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02 September 2022: Clinical Research  

Comparative Evaluation of 3 Commercial Mouthwash Formulations on Clinical Parameters of Chronic Gingivitis

Shahabe Saquib Abullais1ABFG, Sabiha Ilyas Patel2ADEF, Elyas Ali Asiri3ABCE, Adel Ali Ahmed Jathmi3ABE, Afnan Hassan Alkhayri3ADEG, Yosra Mohammed Mousa3BEFG, Atheer Abdulhade Ganem4BCE, Khurshid A. Mattoo5CDE*

DOI: 10.12659/MSM.937111

Med Sci Monit 2022; 28:e937111

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Abstract

BACKGROUND: Chlorhexidine (CHX) is not prescribed as a mouthwash for long-term use; therefore, probiotic/herbal mouthwashes are being investigated. This study compared the effect of 3 commercial mouthwashes on plaque index (PI), gingival index (GI), and bleeding index (BI) in patients with chronic gingivitis.

MATERIAL AND METHODS: Forty-five patients (all with moderate plaque) were randomly allocated into 3 groups (Gp): Gp 1 (CHX), Gp 2 (Manuka), and Gp 3 (Pro-Dental). Three periodontal clinical parameters – PI, GI, and BI – were recorded at baseline and on days 7, 14, and 28. An oral hygiene maintenance program was followed by a double-blinded intervention (coded bottle containing mouthwash). Both inter-group and intra-group comparisons were made using analysis of variance (ANOVA) with multiple t tests. All probable values were considered to have various levels of significance at P<0.05 or below.

RESULTS: All indices for all groups showed higher values (mean) at baseline, which were lower on days 7, 14, and 28. No differences in any clinical parameter at any point of time existed between Gp 1 and Gp 2. There were, however, significant differences (P<0.05) between Gp 1/Gp 3 and Gp 2/Gp 3 for all clinical parameters at all observed time periods (days 7, 14, 28). Intra-group comparison for all groups demonstrated highly significant differences between baseline values and other time points.

CONCLUSIONS: For managing chronic gingivitis, Manuka mouthwash is as effective as a CHX mouthwash, as there were no differences observed in any clinical parameters at any point points.

Keywords: Biofilms, Dental Plaque, Dental Scaling, gingivitis, Mouthwashes, Chlorhexidine, Chronic Disease, Dental Plaque Index, Humans, Periodontal Index, Plant Extracts

Background

The periodontium plays an essential part in defense of teeth against occlusal forces, bacterial invasion, and stress concentration. Common diseases like gingivitis and periodontitis associated with the periodontium of natural teeth are predominantly inflammatory in nature and originate mainly from microbes [1]. Besides multiple risk factors, accretion of plaque biofilm in and around the junction between tooth and gingiva regularly initiates a host inflammatory immune response that in some cases may even be maladaptive and damaging [2]. Irrespective of the severity of the host response, the control of plaque (mechanical or chemical) around the tooth gingiva junction is necessary in preventing and managing development of periodontal disease [3]. Use of mouthwash is considered as an adjunct to primary therapy, which is the mechanical or manual removal of dental plaque using a toothbrush or other aids. Controlling gingivitis is essential to prevent the development of periodontal disease. Evidence suggests that mouthwash used alone reduces mild gingivitis within 4–6 weeks, but is ineffective if gingivitis is moderate or severe, even after 6 months of use. Mechanical removal of plaque in such cases is necessary before prescribing mouthwash [4]. In patients with specific physical disability/psychological conditions or in other medically compromised patients (eg, hemiplegia or frail patients) who have limited dexterity, adjunctive use of chemical agents in addition to primary mechanical removal is considered mandatory [4]. These patients’ ability to follow medical instructions under normal conditions has been established to be meager, thus affecting treatment compliance and treatment satisfaction [5]. Within dentistry, a patient undergoing orthodontic fixed appliance treatment or having a fixed implant prosthesis is more dependent on chemical cleaning rather than physical self-removal of plaque [6]. Thus, mouthwashes play a pivotal role in supragingival plaque control.

Chlorhexidine (CHX) is a salt form of chlorhexidine gluconate/acetate, which is basically a disinfectant and antiseptic. It has long been considered as a scientifically reliable antimicrobial oral mouthwash that has proven long-term efficacy [7]. CHX, being a biocide (broad-spectrum), inactivates by disruption of cell membranes within a short period of time. The cell wall sites (negatively charged) easily bind with its molecule (positively charged), which leads to interference with cell osmosis [8]. Besides its beneficial effects, dysgeusia, tooth stains, dehydration, and painful mucosa limit its long-term use [9]. This has prompted recent research to focus on biological and herbal mouthwashes, for better oral health maintenance, owing to their wide range of biological and medicinal activities, ease of availability, higher safety margins, and lower cost [10]. Biological agents such as probiotic mouthwash increases the commensal flora, thereby preventing the microbiological shift and colonization of pathogens associated with gingival inflammation [11]. Increasing the normal oral microbiota (“good” bacteria) shifts the balance from disease to health and overpowers the ill effects of other bacteria (“bad” bacteria), a mechanism seen in the gut. The probiotic mouthwash formula may either contain strains of Streptococcus or Lactobacillus. These microorganisms are part of the average oral microbiota that occur naturally in the mouth and, when introduced by supplements, can adhere to mucosa easier than other microorganisms and hence colonize the mouth. They can reduce plaque formation, thereby improving overall gingival health [12]. Zinc in addition to bacteria is a powerful antioxidant that plays a role in scavenging free radicals and thereby maintaining periodontal health [13]. These probiotic-based formulations encapsulate bacteria to ensure viable bacteria, which is responsible for its longer shelf life.

Herbal agents that are obtained from plants (chemotherapeutic and medicinal) have also been introduced, which behave as drugs due to the presence of bioactive compounds. Various bioactive compounds (phenolic compounds - flavonoids and phenolic acids) introduce antibacterial properties and therefore have become a substitute for conventional biochemical mouthwashes [14]. Manuka mouthwash contains ingredients that are high nutritive sources of ascorbic acid (vitamin C) and other antioxidants (eg, lutein, alpha linolenic acid, omega-3 fatty acid) [15]. The antioxidants are free scavengers that help in maintaining the integrity of periodontal tissues. Vitamin C is a potent antioxidant that is considered essential for maintaining the integrity of connective tissue, osteoid tissues, and dentine [15]. The antibacterial property of Manuka honey is associated with its sugar content (high). It also inactivates the bacteria through an osmotic effect (phenolic and antioxidant action). Its action is dependent on one of its enzymes (inhibin), which produces hydrogen peroxide on dilution [16]. Generally, studies have shown that mouthwashes either reduce or inhibit bacterial growth (mean bacterial count) with various mean reductions after 2 weeks of use [17].

With the above background, this randomized control trial (RCT) was aimed to evaluate the clinical effectiveness of herbal, probiotic and chlorhexidine mouthwash and their effect of various clinical parameters in healthy patients with dental biofilm-induced gingivitis. The aims of the study were to find a long-term alternative to the commonly used chlorhexidine mouthwash. The objective of the study was to substitute the commonly prescribed CHX mouthwash with a natural alternative that is more biocompatible with oral tissues and does not cause burning, dysgeusia, or tissue dehydration as short-term outcomes and tooth staining as the long-term outcome.

Material and Methods

ETHICS:

This clinical study was conducted between the second and fourth quarter of 2018 in a dental institute situated in the southwestern region of Saudi Arabia. The study plan was permitted by the college and the university ethics committee under ethical clearance number SRC/ETH/2017-18/081, which conducts all clinical studies involving humans and animals according to the standards and regulations of the Helsinki Declaration.

Patients who visited the outpatient department (OPD) of the college are required to provide a written consent for any diagnostic, preventive, or treatment procedure as a protocol set by the college and the university.

STUDY DESIGN:

This study was a double-blind randomized controlled trial (RCT) in which the participants (patients) and the investigators who were assessing the outcome were not aware of the intervention. The study utilized a prospective, exploratory, comparative approach on a cross-sectional population sample of people who sought periodontal treatment in the OPD.

SAMPLE SIZE SELECTION, TREATMENT, AND GROUPING:

The graphical depiction of the study and the sequence of events are presented in Figure 1. The total sample size that would satisfy the research requirements (flexibility, efficiency, and reliability) was calculated to be 45 patients [±5% accuracy, an alpha of 0.05 (95% confidence interval)]. A total of 70 patients were evaluated for preparing the study sample, obtained from the OPD of the Department of Periodontology.

Local and systemic factors that influence plaque deposition formed the basis of inclusion and exclusion criteria. We included patients aged 20–40 years, with a complete set of permanent dentition, with no history of tooth loss, orthodontic, orthognathic or restorative treatment, presence of class 1 molar and canine relation with no evidence of spacing or crowding, ideal proximal contacts, cooperative, with chronic moderate plaque (biofilm) induced gingivitis (mild and/or moderate gingivitis), and not taking any current medication. We excluded patients with a history of systemic disease that would influence periodontal status, smokers, khat chewers, pregnant and lactating women, recent antibiotic use (≤1 month), and having undergone any periodontal treatment in the past 6 months. All patients were informed about the study aims and the need of their cooperation to minimize the effect of confounding factors upon the treatment outcome. Diagnosis of mild to moderate gingivitis was substantiated using current guidelines by a team of experienced clinical staff, double-blinded to the study outcome, as were the participants. Any patients presenting with any form of gingivitis (acute or chronic) that had progressed to periodontitis were excluded from the study. The diagnosis of gingivitis was based on clinical guidelines and included a detailed clinical history, signs and symptoms, and clinical (disclosing solution to disclose dental plaque)/radiographic examination [18]. Gingivitis, which is primarily caused by and/or associated with dental plaque, was graded on the extent and severity of bleeding on probing (BOP). This diagnostic system allows identifying incipient gingivitis even if few sites are affected. BOP scores higher than 30% were considered to indicate generalized gingivitis [18]. Patient allotment to a particular group was done by one of the researchers who had no role in patient treatment or evaluating the treatment outcome after intervention. Patients were assigned to groups by random sequencing generated using SPSS software for Windows, (version 21, Chicago, Illinois, USA). The 3 groups were defined on the basis of the intervention method (commercial mouthwash used) they received after routine treatment. The treatment included removal of plaque by using a combination of hand and ultrasonic scaling. A piezo electric ultrasonic scaler (Satelec Acteon Group, Bordeaux, France) using regular scaler tips was used with chairside distilled water cooling. Enamel polishing after scaling for all patients was done using a prophylaxis brush made of nylon bristles (Pro-Brush™, Kerr, Bioggio, Switzerland) and prophylaxis paste (Cleanic paste, Kerr, Bioggio, Switzerland) rotating at low speed. All patients were educated about the brushing method to be used (Bass method). All patients were provided with a medium-bristle toothbrush (Colgate-Palmolive Arabia, Ltd.) and a dentifrice (Colgate-Palmolive Arabia, Ltd.). The medium-bristled toothbrush has been found to be more effective for removing plaque in the posterior teeth, especially where the tooth surface is contoured toward interproximal areas. As part of the intervention, the patients also received a coded bottle that contained the mouthwash (group-based) and tablet provided by an operator who was blinded to the type of mouthwash in the bottle. Patients were instructed to use their mouthwash after brushing and refrain from drinking, eating, and mouth rinsing for at least 2 hours. The risk of confounding variables influencing the outcome of the study was thus controlled by randomization and restriction within treatment methodology.

Study groups comprised Group 1 patients who were blinded to use of 0.2% Chlorhexidine mouthwash [Chlorhexidine gluconate 0.2% in aqueous flavored base (11.6% alcohol, glycerin, sodium saccharin, flavoring agent, sorbitan diisostearate and water)] (Spimaco, Addwaeih, KSA), twice daily (morning/night) for 14 days; Group 2 patients were blinded to use of herbal mouthwash (Alpine Manuka Mouthwash, Nelson Honey, New Zealand) (Natural Manuka honey, Leptospermum scoparius leaf/flower, water, glycerin, oil – Mentha piperita, Triticum aestivum and Hordeum vulgare leaf extract, menthol, caramel, xylitol) twice daily (morning/night) for 14 days; and Group 3 patients blinded to use of PRO-Dental (Hyperbiotics, Probi, USA, Inc) [Lactobacillus reuteri, Bifidobacterium bifidum and Lactobacillus rhamnosus (0.1 billion colony-forming units [cfu]), zinc, lactilol and fructo oligosaccharides, polysorbate 20, sodium benzoate, oil (Rosmarinus officinalis, Eugenia caryophyllus, Mentha viridis), glycerin, xylitol, peppermint and water], 1 tablet dissolved in 10 ml of normal water and swished once in the morning for 14 days. The patients were instructed not to use any other aids for oral hygiene maintenance until the last follow-up.

MEASURES, DATA EVALUATION, COLLECTION, AND ANALYSIS:

Comparative evaluation in each group and between groups was performed after collecting the data for the following clinical parameters that were recorded at baseline and at 7, 14, and 28 days at regular follow-up. These included the following:

At each follow-up visit, for each clinical parameter, inter-examiner reliability and intra-examiner reliability were ensured by evaluation by 2 different examiners and by repeated measurement of clinical parameter by the same assessor at 2 different times. The intra-class correlation coefficient calculated was 0.87, which was considered to be appropriate.

STATISTICAL ANALYSIS:

Demographic characteristics were described in terms of frequency distribution (categorical variable), while the mean (continuous variable) and standard deviation (SD) were calculated for various clinical parameters. To assess homogeneity among the 3 groups, a chi-square test was used. The inter-group statistical comparison between means (continuous variable) was done using analysis of variance (ANOVA) with Bonferroni correction (to correct the experiment-wise error rate when using multiple t tests) for multiple-group comparisons. The intra-group statistical comparisons were done using ANOVA (repeated measures) in each study group. Assumption of normality (Kolmogorov-Smirnov test) was tested before subjecting each variable to ANOVA. For statistical comparisons, differences between study groups were considered to be statistically significant if the probable value was less than or equal to 0.05. Various levels of sensitivity for statistical significance were determined at multiple probable values (significant at P<0.05, very significant at P<0.01, and highly significant at P<0.001). Formulation of hypothesis was verified using alternatives (2-tailed) against every null hypothesis. The all-inclusive data were statistically investigated using SPSS for Windows, version 21 (Chicago, Illinois, USA).

Results

:

The mean scores of subjects in all the groups decreased from baseline to 28 days. Comparison of mean scores between groups at various time points showed that the difference in mean was very significant (P<0.01) between Group 1 and Group 3 (day 7), between Group 2 and Group 3 (days 14 and 28), whereas the difference in means was found to be highly significant (P<0.001) between Group 1 and Group 3 on day 28 (Table 2). Intra-group comparison (Figure 2) revealed a highly significant (P<0.001) difference in mean values at baseline compared to mean plaque index at days 7, 14, and 28 in all 3 experimental groups. The mean value at day 7 also differed significantly (P<0.05) compared to mean plaque index at day 14 in Groups 2 and 3.

:

The mean gingival index scores among all the groups were found to be higher at baseline, and declined among all groups by day 28, except in Groups 2 and 3, which both showed an increase from day 14 (Group 2 – 0.57±0.21 to 0.61±0.19; Group 3 – 0.85±0.16 to 0.89±0.14). When mean values for all groups were compared, the results show that the differences in mean between Groups 3 and 1 were highly significant (P<0.001) on days 7 and 28, while also being significant (P<0.05) on day 14 and that the differences in mean between Groups 3 and 2 were highly significant (P<0.001) at all observed time points (days 7, 14, 28). The intra-group comparison showed that the baseline values were highly significant (P<0.001) when compared to means on days 7, 14, and 28. Differences in mean values also were significant (P<0.05) in Groups 1 and 2 between days 7 and 28 and in Groups 2 and 3 between days 7 and 14 (Figure 3).

:

The mean bleeding index scores among all the 3 groups were higher at baseline as compared to other time points. There was a decrease in the mean bleeding index scores from baseline to days 7 and 14, while an increase in mean bleeding index scores was observed on day 28 for all groups. When scores were compared between the 3 groups, the mean scores differed significantly (P<0.05) between Groups 1 and 3 on day 7, and the difference was very significant (P<0.01) between Groups 2 and 3 on days 7 and 28, and the difference was highly significant (P<0.001) on day 14. When comparisons were made within groups, the results showed that the difference in means between baseline values and the remaining 3 time points (days 7, 14, and 28) were highly significant (P<0.001), while there was no statistically significant difference in means between other groups (Figure 4).

Discussion

STUDY STRENGTHS AND LIMITATIONS:

This study compared 3 commercial preparations, which eliminated influences that can result due to making a customized or a self-made mouthwash preparation. The results obtained are conclusive that Manuka mouthwash is a reliable alternative to CHX-containing mouthwash, which is generally not indicated when long-term chemical oral hygiene maintenance is desired, as in prosthodontic patients receiving full mouth rehabilitation or orthodontic patients undergoing fixed appliance correction of teeth. The study is limited by its small sample size, the sample chosen from a particular area, and all the limitations that are associated with a cross-sectional sample.

Conclusions

This study showed a decrease in mean PI, GI, and mean bleeding index from baseline to day 28 with the use of 0.2% Chlorhexidine, Manuka, and PRO-Dental formula probiotic mouthwash as adjunct to mechanical therapy in gingivitis patients, indicating that all the 3 mouthwashes are clinically effective in treating plaque-induced gingivitis. Patients using chlorhexidine and Manuka mouthwash experienced a substantial decrease in the clinical parameters among the 3 groups. To overcome the drawbacks of prescribing a CHX-based mouthwash for long-term maintenance of gingival and periodontal health, this study recommends using Manuka, which is equally effective to CHX, while minimizing the adverse effects (eg, staining, mucosal burning, and dehydration) associated with long-term use of CHX. However, long-term studies are needed to investigate the adverse effects of Manuka mouthwash.

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