter rinsing time of 30 seconds was favored.

The efficacy of amine fluoride/stannous fluoride in the suppression of morning breath odour

BACKGROUND

Breath odour is a complaint encountered worldwide, often linked to microbial overload in the oral cavity. This double blind, crossover, randomised study assessed the efficacy of several antiseptic mouthrinses or slurry vs. a control solution in the prevention of morning bad breath during an experimental period of 7 days without mechanical plaque control.

METHODS

Sixteen dental students with a healthy periodontium abolished, after a thorough professional cleaning, all means of mechanical plaque control during five experimental periods of 7 days, interleaved by washout periods of at least 3 weeks. During each experimental period, as the only oral hygiene measure, the students rinsed twice a day with one of the following formulations (in a randomised order): a 0.2% chlorhexidine-alcohol mouthrinse (CHX-Alc), a 0.05% CHX + 0.05% cetylpyridinium chloride + 0.14% zinc lactate mouthrinse (CHX-CPC-Zn), an amine fluoride/stannous fluoride (125 ppm F-/125 ppm F-) containing mouthrinse (AmF/SnF2Mr), a slurry of a tooth paste (AmF/SnF2Sl) containing amine fluoride (350 ppm F-) and stannous fluoride (1050 ppm F-) and a placebo solution (placebo). At days 0, 3 and 7, morning breath was scored via VSC level measurements of the mouth air, and organoleptic ratings of the mouth air and tongue coating. At the same visits both the degree of gingival inflammation and the de novo plaque formation were rated. At the end of each period a questionnaire for subjective ratings was completed and microbiological samples were taken from the tongue dorsum, the saliva and the supragingival plaque for anaerobic and aerobic culturing.

RESULTS

Although oral hygiene during the experimental periods was limited to rinsing, bad breath parameters systematically improved (P < 0.001) with the three mouthrinses (CHX-Alc, CHX-CPC-Zn, AmF/SnF2Mr), with a superiority of the CHX-CPC-Zn solution when only VSC values were considered (P < 0.003). The AmF/SnF2 slurry and the placebo solution showed only minor changes with time. The three mouthrinses reduced significantly (P < 0.001) the bacterial load (aerobic & anaerobic) in the saliva (>or= 0.5 log reduction with a superiority (P < 0.005) for the CHX-Alc when compared to the two others). Changes in the bacterial load on the tongue dorsum could only be detected for the CHX-Alc solution (0.5 log). The antibacterial effect of the placebo solution and the slurry were negligible. The composition of microflora on the other hand did not reveal significant changes. The de novo supragingival plaque formation was significantly (P < 0.05) inhibited by the three mouthrinses with a slight superiority for the CHX-Alc solution. The degree of gingival inflammation at day 7 remained low (< 0.16) for all products. The CHX-Alc solution scored significantly worse for the subjective evaluation (questionnaires) concerning taste and sensitivity of tongue).

CONCLUSIONS

The results of this study demonstrate that morning breath odour can be successfully reduced by the sole twice daily use of CHX-Alc, CHX-CPC-Zn or AmF/SnF2Mr mouthrinses, which all significantly reduced the bacterial load in the saliva and retarded the de novo plaque formation.

Maintenance of mouth hygiene in patients with oral cancer in the immediate post-operative period

BACKGROUND

Little has been written about mouth hygiene measures during the immediate postoperative phase in patients with oral cancer. Mouth hygiene not only involves the care and maintenance of the dentition and its related structures, but also the maintenance of surgical sites, reconstructive techniques such as free flaps and generally keeping the mouth clean, which may optimize healing potential and patient comfort. Ward conditions and novel methods of reconstruction require innovation and improvisation of routine methods of mouth and oral hygiene.

METHODS

A review of techniques of mouth hygiene used during the immediate post-operative phase by our unit over the last nine years and a review of the literature.

RESULTS

Various methods gained from our experience in treating patients with oral cancer at the Austin and Repatriation Medical Centre are documented. Most methods involve a combination of either chlorhexidine or normal saline mouth rinses and mechanical cleaning.

CONCLUSIONS

There are many different methods of mouth care in patients who have had resection for oral tumours. It is important for dental practitioners, hygienists and allied health professionals, who may be involved with care of such patients to have an understanding of the methods that are available and appropriate for such patients.

Effect of different chlorhexidine formulations in mouthrinses on de novo plaque formation

BACKGROUND

Chlorhexidine (CHX) 0.2% solution, still the golden standard as mouthrinse for the prevention of plaque formation and development of gingivitis, has some limited side-effects such as extrinsic tooth staining, poor taste, taste disturbance, sensitivity changes in tongue, pain, and the content of alcohol. These side effects led to the search of new formulations.

METHODS

In this double-blind, randomised, cross-over study, 16 young dental students with a healthy periodontium, abolished all means of mechanical plaque control during 4 experimental periods of 11 days (separated from each other by a washout period of 3 weeks). During each experimental period, they rinsed 2x daily with one of the following mouthrinses in a randomised order: CHX 0.2% + alcohol (Corsodyl), CHX 0.12% + alcohol (Perio.Aid), CHX 0.12% + sodium fluoride 0.05% (Cariax Gingival) and CHX 0.12% + CPC 0.05% (Perio.Aid, new formulation). After 7 and 11 days of undisturbed plaque formation, clinical parameters were recorded, questionnaires completed and plaque samples (supragingivally and saliva) collected.

RESULTS

The CHX 0.12% + alcohol and the CHX 0.12% + CPC 0.05% formulations were as efficient as the CHX 0.2% mouthrinse in retarding de novo plaque formation (proven by clinical observations as well as by anaerobic and aerobic culture data), and always superior (p<0.001) to the CHX 0.12% + sodium fluoride 0.05% solution. The subjective ratings were in favour of the new CHX formulation when compared with the other CHX formulations, especially for taste (p<0.05).

CONCLUSIONS

The results of this study demonstrated the potential of a new CHX 0.12% + CPC 0.05% non-alcoholic formulation as an effective anti-plaque and anti-inflammatory agent with reduced unpleasant subjective side-effects.

Effect of different mouthrinses on morning breath

BACKGROUND

Morning breath odor is an often-encountered complaint. This double-blind, crossover, randomized study aimed to examine the bad breath-inhibiting effect of 3 commercially available mouthrinses on morning halitosis during an experimental period of 12 days without mechanical plaque control.

METHODS

Twelve medical students with a healthy periodontium refrained from all means of mechanical plaque control during 3 experimental periods of 12 days (with intervening washout periods of at least 3 weeks). A professional oral cleaning preceded each period. During each experimental period, as the only oral hygiene measure allowed, the students rinsed twice a day with one of the following formulations in a randomized order: CHX-Alc (a 0.2% chlorhexidine [CHX] solution); CHX-NaF (CHX 0.12% plus sodium fluoride 0.05%); or CHX-CPC-Zn (CHX 0.05% plus cetylpyridinium chloride 0.05% plus zinc lactate 0.14%). After 12 days, morning breath was scored via volatile sulfur compound (VSC) level measurements of the mouth air and organoleptic ratings of the mouth air, the expired air, and a scraping of the tongue coating. At the 12-day visit, a questionnaire (subjective ratings) was completed and samples taken from both the tongue coating and the saliva for anaerobic and aerobic culturing and vitality staining. The de novo supragingival plaque formation was also recorded. All parameters were correlated with the baseline registrations.

RESULTS

Although oral hygiene during the 3 experimental periods was limited to oral rinses, bad breath parameters systematically improved, with the exception of a slight increase in VSC levels while using CHX-Alc, a finding which was associated with the direct influence of the CHX on the sulfide monitor. The oral microbial load after the use of CHX-NaF remained unchanged, while for the CHX-Alc and CHX-CPC-Zn, significant reductions in both aerobic and anaerobic colony forming units (CFU)/ml were noticed in comparison with baseline data for both tongue coating and saliva samples. The composition of microflora, on the other hand, did not reveal significant changes. The supragingival plaque formation was inhibited, in descending order, by CHX-Alc, CHX-CPC-Zn, and CHX-NaF. The subjective scores for the rinses indicated a higher appreciation for CHX-CPC-Alc and CHX-NaF because of a better taste and fewer side effects.

CONCLUSIONS

The results of this study demonstrate that morning halitosis can be successfully reduced via daily use of mouthrinses. CHX-Alc and CHX-CPC-Zn mouthrinses result in a significant reduction of the microbial load of tongue and saliva.

Effects of 0.12% chlorhexidine gluconate on experimental gingivitis in non-human primates: clinical and microbiological alterations

OBJECTIVE

This study examined the efficacy of 0.12% chlorhexidine gluconate (Peridex) to reduce gingival inflammation in the absence of mechanical hygiene and its effect on the oral microbial ecology in a non-human primate (NhP) model of gingivitis.

DESIGN

Twelve NhP were stratified based on existing inflammation into two groups of six NhP per group. Oral hygiene was performed on both groups so as to reach a level of gingival health (BOP < or = 0.3) at the conclusion of the hygiene phase. One group received 30 ml of 0.12% chlorhexidine gluconate twice daily 7 days/week, and a second group received 30 ml of placebo (distilled water colored to match the active) using the same regimen for 10 weeks. MEASUREMENT OUTCOMES: Clinical parameters including plaque (PLI), pocket depth (PD), attachment level (AL), and bleeding on probing (BOP) were evaluated at 2-week intervals. Subgingival plaque samples were collected by paper point at 2-week intervals and cultured for predominant cultivable bacteria.

RESULTS

By week 2, there was a difference in BOP between the groups, which reached statistical significance by week 4. This difference in BOP was maintained throughout the course of the study. Chlorhexidine gluconate (0.12%) had no significant effect on PLI, PD, or AL; although PD was greater in the placebo group after week 2 and throughout the study. Microbiologically, at week 4, the treatment group had a reduction in total bacterial counts, as well as Gram positive bacteria, and total black pigmented bacteria, compared to the placebo group. However, only the differences in Actinomyces spp. reached significance. Interestingly, when both groups received only one treatment/day on the weekends (i.e., day 6 and 7), an associated loss of statistically significant differences between the two groups was observed. Additional experiments dosing the non-human primates once daily, 5 days/week yielded no significant differences in clinical parameters, including bleeding, when compared with the placebo group.

CONCLUSION

Non-human primates provided a model system of gingivitis for testing antimicrobial agent effects on the subgingival ecology and accompanying inflammatory responses. Chlorhexidine gluconate (0.12%), even in the absence of mechanical hygiene, was effective in inhibiting clinical signs of inflammation, associated with alterations in the subgingival microbial ecology, most notably Actinomyces spp.

One stage full- versus partial-mouth disinfection in the treatment of chronic adult or generalized early-onset periodontitis. I. Long-term clinical observations

BACKGROUND

A standard treatment strategy for periodontal infections often consists of 4 consecutive sessions of scaling and root planing (per quadrant, at 1- to 2-week intervals), without proper disinfection of the remaining intra-oral niches for periodontopathogens. This could theoretically lead to a reinfection of previously disinfected pockets by bacteria from an untreated region/niche. This study aimed to investigate, over an 8-month period, the clinical benefits of a one stage full-mouth disinfection in the control of severe periodontitis.

METHODS

Sixteen patients with early-onset periodontitis and 24 patients with severe adult periodontitis were randomly assigned to test and control groups. The control group was scaled and root planed, per quadrant, at 2-week intervals and given standard oral hygiene instructions. A one stage full-mouth disinfection (test group) was sought by scaling and root planing the 4 quadrants within 24 hours in combination with the application of chlorhexidine to all intra-oral niches for periodontopathogens. Besides oral hygiene, the test group also rinsed twice daily with a 0.2% chlorhexidine solution and sprayed the tonsils with a 0.2% chlorhexidine spray, for 2 months. The plaque index, gingival index, probing depth, bleeding on probing, gingival recession, and clinical attachment level were recorded at baseline and at 1, 2, 4, and 8 months afterwards.

RESULTS

The one stage full-mouth disinfection resulted, in comparison to the standard therapy, in a significant (P <0.001) additional probing depth reduction and gain in attachment up to 8 months. For initial pockets > or =7 mm, the "additional" probing depth reduction at the 8 month follow-up was 1.2 mm for single-rooted and 0.9 mm for multi-rooted teeth, with corresponding additional gains in attachment of 1.0 mm and 0.8 mm, respectively. The additional improvements were observed for all subgroups (adult periodontitis, generalized early-onset cases, smokers), with the largest differences in the non-smoking adult periodontitis patients.

CONCLUSIONS

These findings suggest that a one stage full-mouth disinfection results in an improved clinical outcome for the treatment of chronic adult or early-onset periodontitis as compared to scaling and root planing per quadrant at 2-week intervals.

6-month use of 0.2% delmopinol hydrochloride in comparison with 0.2% chlorhexidine digluconate and placebo. (I). Effect on plaque formation and gingivitis

A double-blind, randomised, 6-month clinical trial with parallel group design in 149 patients with gingivitis was conducted to study the efficacy and safety of delmopinol hydrochloride 2 mg/ml (0.2% w/v, Decapinol Mouthwash) used for partly supervised mouthrinsing in comparison with chlorhexidine digluconate 2 mg/ml (0.2% w/v, Hibitane Dental, ICI Pharmaceuticals, UK) and placebo as an addition to normal oral hygiene. Assessments of efficacy were performed using the plaque index and bleeding on probing (BOP). Delmopinol showed 22% lower plaque index scores than placebo after 3 months (p<0.01) and 13% lower scores after 6 months. The corresponding figures for chlorhexidine were 38% (p<0.001) and 38% (p<0.001) after 3 and 6 months, respectively. Bleeding on probing was reduced for delmopinol in comparison with placebo by 11% after 3 months and by 18% (p<0.05) after 6 months. For chlorhexidine the corresponding figures were 18% (p<0.01) and 22% (p<0.01) after 3 and 6 months, respectively. While chlorhexidine showed greater plaque reduction than delmopinol (p<0.01 at 6 months), no statistically significant difference was reached between these two solutions regarding BOP. Both active solutions showed an increased amount of dental calculus in comparison with placebo. A transient anaesthetic sensation in the oral mucosa and taste affection were commonly reported adverse events in both the delmopinol and the chlorhexidine groups. The number of patients withdrawn from treatment due to adverse events or lack of cooperation was 7 in the chlorhexidine group, 4 in the placebo group and 1 in the delmopinol group. The results showed that rinsing with either 0.2% delmopinol hydrochloride or 0.2% chlorhexidine digluconate twice daily for 60 secs for 6 months results in less plaque formation and gingivitis than rinsing with placebo. Mouthrinsing with the 0.2% delmopinol hydrochloride solution was well accepted in this study.

Modern supragingival plaque control

Supragingival plaque control is essential for the maintenance of oral health. Despite the many chemotherapeutic agents available as mouthrinses and toothpastes, mechanical plaque removal is still the best method to achieve effective plaque control. This is due, in part, to the lack of development of oral antimicrobials with the effectiveness and substantivity of chlorhexidine gluconate but without its adverse effects of dental staining and calculus formation. The use of the numerous mechanical (manual and electric) oral hygiene devices extant and their effectiveness, however, are dependent upon patient dexterity and compliance and concomitant active professional treatment for the monitoring of home care, oral hygiene instruction and patient motivation. This paper evaluates the current methods available to reduce plaque and gingivitis with emphasis on their effectiveness at both supragingival plaque control and disease prevention. In addition, recent studies on the newer oscillating/rotating electric plaque removers and interdental cleaning devices will be discussed as related to their efficacy and compliance.

Plaque formation and gingivitis after supervised mouthrinsing with 0.2% delmopinol hydrochloride, 0.2% chlorhexidine digluconate and placebo for 6 months

OBJECTIVES AND METHODS

A double-blind, randomized, 6-month clinical trial with parallel group design in 162 patients with gingivitis divided into three rinsing groups was conducted in order to study the efficacy and safety of a flavoured solution of delmopinol hydrochloride 2 mg ml-1 (0.2% w/v, Decapinol Mouthwash) used for supervised mouthrinsing in one rinsing group, in comparison with chlorhexidine digluconate 2 mg ml-1 (0.2% w/v, Hibitane Dental) in a second rinsing group, and placebo in the third group. The criteria of the Plaque Index (PI) were used to assess plaque formation. Bleeding on probing (BOP) to the bottom of the pocket with a standard pressure was used as the primary gingivitis assessment. The occurrence of supragingival dental calculus and extrinsic tooth staining were also assessed. In addition, patients were asked to report adverse events at each visit.

RESULTS

Delmopinol and chlorhexidine exhibited lower scores of the mean PI and the BOP percentage than placebo, both at the 3-month and 6-month examinations. Furthermore, both active solutions showed a higher extent of staining of the teeth than placebo during these two observation periods. Rinsing with chlorhexidine resulted in more dental calculus than placebo after 6 months. Chlorhexidine showed lower scores for plaque formation and gingivitis development but higher scores of supragingival dental calculus (after 6 months) and tooth staining than did delmopinol. Both active solutions were reported by the patients--approximately to the same extent but more frequently than placebo--to induce taste alterations and a transient anaesthetic sensation of the oral mucosa. However, subjective staining of the teeth and tongue was reported by 16% of the delmopinol patients, but by 86% of the patients rinsing with chlorhexidine for 6 months. Furthermore, 24% of the patients in the chlorhexidine group, 9% in the delmopinol group and 4% in the placebo group wished to withdraw from treatment.

CONCLUSIONS

The results from this clinical trial indicate that supervised rinsing with 0.2% delmopinol hydrochloride or with 0.2% chlorhexidine digluconate twice daily for 60 s as a supplement to normal mechanical oral hygiene procedures resulted in less plaque formation and gingivitis than rinsing with placebo. Although chlorhexidine was more effective than delmopinol regarding plaque formation and gingivitis, it was considered by the patients as less tolerable.

Perioperative use of 0.12% chlorhexidine gluconate for the prevention of alveolar osteitis: efficacy and risk factor analysis

OBJECTIVES

The purposes of this study were to evaluate the use of 0.12% chlorhexidine gluconate as a prophylactic therapy for the prevention of alveolar osteitis and to further examine subject-based risk factors associated with alveolar osteitis.

STUDY DESIGN

The trial was a randomized, double-blind, placebo-controlled, parallel-group study conducted among 279 subjects, each of whom required oral surgery for the removal of a minimum of one impacted mandibular third molar. Subjects were instructed to rinse twice daily with 15 ml of chlorhexidine or placebo mouthrinse for 30 seconds for 1 week before and 1 week after the surgical extractions. This regimen included a supervised presurgical rinse. Alveolar osteitis diagnosis was based on the subjective finding of increasing postoperative pain at the surgical site that was not relieved with mild analgesics, supported by clinical evidence of one or more of the following: loss of blood clot, necrosis of blood clot, and exposed alveolar bone.

RESULTS

In comparison with use of the placebo mouthrinse, prophylactic use of the chlorhexidine mouthrinse resulted in statistically significant (p < 0.05) reductions in the incidence of alveolar osteitis. With chlorhexidine therapy, the subject- and extraction-based incidences of alveolar osteitis in the evaluable subset (271 subjects) were reduced, relative to placebo, by 38% and 44%, respectively. The corresponding odds ratios that describe the increased odds of experiencing alveolar osteitis in the placebo group were 1.87 and 2.05 for subject- and extraction-based analyses, respectively. In comparison with nonuse of oral contraceptives, the use of oral contraceptives in female subjects was related to a statistically significant increase in the incidence of alveolar osteitis (odds ratio = 1.92, p = 0.035). Relative to male subjects, the observed incidence of alveolar osteitis for female subjects not using oral contraceptives was not statistically significant (odds ratio = 1.18, p = 0.64). Smoking did not increase the incidence of alveolar osteitis relative to not smoking (odds ratio = 1.20, p = 0.33).

CONCLUSIONS

These data confirm that the prophylactic use of 0.12% chlorhexidine gluconate mouthrinse results in a significant reduction in the incidence of alveolar osteitis after the extraction of impacted mandibular third molars. In addition, oral contraceptive use in females was confirmed to be a risk factor for the development of alveolar osteitis.

Chlorhexidine: is it still the gold standard?

After 20 years of use by the dental profession, chlorhexidine is recognized as the gold standard against which other antiplaque and gingivitis agents are measured. Chlorhexidine's antiplaque effect is a result of the dicationic nature of the chlorhexidine molecule, which affords the agent the property of persistence of antimicrobial effect at the tooth surface, through both bactericidal and bacteriostatic effects. Although other antiplaque agents may show either purely immediate effect, or limited persistence, the degree of chlorhexidine's persistence of effect at the tooth surface is the basis of its clinical efficacy. Similarly, the cationic nature of the chlorhexidine molecule is the basis of the most common side effect associated with the use of the agent--extrinsic tooth staining. Such tooth staining seems to be the result of a local precipitation reaction between tooth-bound chlorhexidine and chromogens found within foodstuffs and beverages. The cationic nature of the chlorhexidine molecule also means that the activity of the agent is rapidly reduced in the presence of anionic agents, specifically those found within certain types of toothpaste; thus care is required when using normal toothbrushing alongside chlorhexidine. By understanding how the chemical properties of the chlorhexidine molecule can explain the plethora of clinical efficacy and safety data, the use of chlorhexidine can be optimally aimed towards the patient groups who would most benefit from the superior therapeutic effect of the agent. Specifically, chlorhexidine would seem to be of most value to patients in whom the ability to perform adequate oral hygiene procedures has been compromised. In these individuals the delivery of the correct dose of chlorhexidine to the tooth surface can be optimized through the judicial use of the several different chlorhexidine formulations now available. Thus, by understanding the properties and limitations of the chlorhexidine molecule, the dental profession can ensure that the efficacy of the agent is maximized, and the side effects associated with the agent are minimized, allowing chlorhexidine to rightly remain the gold standard against which other antiplaque agents are measured.

The effects of a 0.12% chlorhexidine-digluconate-containing mouthrinse versus a placebo on plaque and gingival inflammation over a 3-month period. A multicentre study carried out in general dental practices

Several previous studies have evaluated the effects of 0.12% chlorhexidine digluconate (ChD) mouthrinses on plaque and gingival inflammation. However, previously, none have been based in general dental practices. The aim of this study was to evaluate the potential to conduct controlled periodontal clinical trials in co-operation with general dental practitioners (gdps). The project took place in 5 general dental practices in the South of England. 121 healthy subjects (24 at 4 sites and 25 at the 5th), aged 18-65 years, mean 35 +/- 12) years participated in a double-blind, randomised study during which they received full mouth assessments for plaque and gingival bleeding at baseline, 6 and 12 weeks. 60 subjects were randomly assigned to use the 0.12% ChD mouthwash and 61 the placebo. The assessments were carried out by 5 gpds, who had previously achieved inter-examiner kappa scores of 0.78-0.85 (mean 0.81) for the plaque index (PII), and of 0.73-0.94 (mean 0.87) for a modified gingival index (mGI), and who maintained kappa scores of 0.51-0.90 for PII and of 0.73-1.00 for mGI during the 12 months required to complete the study. 98 subjects (48 ChD and 50 placebo) completed the study. Even though the baseline levels of plaque and gingivitis were low, by week 12, mean whole mouth plaque score of the ChD mouthwash users had fallen from 1.33 at baseline to 0.96 and was significantly lower (p < 0.001) than for the placebo users, 1.31 at baseline to 1.13. Whole-mouth gingival bleeding score fell from 0.56 to 0.42 in the ChD mouthwash group but was unchanged (0.54-0.55) in the placebo group. A subsidiary data analysis which considered the effects at sites indicated that within these overall differences, the ChD users experienced almost 2 x the reduction from plaque score 2 at baseline at proximal molar sites over a 12-week period (50.6% ChD versus 27.6% placebo). It was concluded that 0.12% ChD mouthwash reduced plaque accumulation by 28% and gingival inflammation by 25% over a 12-week period, that it is feasible for a group of gdps to maintain high levels of inter-examiner consistency in the use of PII and mGI, that it is also feasible to carry out such a multicentre study in general dental practice, and that the use of mean mouth scores per subject to analyse the effects of mouthrinses may well mask variations in response throughout the mouth.

Therapeutic effects of supervised chlorhexidine mouthrinses on untreated gingivitis

AIM

The aim of the present study was to test the presumptive therapeutic effect of chlorhexidine digluconate in a population with untreated gingivitis and presence of abundant calculus. SETTING AND STUDY DESIGN: Sixty subjects (approximately mean age of 23.4) were recruited from a knitting factory in the Province of Guangdong, People's Republic of China. By applying a double-blind clinical trial design the participants were divided into two groups (Test and Control) and matched according to their mean GI scores. The Test group (n = 20) was assigned to two daily mouthrinses for 6 days per week using 0.12% chlorhexidine digluconate (Peridex). The Control group (n = 40) rinsed twice daily with a placebo solution. All the rinsings were supervised and timed for 45 s. No attempt was made to influence the oral hygiene habits of the participants. Prior to and after 3 months of the supervised rinsing, plaque was scored using the Plaque Index system (PII), and gingivitis was assessed using the criteria of the Gingival Index system (GI). Calculus was scored according to the Calculus Surface Severity Index system (CSSI), and stain was also graded by the Discoloration Index system (DI).

RESULTS

After 3 months, the Test group (n = 13) showed significant reduction in mean PII, GI and percentage of gingival bleeding (GB%), while significant increases in mean DI were observed. The improvement in gingival health was observed at all regions with marked reduction in mean GI (from GI = 1.40 to 1.08) and GB% reduction by 24-52%. The proportion of GI = 2 was also reduced significantly from 50-36%. The Control group (n = 23) also showed a decrease in mean PII but significant increases in the mean GI and GB%. Intergroup comparison showed statistically significant differences between mean GI, percentage of gingival bleeding (GB%) and mean DI for the test and control groups after 3 months of supervised rinsing. However, there were no significant intergroup differences for mean PII.

CONCLUSION

In conclusion, there was a significant effect of chlorhexidine on gingivitis, although the effect may be too limited to assure prognostic benefits in the prevention of future disease progression.

Full- versus partial-mouth disinfection in the treatment of periodontal infections. Long-term clinical observations of a pilot study

A classical treatment for chronic adult periodontitis consists of four to six consecutive sessions of scaling and root planing at a 1- to 2-week interval. Such a so-called "quadrant or sextant therapy" might result in a reinfection of a previously disinfected area by bacteria from an untreated region. The purpose of this study was to investigate, over an 8-month period, the clinical benefits of full-mouth disinfection within a 24-hour period in the control of chronic periodontitis. Ten adult patients with advanced chronic periodontitis were randomly assigned to a test and a control group. The control group received the standard scheme of initial periodontal therapy, consisting of scaling and root planing of the four quadrants was performed within 24 hours and immediately followed by a thorough supra- and subgingival chlorhexidine application to limit any transfer of bacteria. The latter involved tongue brushing with a 1% chlorhexidine gel for 60 seconds, mouthrinsing with a 0.2% chlorhexidine solution twice for 60 seconds, repeated subgingival irrigation of all pockets with a 1% chlorhexidine gel (3 times within 10 minutes), and mouthrinsing twice daily with a 0.2% chlorhexidine solution during 2 weeks. In addition, both groups received thorough oral hygiene instructions. The plaque index, gingival index, probing depth, gingival recession, and bleeding on probing were recorded prior to professional cleaning and at 1, 2, 4, and 8 months afterwards. Although the test group scored higher plaque indices than the control group, especially at months 2 and 4, the gingival index and bleeding tendency showed similar improvements with time. However, when the gingival/plaque ratio was considered, the latter was lower in the test group at all follow-up visits. For pockets > or = 7 mm, full-mouth disinfection showed a significantly (P = 0.01) higher reduction in probing depth at each follow-up visit with, at month 8, a reduction of 4 mm (from 8 mm to 4 mm), in comparison to 3 mm (from 8 mm to 5 mm) for the classical therapy. The increase in gingival recession in the full-mouth disinfection group remained below 0.7 mm, while in the control group it reached 1.9 mm after 8 months. This resulted in a gain of clinical attachment level of 3.7 mm for the test group versus 1.9 mm for the control group. A radiographical examination also indicated a superior improvement for the test group when compared to the control group. This pilot study suggests that a full-mouth disinfection in one day results in an improved clinical outcome in chronic periodontitis as compared to scalings per quadrant at 2-week intervals over several weeks.

The efficacy of an anti-gingivitis chewing gum

Chlorhexidine is a well-established agent used for the control of supragingival plaque but is not without disadvantages, such as tooth staining, which limits its clinical applications to short-term use. This clinical trial studied the clinical effectiveness and stain-forming potential of chlorhexidine in a chewing gum base. Subjects (151) were screened for baseline plaque and gingival indices before receiving a dental prophylaxis and randomized into 3 treatment groups: group 1 chewed 2 pieces of chlorhexidine diacetate gum for 10 min 2x a day (total daily chlorhexidine = 20 mg), group 2 chewed 2 pieces of placebo gum for 10 min 2x a day and group 3 rinsed with 10 ml of 0.2% chlorhexidine gluconate mouthwash for 1 min 2x per day (total daily chlorhexidine = 40 mg). Plaque, gingivitis and stain evaluations were made at 4 and 8 weeks. Plaque and bleeding scores were significantly lower at 4 and 8 weeks in the chlorhexidine gum group compared to the placebo gum group and similar at 8 weeks to the rinse group. Stain intensity at week 8 was significantly less for the chlorhexidine gum than rinse. The staining measured by extent was also less with the chlorhexidine gum than the rinse, but the difference was not significant at week 4. At week 8, stain extent was significantly lower in the chlorhexidine gum group than chlorhexidine rinse. In conclusion, the results of this study demonstrate that this chlorhexidine chewing gum used with normal tooth cleaning provides similar adjunctive benefits to oral hygiene and gingival health as a 0.2% chlorhexidine rinse.

The effect of a commercially available triclosan-containing toothpaste compared to a sodium-fluoride-containing toothpaste and a chlorhexidine rinse on 4-day plaque regrowth

Many compounds could be added to toothpaste to assist plaque inhibition, but ionic interactions can cause formulation difficulties. Moreover, the actual chemical action of a plaque inhibitory agent added to a toothpaste is difficult to assess when the product is used in the conventional manner, i.e., in addition to toothbrushing. The non-ionic antimicrobial triclosan has been incorporated in toothpastes and shown to have variable plaque inhibitory activity both alone and in conjunction with certain polymers or metal ions. Little is known of the efficacy of triclosan toothpastes compared to conventional fluoride toothpastes. The aim of this study was to compare a commercially available toothpaste containing 0.3% triclosan/co-polymer with a sodium fluoride toothpaste for chemical plaque inhibitory effects over a 4-day period. The study was designed to stratify the relative efficacy plaque inhibitory action of the products, comparisons were made with a positive control, chlorhexidine rinse and a negative control, saline. The study design was a randomised single blind crossover design balanced for first-order carryover. A total of 18 healthy, dentate volunteers participated in the study. On day 1 of each period the volunteers suspended toothcleaning and rinsed 2 x daily with the allocated mouthrinse or toothpaste slurry. On day 5, the plaque on the teeth was disclosed and scored by index and area. Increasing plaque scores were in the order chlorhexidine, triclosan toothpaste, fluoride toothpaste, and saline. Chlorhexidine was significantly more effective than all the other agents tested, and both toothpaste preparations were significantly better than the saline rinse. There was no significant difference between the two toothpaste rinses. Consistent with other studies the triclosan toothpaste offers only moderate plaque inhibitory properties when compared to a conventional toothpaste.