Effects of green tea (Camellia sinensis) mouthwash containing 1% tannin on dental plaque and chronic gingivitis: a double-blinded, randomized, controlled trial

Antibacterial activities of Miang extracts against selected pathogens and the potential of the tannin-free extracts in the growth inhibition of Streptococcus mutans

Bacterial pathogens have remained a major public health concern for several decades. This study investigated the antibacterial activities of Miang extracts (at non-neutral and neutral pH) against Bacillus cereus TISTR 747, Escherichia coli ATCC 22595, Salmonella enterica serovar Typhimurium TISTR 292 and Streptococcus mutans DMST 18777. The potential of Polyvinylpolypyrrolidone (PVPP)-precipitated tannin-free Miang extracts in growth-inhibition of the cariogenic Streptococcus mutans DMST 18777 and its biofilms was also evaluated. The tannin-rich fermented extracts had the best bacterial growth inhibition against S. mutans DMST 18777 with an MIC of 0.29 and 0.72 mg/mL for nonfilamentous fungi (NFP) Miang and filamentous-fungi-processed (FFP) Miang respectively. This observed anti-streptococcal activity still remained after PVPP-mediated precipitation of bioactive tannins especially, in NFP and FFP Miang. Characterization of the PVPP-treated extracts using High performance liquid chromatography quadrupole-time of flight-mass spectrometry (HPLC-QToF-MS) analysis, also offered an insight into probable compound classes responsible for the activities. In addition, Crystal violet-staining also showed better IC50 values for NFP Miang (4.30 ± 0.66 mg/mL) and FFP Miang (12.73 ± 0.11 mg/mL) against S. mutans DMST 18777 biofilms in vitro. Homology modeling and molecular docking analysis using HPLC-MS identified ligands in tannin-free Miang supernatants, was performed against modelled S. mutans DMST 18777 sortase A enzyme. The in silico analysis suggested that the inhibition by NFP and FFP Miang might be attributed to the presence of ellagic acid, flavonoid aglycones, and glycosides. Thus, these Miang extracts could be optimized and explored as natural active pharmaceutical ingredients (NAPIs) for applications in oral hygienic products.

Prevention of Dental Biofilm Formation with Polyphenols: A Systematic Review

Polyphenols are plant secondary products with health-promoting properties against various degenerative or infectious diseases, and thus may help in the prevention of oral diseases. The aim of the present systematic review was to investigate polyphenols as a possible adjuvant in inhibiting dental biofilm formation, which is an important precondition for the most prevalent oral disease - caries and periodontitis. A literature search was conducted using the databases PubMed, CENTRAL and Scopus. Only studies with oral healthy participants and plaque level as outcome were included. Data search and extraction was conducted by two authors independently. Of the 211 initially identified studies, only six met all inclusion criteria. Meta-analysis was performed with five studies using the random effect model. Treatment with polyphenols reduced the plaque level in comparison to a negative control, but not significantly. Strong evidence of heterogeneity was observed. The diversity and complexity of polyphenols and their preparation need to be considered. There is no clear evidence that clinical use of polyphenols can prevent dental biofilm formation. Additional research with more and larger randomized controlled trials are required.

Green Alternatives as Antimicrobial Agents in Mitigating Periodontal Diseases: A Narrative Review

Periodontal diseases and dental caries are the most common infectious oral diseases impacting oral health globally. Oral cavity health is crucial for enhancing life quality since it serves as the entranceway to general health. The oral microbiome and oral infectious diseases are strongly correlated. Gram-negative anaerobic bacteria have been associated with periodontal diseases. Due to the shortcomings of several antimicrobial medications frequently applied in dentistry, the lack of resources in developing countries, the prevalence of oral inflammatory conditions, and the rise in bacterial antibiotic resistance, there is a need for reliable, efficient, and affordable alternative solutions for the prevention and treatment of periodontal diseases. Several accessible chemical agents can alter the oral microbiota, although these substances also have unfavorable symptoms such as vomiting, diarrhea, and tooth discoloration. Natural phytochemicals generated from plants that have historically been used as medicines are categorized as prospective alternatives due to the ongoing quest for substitute products. This review concentrated on phytochemicals or herbal extracts that impact periodontal diseases by decreasing the formation of dental biofilms and plaques, preventing the proliferation of oral pathogens, and inhibiting bacterial adhesion to surfaces. Investigations examining the effectiveness and safety of plant-based medicines have also been presented, including those conducted over the past decade.

Clinical efficacy of green tea, aloe vera and chlorhexidine mouthwashes in the treatment of dental biofilm induced gingivitis: A multi-arm, double-blinded, randomized controlled clinical trial

OBJECTIVE

This multi-arm, randomized, double-blinded, controlled clinical trial was designed to evaluate the clinical efficacy of 0.5% green tea (GT), 0.2% chlorhexidine (CHX) and aloe vera (AV) mouthwash as compared to the control (CNT) group (scaling and polishing alone with no mouthwash) in the management of dental biofilm induced gingivitis among 18-40-year-old patients.

MATERIAL AND METHODS

Sixty patients with generalized dental biofilm-induced gingivitis were randomly allocated to four study groups (n = 15 each) for treatment, namely Group GT, Group CHX, Group AV and Group CNT after scaling and polishing were administered to all the patients. Plaque index (PI), gingival index (GI) and sulcular bleeding index (SBI) were recorded at baseline, 14th and 21st day.

RESULTS

PI, GI and SBI at various time intervals (baseline, 14th and 21st day) showed high statistically significant differences within the group (p < 0.01). Among these, the maximum percentage change was found in the CHX group followed by GT when evaluated from baseline to 21st day. The least percentage change was found in the AV group for PI and GI while the CNT group showed the least percentage change for sulcular index when evaluated from 14th to 21st day. Inter-group results showed high statistically significant differences (p < 0.01) for PI and GI when evaluated between baseline to 14th day and baseline to 21st day. SBI also showed statistically significant differences (p < 0.05) when evaluated between baselines to 14th day and baseline to 21st day.

CONCLUSION

Green tea mouthwash displayed a significant reduction in plaque index, gingival index and sulcular bleeding index. 0.5% green tea catechin has equivalent anti-plaque efficacy as 0.2% chlorhexidine gluconate and can be considered a potent alternative to prevent and treat gingival diseases.

Efficacy of medicinal plant extracts as dental and periodontal antibiofilm agents: A systematic review of randomized clinical trials

ETHNOPHARMACOLOGICAL RELEVANCE

The presence of biofilm in oral cavity is associated with dental plaque and related diseases, including gingivitis, periodontitis and inflammatory responses. Some medicinal plants traditionally used for biofilm-associated pathologies such as Camellia sinensis (L.) Kuntze, Punica granatum L. and Lippia sidoides Cham. are currently incorporated into dosage forms as antiplaque agents.

AIMS OF THE STUDY

To present the current application of medicinal plant extracts associated in drug dosages to control microbial biofilms, with emphasis on those present in the oral cavity, especially to treat dental plaque.

MATERIALS AND METHODS

A PRISMA-compliant systematic search was conducted using the PubMed, Web of Science and Scopus databases. After the abstract and full-text analysis, the Cochrane Collaboration's tools for clinical studies was applied to assess the methodological quality of randomized clinical trials.

RESULTS

Of 964 potentially eligible studies, 47 studies met the inclusion criteria and were included in the systematic review. Camellia sinensis was the most commonly used species (8 studies), with positive results in reducing both the PI and GI in the form of mouthwash, toothpaste and gel. The Melaleuca alternifolia oil (5 studies) demonstrated low reduction in PI but important effects on GI scores. Azadirachta indica (4 studies) extracts presented efficacy similar to CHX to improve the periodontal parameters, including PI and GI. Ricinus communis oil (3 studies), despite reducing microbiological counts and GI, did not prove to be better than the hypochlorite solution, used as an alternative treatment for dentures. The main bioactive compounds described for the plant species are polyphenols, essential oils and alkaloids, most of them with identified antibiofilm activities.

CONCLUSIONS

These active species could lead to future development of safer and newer treatments for oral biofilm-associated infections. However, more studies are needed to further understand the clinical relevance of their application.

Camellia sinensis in Dentistry: Technological Prospection and Scientific Evidence

Purpose

This study aimed to evaluate reports of patents for oral care formulations, based on Camellia sinensis (C. sinensis), deposited and granted in intellectual property banks.

Methods

A survey was conducted through collection, treatment, and analysis of extracted information from patent reports selected. The documentary research was conducted in January 2021 on formulations with C. sinensis for dental applications, including since the first patent deposits until the current time. The risk of bias of clinical trials with these formulations was analyzed to verify the scientific evidence. The data extracted represent the distribution of the number of patents by banks, annual evolution of patent deposits, applicant of patents by country, distribution of patents according to International Patent Classification codes, and the types of patented products.

Results

Data and information from 20 selected patents were extracted. The United States Patent and Trademark Office (USPTO) and World Intellectual Property Organization (WIPO) were the banks with the largest number of patents for products/formulations with C. sinensis for oral care applications with 7 (35%) and 6 (30%) patent registrations, respectively. Other banks did not provide patents related to the search. Patents of compositions were the largest with 14 filings, and the remainder of formulations are represented specially by mouthwashes and toothpastes. As for clinical application, 18 patents were filed as products with antimicrobial and antibiofilm action, while 2 patents are directed to the treatment of xerostomia. In general, the aspects of the studies of clinical efficacy pointed to a low risk of bias.

Conclusion

The study pointed out a small number of products protected by patents for Camellia sinensis for oral care indication, highlighting mainly mouthwash compositions and formulations. In the methodological parameters of clinical trials carried out with the formulations, the majority pointed out a low risk of bias.

Effect of green tea, ginger plus green tea, and chlorhexidine mouthwash on plaque-induced gingivitis: A randomized clinical trial

Background:

Dental plaque, a microbial biofilm, is the primary etiological factor leading to the initiation of gingivitis and dental caries. It is therefore important to prevent it by taking effective plaque control measures. This research aimed at comparing the anti-plaque and anti-gingivitis effects of green tea (GT), GT plus ginger (GT + G), and chlorhexidine mouthwash (CHX) in children.

Materials and Methods:

This was a randomized clinical trial, with a sample size of 60 children between the age group of 10–14 years with plaque and gingivitis. They were randomly allocated in three different groups, depending upon the mouthwash used: Group A (GT mouthwash), Group B (GT plus ginger mouthwash), and Group C (CHX mouthwash). Plaque index and gingival index were recorded at baseline, then at interval of 15 days and 30 days after using mouthwash.

Results:

The mean gingival score and plaque showed a significant reduction from the baseline among all the three groups when compared with subsequent recall visits (15 days after using mouth-rinse and 30 days after using mouthwash) with P < 0.05.

Conclusion:

It can be concluded that the results of all three groups are comparable and hence herbal mouthwash can be used effectively as an alternative to CHX and as an adjunct to mechanical plaque control.

Green and white teas as health-promoting foods

Tea is one of the most consumed beverages around the world and as such, it is constantly the object of novel research. This review focuses on the research performed during the last five years to provide an updated view of the current position of tea regarding human health. According to most authors, tea health benefits can be traced back to its bioactive components, mostly phenolic compounds. Among them, catechins are the most abundant. Tea has an important antioxidant capacity and anti-inflammatory properties, which make this beverage (or its extracts) a potential aid in the fight against several chronic diseases. On the other hand, some studies report the possibility of toxic effects and it is advisable to reduce tea consumption, such as in the last trimester of pregnancy. Additionally, new technologies are increasing researchers' possibilities to study the effect of tea on human gut microbiota and even against SARS CoV-2. This beverage favours some beneficial gut microbes, which could have important repercussions due to the influence of gut microbiota on human health.

Influence of the new formulation based on silver alginate microcapsules loaded with tannic acid on the microcirculation of the experimental periodontitis in rats

The microvascular changes caused by disorders of host immune response to oral microorganisms resulting in long-lasting inflammation of gums play a critical role in the periodontal lesion in the pathogenesis of chronic periodontitis. Current strategies of non-surgical periodontal therapy are aimed at the attainment of anti-inflammatory effects. We hypothesized that the usage of the microencapsulated form of anti-inflammatory substances with vasoactive effects could enhance the efficiency of the therapy by the prolonged release of active components. The prepared suspension of silver-alginate microcapsules loaded with tannic acid in the hydrogel was applied in vivo to the experimental model of periodontitis in rats induced by a ligature. The effect of this formulation was assessed by monitoring changes in local microcirculation performed by the Laser Doppler Flowmetry (1 and 24 h after application of hydrogel on intact gums and 21-days after the start of periodontitis' modeling). Application of the hydrogel containing multicomponent microcapsules to the affected area of gums allows correction of inflammatory microcirculatory disorders in model periodontitis. Immobilization of tannic acid into microcapsules allows increasing the correction of the following parameters: perfusion disorders, neurogenic tone of arterioles, myogenic tone of precapillary sphincters, as well as a venous outflow in the microvasculature of the gums. The hydrogel containing multicomponent microcapsules reduces the vascular inflammatory response in the model of periodontitis. Loading of silver-alginate microcapsules with tannic acid enhances the efficiency of microvascular disorders' correction in the model of periodontitis that suggests the prospects for application of this drug delivery system for non-surgical treatment of periodontitis.

Impact of Green Tea (Camellia Sinensis) on periodontitis and caries. Systematic review and meta-analysis

Background

The oral health-promoting effects of green tea are attributed to its polyphenol components. Aim of this work was to systematically review the literature in search for clinical trials assessing green tea for managing periodontitis and caries.

Methods

Randomized clinical trials comparing the efficacy of green tea versus control groups in oral hygiene and gingival health; periodontitis; caries; periodontal pathogens number; Streptococcus mutans, Lactobacillus spp. Meta-analysis and meta-regression analysis were performed.

Literature searches were carried out using MedLine (PubMed), Scopus, and the Cochrane Library. Eighteen studies (870 subjects) were included.

Results

Green tea treatment had medium positive effect size in reducing GI (SMD: 0.50; 95%CI: −0.02/1.01); PI (SMD: 0.54; 95%CI: 0.14/0.95); GBI (SMD: 0.58; 95%CI: −0.41/1.56) and BOP (SMD: 0.52; 95%CI: −0.57/1.60) in respect to the control group. Splitting to subgroups, green tea showed a small negative effect in the chlorhexidine control groups. Green tea treatment had medium positive effect size in reducing CAL (SMD 0.58; 95%CI: −0.49/1.65) and large positive effect size in reducing PPD (SMD:1.02; 95%CI: 0.45/1.59).

Conclusion

Even if the results are encouraging, there is insufficient evidence to recommend the use of green tea formulation as first choice treatment for gingivitis, periodontitis and caries.

Different applications forms of green tea (Camellia sinensis (L.) Kuntze) for the treatment of periodontitis: a systematic review and meta-analysis

BACKGROUND

Scaling and root planning (SRP) is the gold standard for non-surgical periodontal treatment. Green tea as a supporting alternative in non-surgical periodontal treatment has been suggested as a therapeutic option in the treatment of periodontitis.

OBJECTIVE

To analyse the comparative effectiveness of green tea (Camellia sinensis) in its different forms and applications for the treatment of periodontitis.

METHODS

We included randomized clinical trials evaluating green tea as an adjuvant therapeutic agent to scaling and root planning (SRP) in the treatment of periodontitis. For the meta-analysis, we calculated standardized mean difference (SMD) and 95%CI comparing green tea and control (only SRP). We subgrouped by types of application forms of green tea. The certainty of the evidence was assessed through GRADE.

RESULTS

Nine studies were included. The follow-up time of treatments varied from 21 days to 6 months. The subgroup meta-analysis showed that the green tea as sachet reduced probing bleeding (SMD = -0.71; 95%CI) and the gingival index (SMD = -0.78; 95%CI) compared to SRP with very low certainty of evidence. The sachet (SMD = -0.29; 95%CI) and dentifrice (SMD = -1.31; 95%CI) reduced plaque index with very low certainty compared to the control. All forms of application of green tea showed very low certainty of evidence (SMD = -0.27; 95% CI) in reducing the probing depth, as well as for the loss of clinical insertion (SMD = -0.42; 95% CI) with low certainty of evidence.

CONCLUSION

There was not a difference in the effectiveness of green tea isolated or in combination with SRP to reduce probing depth. Green tea adjunct to periodontal therapy showed very low certainty of effectiveness for the treatment of periodontal disease.

Camellia Sinensis Mouthwashes in Oral Care: a Systematic Review

Herbal products are increasingly growing in the oral care market. Some of the related herbal compounds in this field have considerable clinical evidence for use in mouthwashes in their background. Camellia sinensis or tea plant has attracted numerous researchers of dentistry and pharmaceutical sciences, in recent years, for its biologic and medicinal properties. The effects such as anti-septic, anti-oxidative, and anti-inflammatory activities have made this plant a suitable candidate for preparation of mouthwashes. In this systematic review, we tried to find, evaluate, and categorize the sparse evidence in medical literature about Camellia sinensis mouthwashes. We explored three scientific databases with keywords including tea, dental care, Camellia sinensis, and mouthwashes and found 69 relevant studies including 41 randomized controlled trials (RCTs), which are generally proposing anti-microbial, anti-plaque, and analgesic indications for these tea formulations. Considering the main trend in clinical evidence and favorable safety profile, Camellia sinensis products are able to act as antiseptic, anti-plaque, and anti-inflammatory agents and can be used as useful mouthwashes in the future clinical studies and practice.

Effects of Experimental Agents Containing Tannic Acid or Chitosan on the Bacterial Biofilm Formation in Situ

Chitosan and tannic acid are known for their antibacterial properties. In the present in-situ study, their antibacterial and anti-adherent effects on biofilm formation on enamel were investigated. Six subjects carried upper jaw splints with bovine enamel specimens, allowing in-situ biofilm formation. During the two-day trial, subjects rinsed with experimental solutions that contained either chitosan, tannic acid (pH = 2.5), tannic acid (pH = 7) or hydrochloric acid. Water served as the negative and chlorhexidine as the positive control. Rinsing occurred four or five times following two different rinsing protocols to investigate both the immediate and long-lasting effects. After 48 h of intraoral exposure, the dental plaque was stained with LIVE/DEAD^® BacLight, and fluorescence micrographs were evaluated by using the software ImageJ. The results were verified by scanning electron microscopy. Rinsing with chitosan resulted in little immediate antibacterial and anti-adherent effects but failed to show any long-lasting effect, while rinsing with tannic acid resulted in strong immediate and long-lasting effects. Except for a slightly lower antibacterial effect, the neutral solution of tannic acid was as good as the acidic solution. Hydrochloric acid showed neither an antibacterial nor an anti-adherent effect on dental biofilm formation. Experimental solutions containing tannic acid are promising anti-biofilm agents, irrespective of the pH values of the solutions. Chitosan, on the other hand, was not able to prevent biofilm formation.

Solidago virgaurea L. Plant Extract Targeted Against Candida albicans to Reduce Oral Microbial Biomass: a Double Blind Randomized Trial on Healthy Adults

Oral microbiome plays an important part on oral health and endogenous bacteria and fungi should not be eradicated. However, their proliferation must be controlled by oral hygiene care. In vitro, Solidago virgaurea ssp. virgaurea L. (SV) plant extract inhibits the adherence and hyphal formation of a fungus, Candida albicans. It reduces the biomass of Candida-bacterial biofilms but not fungal or bacterial growth. Unlike chemical antiseptics, like triclosan and chlorhexidine for instance, SV is a plant extract easily biodegradable. The purpose of this study was to assess the in vivo effectiveness of SV extract in reducing oral biomass. A randomized, double-blind clinical study, with dental plaque evaluation designed to assess the effectiveness of a fluorinated toothpaste containing SV (Bucovia™, Givaudan, Vernier, Switzerland) was conducted. Sixty-six subjects (SV group n = 33 vs. control n = 33) brushed their teeth twice a day for a 4-week period. Supragingival dental plaque was sampled. Total bacterial load (broad spectral bacterial quantitative Polymerase Chain Reaction (qPCR)), C. albicans and seven bacterial species were quantified by qPCR. In the Intervention group, there was a decrease of Total bacterial load (ΔD0D28 p = 0.005 and ΔD14D28 p = 0.026), Streptococcus mutans (ΔD0D14 p = 0.024) and C. albicans (ΔD0D28 p = 0.022). In the Control group Total bacterial load tended to decrease from baseline to day 28 (ΔD0D28 p = 0.062 and ΔD14D28 p = 0.009). Plaque Index and Gingival Index improved in both groups.

Effects of Herbal Mouthwashes on Plaque and Inflammation Control for Patients with Gingivitis: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

Objective

The aim of this study was to evaluate the overall effects of herbal mouthwashes as supplements to daily oral hygiene on plaque and inflammation control compared with placebos and chlorhexidine (CHX) mouthwashes in the treatment of gingivitis.

Methods

PubMed, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and grey literature databases were searched. Only randomised controlled trials (RCTs) comparing herbal mouthwashes with placebos or CHX in the daily oral hygiene of patient with gingivitis were included to compare the effect of different mouthwashes on plaque and inflammation control.

Results

A total of 13 studies satisfied the eligibility criteria, and 11 studies were included in meta-analyses. Significant differences were observed in favour of herbal mouthwashes compared with placebos in both plaque- and inflammation-related indices (Quigley-Hein Plaque Index, QHPI: WMD = −0.61, 95% CI (−0.80, −0.42), P < 0.001; Gingival Index, GI: −0.28 (−0.51, −0.06), P=0.01; Modified Gingival Index, MGI: −0.59 (−1.08, −0.11), P=0.02; Gingival Bleeding Index, GBI: −0.06 (−0.09, −0.04), P < 0.001). No significant difference was found between herbal and CHX mouthwashes.

Conclusions

Herbal mouthwashes have potential benefits in plaque and inflammation control as supplements to the daily oral hygiene of patients with gingivitis. Although no difference was observed between herbal and CHX mouthwashes in the selected studies, further high-quality RCTs are needed for more firm support before advising patients with gingivitis about whether they can use herbal mouthwashes to substitute for CHX mouthwashes or not (PROSPERO registration number: CRD42019122841).

Gingival Inflammatory Indices and Dental Stain Index after Using Aloe Vera-Green Tea Mouthwash, Matrica Mouthwash, or 0.2% Chlorhexidine Mouthwash Compared with Placebo in Patients with Gingival Inflammation

Introduction:

The purpose of this study was to evaluate and compare the effects of composition of aloe vera-green tea, matrica, and chlorhexidine on gingival inflammatory indices and dental stain index.

Materials & Methods:

In this double-blinded placebo-controlled clinical trial, anti-inflammatory, anti-plaque formation, and dental staining effects of two herbal mouthwashes, including aloe vera-green tea and matrica in comparison with chlorhexidine in 60 patients with plaque induced gingivitis referring to Isfahan University of Medical Sciences, School of Dentistry were evaluated. The indices evaluated in this study were plaque index (Silness and Loe), gingival index (Loe and Silness), bleeding on probing index (Ainamo and Bay) and dental stain index (Lobene stain index). They were evaluated on the first day of using mouthwashes and two weeks later. The obtained data were analyzed using SPSS software version 22. One-way ANOVA, Tukey post hoc, and paired t and Chi-square tests (α=0.05) were used as appropriate.

Results:

There was no significant difference between the four groups in terms of the mean values of plaque index, gingival index, BOP index, and stain index before the application of mouthwash. However, after mouthwash application, the mean values of indices were significantly different between the four groups. Aloe vera-green tea and chlorhexidine mouthwashes reduced plaque index, gingival index, and bleeding on probing index significantly and there was no significant difference between these two mouthwashes (P>0.05). The effect of matrica mouthwash on plaque index and gingival index was significantly lower than aloe vera-green tea and chlorhexidine (P<0.05). The mean reduction in BOP index was not significantly different between the aloe vera-green tea, chlorhexidine, and matrica groups. Regarding dental stain index, both herbal mouthwashes caused significantly lower dental stain in comparison with chlorhexidine (P<0.05).

Conclusion:

The results of the present study show that aloe vera-green tea mouthwash may be an effective mouthwash owing to its antiplaque and anti-inflammatory properties and may be an ideal substitute for chlorhexidine.

Clinical Trial:

The clinical trial code: IR.MUI.REC.1395.3.573

The effect of green tea as an adjunct to scaling and root planing in non-surgical periodontitis therapy: a systematic review

OBJECTIVE

To provide a systematic overview on the efficacy of green tea catechin as an adjunct to scaling and root planing (SRP) in terms of probing pocket depth (PPD).

MATERIALS AND METHODS

A systematic literature search was performed using electronic databases in PubMed, Scopus, Medline, Cochrane, CINAHL, and Web of Science on randomized clinical trials up to January 2017. The research question was posed in accordance with PRISMA guidelines.

RESULTS

The search provided 234 studies. After analyzing the full texts, five studies were included, with four studies qualifying for meta-analysis. Mean PPD reduction was significantly higher (α = 0.05) when green tea catechin was used as an adjunct to SRP (test group) than with SRP alone (control group). The difference in the reduction was 0.74 mm [0.35-1.13; 95% CI].

CONCLUSION

The local application of green tea catechin as an adjunct to SRP may result in a beneficial reduction in PPD. Due to the highly heterogeneous data and some risk of bias, however, this data still needs to be interpreted with caution.

CLINICAL RELEVANCE

The finding suggests that green tea catechin may be a topical adjunct to SRP without negative side effects.

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.