Australian Dental Journal, December, 1975
397
Volume 20,
No. 6
A clinical trial of the efficacy of a cetylpyridinium chloride-based mouthwash* 1. Effect on plaque accumulation and gingival condition J. D. Holbechet M. K. Ruljancich AND
P. C. Reade Department of Dental Medicine and Surgery, University of Melbourne ABSTRACT-A commercially available mouthwash, containing 0.05 per cent w /v cetylpyridinium chloride, reduced dental plaque accumulation by 30 per cent in a clinical trial when used briefly, three times a day, after meals.
(Received f o r publication January, 1975)
Introduction It is commonly accepted that the aetiology of both smooth surface dental caries and periodontal disease is directly associated with the accumulation on teeth of bacterial plaque1.2 and hence the wntrol of these diseases could be directed at inhibiting plaque accumulation.
Supported by a grant from Richardson-Merrell P.ty. Ltd.
t Supported by a scholarship from Richardson-Merrell.
Fitzgerald, R. J., and Keyes, P. G.-Demonstration of the etiologic role of streptococci in experimental caries in the hamster. J.A.D.A., 61:l. 9-19 (July) 1960. 2LOe, H.,Thielade, E., and Jensen, S. B.-Experimental gingivitis in man. J. Periodont., 36:3, 177-187 (MayJune) 1965. 3 Mandel, I. D.-New approaches to plaque prevention. Dent. Clin. North Am.. 16:4. 661-671 (Oct.) 1972. 4 Kaslick, R. S., Tuckman. M. A.. and Chasms, A. 1.-Effect of topical vancomycin on plaque and chronic gingival inflammation. J. Periodont., 44:6, 366-368 (June) 1973. 1
Some of the substances which have been tested for their ability either to disrupt plaque or prevent its formation are enzymes, such as dextranases3, antibiotics such as vanwmycin4.5, kanamycina, the macrolide antibiotic designated CC102327 and antiseptics which have ranged from simple organic compounds such as hydrogen peroxide and sodium hypochloride to complex organic compounds such as the guanides. A considerable amount of work has been done on H. V., and Sumney, D. L.-Root surface caries: review of the literature and significance of the problem. J. Periodont., 44:3, 158-163 (March) 1973. 6 Loesche. W. J., and Nafe, D.-Reduction of supragingival plaque accumulations in institutionalized Down's syndrome patients by periodic treatment with topical kanamycin. Arch. Oral Bid. 18:9, 1131-1143 (Sept.) 1973. 'IStallard, R. E., Volpe, A. R., Orban. J. E., and King, W. J.-The effect of an antimicrobial mouth rinse on dental plaque, calculus and gingivitis. J. Periodont., 40:12, 583-694 (Dec.) 1%9. 5 Jordan,
398 the antiseptic, chlorhexidine. This compound has been shown to inhibit markedly plaque formation* and also effectively suppress Streptococcus mutanso which is generally believed to have a key role in the initiation of smooth surface caries. Although the toxicity of chlorhexidine appears to be generally low, it frequently stains the teeth and tongue of users and occasionally produces other undesirable side-effects such as oral mucous membrane hypersensitivity reactions. In an effort to find a suitable chemical plaque control agent our attention was directed towards the use of a quarternary ammonium compound. Features of the quarternaries which have made them especially useful as antiseptics are that they do not contain potentially irritating substances such as phenol, iodine, active chlorine, mercury or other heavy metals and are nontoxic when used at the recommended concentration. They are colourless. odourless. highly stable and active against a wide range of Gram-positive and Gram-negative bacteria. The germicidal properties of these agents have been recently reviewed by Lawrencelo. When reviewing the literature it was noted that there were clear indications that mouthwashes containing between 0.025 per cent and 0.05 per cent w/v of the quarternary ammonium compound, cetylpyridinium chloride (CPC), reduced the numbers of micro-organisms of the oral flora which are represented in saliva and in buccal mucosal scrapings. However, clinical trials designed to assess the plaque-inhibiting effectiveness of CPC such as those of Schroeder", Muller, Schroeder and Mlihlemannlz, Volpe and colleagues13, and Ciancio, Mather and Bunnell14,
8 G e , H.-Does
chlorhexidine have a place in the prophylaxis of dental diseases? In. Symposium on chlorhexidine in the prophylaxis Of dental disease. Edit. M e , H . J. Periodont. Res.. 8, Suppl. 12, 93-99, 1973 0 Schiott, C. R.-The effect of chlorhexidine on the microflora of the oral cavity. In Symposium on chlorhexidine in the prophylaxis of denti1 diseases. Edit. Lac, H . J. Periodont. Res., 8, Suppl. 12. 7-10, 1973. 10 Lawrence, C. A.-Qusrtcrnary ammonium surface-active disinfectants. In. Halies disinfection, sterilization and preservation. Edit. Lawrence, C. A., and Block. S. S . , Philadelphia, Lea and Febiger, 1968, pp. 430-452. 11 Schroeder. H . E.-Formation and inhibition of dental calculus. Berne, Hans Huber, 1969. 12 Muller, E., Schroeder, H. E. and Mahlemann. H . R.-The effect of two oral antiseptics on early calculus formation. Helv. Odont. Acta, 6, 42-45 (Oct.) 1966. W Volpe, A . R., Kupczak, L. F . , Brant, J. H., King, W. J., Kestenbaurn, R. C., and Schlissel, H. J.-Antimicrobial control of bacterial plaque and calculus and the effects of these agents on oral flora. J. Dent. Res., 48, Suppl. 5 , 832-841 (Sept.-Oct.) 1969. 14 Ciancio, S. G.. Mather, M. L.. and Bunnell. H. J.-Clinical evaluation of a quarternary ammonium mouth rinse. Int. Assoc. Dent. Res. 51st General Session, Abstr. No. 807, Chicago (Apr.) 1973.
Australian Dental Journal, December, 1975 provided various problems in interpretation and it was decided therefore, to undertake a clinical trial to assess the plaque-inhibiting effectiveness of a commercially available CPC-containing mouthwash, Cepacol, when used regularly in conjunction with normal oral hygiene procedures. Materials and methods (a) Subjects involved and methods of examination Most of the subjects in the trial were dental science undergraduates and dental nurses at the Royal Dental Hospital of Melbourne. Of the 110 participants who began the trial, 100 completed the trial. Their distribution according to age and sex is shown in Table 1. Each subject was examined four times by the same dentist; at the commencement of the trial, and at the end of each subsequent week. At each of the four examinations, which were carried out with the aid of a dental light, mouth mirror and dental probe, clinical assessments were made of plaque thickness, plaque extent and gingival condition. The examinations were carried out between the morning and the midday meals.
(b) Design of the trial The clinical trial was a triphasic three week double-blind cross-over study during which each of the subjects used both the trial mouthwash and a placebo mouthwash for periods of one week. The mouthwashes used in the first test period comprised equal numbers of randomly distributed active and placebo preparations. In the second test period subjects used the alternative preparation to that used in the first test period and hence each of the subjects used both the trial mouthwash and a placebo mouthwash for a period of one week. The schedule carried out by each patient in the trial was as follows:Week 1: normal oral hygiene procedures were carried out; Week 2: normal oral hygiene procedures were carried out in conjunction with the use of the first mouthwash, either active or placebo; Week 3: normal oral hygiene procedures were carried out in conjunction with the use of the alternative mouthwash, either active or placebo. The subjects were instructed to rinse vigorously with 20 ml of mouthwash for 15 seconds. Half of the subjects were instructed to rinse before meals and the other half after meals. If a toothbrush was normally used by members of this latter group after meals, they were asked
399
Australian Dental Journal, December, 1975 to rinse after toothbrushing. It was anticipated that an improvement of oral hygiene might result because the subjects were participating in a trial and consequently the first week of the trial period when no mouthwash was used was included in the protocol of the experiment to allow any TABLE 1
Characteristics of subjects who completed the clinical trial ~~
Total Age range Mean age number Males Females (years) (years)
Dental science students 65 Dental nurses 30 5 Others
57 0 3
8 30 2
19-28 16-25 21-35
21.1 19.5 21.4
100
60
40
16-35
21.0
Total
alterations in oral hygiene to stabilize. Thus there were four separate groups of subjects:(i) those rinsing before meals and using the placebo mouthwash during the first test period; (ii) those rinsing before meals and using the trial mouthwash during the first test period; (iii) those rinsing after meals and using the placebo mouthwash during the first test period; (iv) those rinsing after meals and using the trial mouthwash during the first test period.
(c) Methods of assessment For inclusion in the trial all subjects had to possess at least 20 permanent erupted teeth which included: (i) the upper right first standing molar, (ii) the upper left first standing incisor. (iii) the upper left first standing premolar, (iv) the lower right first standing molar, (v) the lower right first standing incisor and (vi) the lower right first standing premolar. These teeth comprised the six standard teeth which were used for the assessment of the thickness and extent of plaque and of gingival condition. They were the teeth suggested by Ramfjord15 as being representative of the general plaque accumulation and gingival health. (d) Indices used in the trial (i) The plaque index of Silness and Lik.18 was
used to measure plaque thickness and the buccal and lingual surface of each tooth was given a score of 0 to 3. (ii) A modified Craig-Dunn index" was used to measure the extent of plaque and here the buccal and lingual surfaces of each tooth were scored 0 to 4. (iii) To measure the gingival condition, the gingival index of Lael8 was used and each tooth surface was scored 0 to 3. For each of the above indices, all the scores were added to give a total score for that index for each individual patient. (e) Mouthwashes The mouthwashes used in the trial were Cepaml* (containing 0.05 w/v CPC, 14 per cent v/v ethyl alcohol, flavouring oils and phosphate buffers) and a placebo mouthwash? containing neither CPC nor alcohol. The mouthwashes were provided in identical bottles marked only with a code number and directions for use. Each participant was provided with a supply of 20 ml cups for measuring the volume of mouthwash to be used and also a proprietary non-fluoridated toothpaste which he/she was instructed to use throughout the trial. Two subjects complained of a moderately severe local reaction to this toothpaste and changed to another proprietary non-fluoridated toothpaste. (f) Analysis of results At the completion of the trial, the investigators were provided with the code to the mouthwashes and the results were then collated and tabulated in preparation for statistical evaluation in the Department of Statistics. University of MelThe method of analyses used are bourne. mentioned in the results section. Rerulb In general terms, both mouthwashes were found to of the patients in the trial mucous membrane irritation side-effects was noticed.
active and placebo be acceptable to all and no evidence of or other undesirable
(a) Thickness of plaque accumulation (i) Plaque scores ut control examinations The plaque scores at examinations 1 and 2 ~~~
~~
Richardson-Merrell Pty Ltd Sydney Australia. Richardsoh4e;;ell Pty. 'Ltd.
t Prepared by S. P.-Indices for prevalence and incidence of periodontal disease. J. Periodont., 30:l. 51-59 (Jan.) 1959. 16 Silness, J., and m e , H.-Periodontal disease in pregnancy. n. Correlation between oral hygiene and periodontal condition. Acta Odont. Scand. 22:l. 121-135 (Feb.) 1964.
15 Ramfjord.
17Crrig. G. G., and Dunn, G. R.-A guide to the practice of preventive dentistry. University of Sydney, Dental Health and Research Foundation, 1971. 18 L6e. H.-The gingival index, the plaque index and the retention index systems. J. Periodont.. 38:6, 610-616 (Nov.-Dec.) 1967.
400
Australian Dental Journal, December, 1975 TABLE 2
Thickness of plaque (total scores): summary oj results Ana!ysis of variance Plaque score at examination 1
Before meals
After meals
Placebo first (n = 24) Active first ( n = 26) Placebo first (n=24) Active first (n =26)
2
3
2v3
3v4
2v4
F-ratio
t
t
t
4
Mean 11.13
9.54
9.46 (P) 8.46(A)
s.d.
3.80
4.83
4.51
4.50
Mean 10.88
9.69
8.92 (A)
8.85 (P)
s.d.
4.18
4.15
3.79
4.65
Mean 10.58
8.96
8.54(P)
5.79(A)
s.d.
4.14
4.08
3.73
3.65
Mean 9.50
9.08
7.04(A)
7.96(P)
s.d.
4.26
3.96
3.76
4.16
A
=
score after rinsing with active mouthwash
P
=
score after rinsing with placebo mouthwash
To investigate this reduction more closely the buccal and lingual plaque scores at examinations 1 and 2 were considered separately. Paired t-tests were again performed and this analysis indicated a significant difference (P
397
Volume 20,
No. 6
A clinical trial of the efficacy of a cetylpyridinium chloride-based mouthwash* 1. Effect on plaque accumulation and gingival condition J. D. Holbechet M. K. Ruljancich AND
P. C. Reade Department of Dental Medicine and Surgery, University of Melbourne ABSTRACT-A commercially available mouthwash, containing 0.05 per cent w /v cetylpyridinium chloride, reduced dental plaque accumulation by 30 per cent in a clinical trial when used briefly, three times a day, after meals.
(Received f o r publication January, 1975)
Introduction It is commonly accepted that the aetiology of both smooth surface dental caries and periodontal disease is directly associated with the accumulation on teeth of bacterial plaque1.2 and hence the wntrol of these diseases could be directed at inhibiting plaque accumulation.
Supported by a grant from Richardson-Merrell P.ty. Ltd.
t Supported by a scholarship from Richardson-Merrell.
Fitzgerald, R. J., and Keyes, P. G.-Demonstration of the etiologic role of streptococci in experimental caries in the hamster. J.A.D.A., 61:l. 9-19 (July) 1960. 2LOe, H.,Thielade, E., and Jensen, S. B.-Experimental gingivitis in man. J. Periodont., 36:3, 177-187 (MayJune) 1965. 3 Mandel, I. D.-New approaches to plaque prevention. Dent. Clin. North Am.. 16:4. 661-671 (Oct.) 1972. 4 Kaslick, R. S., Tuckman. M. A.. and Chasms, A. 1.-Effect of topical vancomycin on plaque and chronic gingival inflammation. J. Periodont., 44:6, 366-368 (June) 1973. 1
Some of the substances which have been tested for their ability either to disrupt plaque or prevent its formation are enzymes, such as dextranases3, antibiotics such as vanwmycin4.5, kanamycina, the macrolide antibiotic designated CC102327 and antiseptics which have ranged from simple organic compounds such as hydrogen peroxide and sodium hypochloride to complex organic compounds such as the guanides. A considerable amount of work has been done on H. V., and Sumney, D. L.-Root surface caries: review of the literature and significance of the problem. J. Periodont., 44:3, 158-163 (March) 1973. 6 Loesche. W. J., and Nafe, D.-Reduction of supragingival plaque accumulations in institutionalized Down's syndrome patients by periodic treatment with topical kanamycin. Arch. Oral Bid. 18:9, 1131-1143 (Sept.) 1973. 'IStallard, R. E., Volpe, A. R., Orban. J. E., and King, W. J.-The effect of an antimicrobial mouth rinse on dental plaque, calculus and gingivitis. J. Periodont., 40:12, 583-694 (Dec.) 1%9. 5 Jordan,
398 the antiseptic, chlorhexidine. This compound has been shown to inhibit markedly plaque formation* and also effectively suppress Streptococcus mutanso which is generally believed to have a key role in the initiation of smooth surface caries. Although the toxicity of chlorhexidine appears to be generally low, it frequently stains the teeth and tongue of users and occasionally produces other undesirable side-effects such as oral mucous membrane hypersensitivity reactions. In an effort to find a suitable chemical plaque control agent our attention was directed towards the use of a quarternary ammonium compound. Features of the quarternaries which have made them especially useful as antiseptics are that they do not contain potentially irritating substances such as phenol, iodine, active chlorine, mercury or other heavy metals and are nontoxic when used at the recommended concentration. They are colourless. odourless. highly stable and active against a wide range of Gram-positive and Gram-negative bacteria. The germicidal properties of these agents have been recently reviewed by Lawrencelo. When reviewing the literature it was noted that there were clear indications that mouthwashes containing between 0.025 per cent and 0.05 per cent w/v of the quarternary ammonium compound, cetylpyridinium chloride (CPC), reduced the numbers of micro-organisms of the oral flora which are represented in saliva and in buccal mucosal scrapings. However, clinical trials designed to assess the plaque-inhibiting effectiveness of CPC such as those of Schroeder", Muller, Schroeder and Mlihlemannlz, Volpe and colleagues13, and Ciancio, Mather and Bunnell14,
8 G e , H.-Does
chlorhexidine have a place in the prophylaxis of dental diseases? In. Symposium on chlorhexidine in the prophylaxis Of dental disease. Edit. M e , H . J. Periodont. Res.. 8, Suppl. 12, 93-99, 1973 0 Schiott, C. R.-The effect of chlorhexidine on the microflora of the oral cavity. In Symposium on chlorhexidine in the prophylaxis of denti1 diseases. Edit. Lac, H . J. Periodont. Res., 8, Suppl. 12. 7-10, 1973. 10 Lawrence, C. A.-Qusrtcrnary ammonium surface-active disinfectants. In. Halies disinfection, sterilization and preservation. Edit. Lawrence, C. A., and Block. S. S . , Philadelphia, Lea and Febiger, 1968, pp. 430-452. 11 Schroeder. H . E.-Formation and inhibition of dental calculus. Berne, Hans Huber, 1969. 12 Muller, E., Schroeder, H. E. and Mahlemann. H . R.-The effect of two oral antiseptics on early calculus formation. Helv. Odont. Acta, 6, 42-45 (Oct.) 1966. W Volpe, A . R., Kupczak, L. F . , Brant, J. H., King, W. J., Kestenbaurn, R. C., and Schlissel, H. J.-Antimicrobial control of bacterial plaque and calculus and the effects of these agents on oral flora. J. Dent. Res., 48, Suppl. 5 , 832-841 (Sept.-Oct.) 1969. 14 Ciancio, S. G.. Mather, M. L.. and Bunnell. H. J.-Clinical evaluation of a quarternary ammonium mouth rinse. Int. Assoc. Dent. Res. 51st General Session, Abstr. No. 807, Chicago (Apr.) 1973.
Australian Dental Journal, December, 1975 provided various problems in interpretation and it was decided therefore, to undertake a clinical trial to assess the plaque-inhibiting effectiveness of a commercially available CPC-containing mouthwash, Cepacol, when used regularly in conjunction with normal oral hygiene procedures. Materials and methods (a) Subjects involved and methods of examination Most of the subjects in the trial were dental science undergraduates and dental nurses at the Royal Dental Hospital of Melbourne. Of the 110 participants who began the trial, 100 completed the trial. Their distribution according to age and sex is shown in Table 1. Each subject was examined four times by the same dentist; at the commencement of the trial, and at the end of each subsequent week. At each of the four examinations, which were carried out with the aid of a dental light, mouth mirror and dental probe, clinical assessments were made of plaque thickness, plaque extent and gingival condition. The examinations were carried out between the morning and the midday meals.
(b) Design of the trial The clinical trial was a triphasic three week double-blind cross-over study during which each of the subjects used both the trial mouthwash and a placebo mouthwash for periods of one week. The mouthwashes used in the first test period comprised equal numbers of randomly distributed active and placebo preparations. In the second test period subjects used the alternative preparation to that used in the first test period and hence each of the subjects used both the trial mouthwash and a placebo mouthwash for a period of one week. The schedule carried out by each patient in the trial was as follows:Week 1: normal oral hygiene procedures were carried out; Week 2: normal oral hygiene procedures were carried out in conjunction with the use of the first mouthwash, either active or placebo; Week 3: normal oral hygiene procedures were carried out in conjunction with the use of the alternative mouthwash, either active or placebo. The subjects were instructed to rinse vigorously with 20 ml of mouthwash for 15 seconds. Half of the subjects were instructed to rinse before meals and the other half after meals. If a toothbrush was normally used by members of this latter group after meals, they were asked
399
Australian Dental Journal, December, 1975 to rinse after toothbrushing. It was anticipated that an improvement of oral hygiene might result because the subjects were participating in a trial and consequently the first week of the trial period when no mouthwash was used was included in the protocol of the experiment to allow any TABLE 1
Characteristics of subjects who completed the clinical trial ~~
Total Age range Mean age number Males Females (years) (years)
Dental science students 65 Dental nurses 30 5 Others
57 0 3
8 30 2
19-28 16-25 21-35
21.1 19.5 21.4
100
60
40
16-35
21.0
Total
alterations in oral hygiene to stabilize. Thus there were four separate groups of subjects:(i) those rinsing before meals and using the placebo mouthwash during the first test period; (ii) those rinsing before meals and using the trial mouthwash during the first test period; (iii) those rinsing after meals and using the placebo mouthwash during the first test period; (iv) those rinsing after meals and using the trial mouthwash during the first test period.
(c) Methods of assessment For inclusion in the trial all subjects had to possess at least 20 permanent erupted teeth which included: (i) the upper right first standing molar, (ii) the upper left first standing incisor. (iii) the upper left first standing premolar, (iv) the lower right first standing molar, (v) the lower right first standing incisor and (vi) the lower right first standing premolar. These teeth comprised the six standard teeth which were used for the assessment of the thickness and extent of plaque and of gingival condition. They were the teeth suggested by Ramfjord15 as being representative of the general plaque accumulation and gingival health. (d) Indices used in the trial (i) The plaque index of Silness and Lik.18 was
used to measure plaque thickness and the buccal and lingual surface of each tooth was given a score of 0 to 3. (ii) A modified Craig-Dunn index" was used to measure the extent of plaque and here the buccal and lingual surfaces of each tooth were scored 0 to 4. (iii) To measure the gingival condition, the gingival index of Lael8 was used and each tooth surface was scored 0 to 3. For each of the above indices, all the scores were added to give a total score for that index for each individual patient. (e) Mouthwashes The mouthwashes used in the trial were Cepaml* (containing 0.05 w/v CPC, 14 per cent v/v ethyl alcohol, flavouring oils and phosphate buffers) and a placebo mouthwash? containing neither CPC nor alcohol. The mouthwashes were provided in identical bottles marked only with a code number and directions for use. Each participant was provided with a supply of 20 ml cups for measuring the volume of mouthwash to be used and also a proprietary non-fluoridated toothpaste which he/she was instructed to use throughout the trial. Two subjects complained of a moderately severe local reaction to this toothpaste and changed to another proprietary non-fluoridated toothpaste. (f) Analysis of results At the completion of the trial, the investigators were provided with the code to the mouthwashes and the results were then collated and tabulated in preparation for statistical evaluation in the Department of Statistics. University of MelThe method of analyses used are bourne. mentioned in the results section. Rerulb In general terms, both mouthwashes were found to of the patients in the trial mucous membrane irritation side-effects was noticed.
active and placebo be acceptable to all and no evidence of or other undesirable
(a) Thickness of plaque accumulation (i) Plaque scores ut control examinations The plaque scores at examinations 1 and 2 ~~~
~~
Richardson-Merrell Pty Ltd Sydney Australia. Richardsoh4e;;ell Pty. 'Ltd.
t Prepared by S. P.-Indices for prevalence and incidence of periodontal disease. J. Periodont., 30:l. 51-59 (Jan.) 1959. 16 Silness, J., and m e , H.-Periodontal disease in pregnancy. n. Correlation between oral hygiene and periodontal condition. Acta Odont. Scand. 22:l. 121-135 (Feb.) 1964.
15 Ramfjord.
17Crrig. G. G., and Dunn, G. R.-A guide to the practice of preventive dentistry. University of Sydney, Dental Health and Research Foundation, 1971. 18 L6e. H.-The gingival index, the plaque index and the retention index systems. J. Periodont.. 38:6, 610-616 (Nov.-Dec.) 1967.
400
Australian Dental Journal, December, 1975 TABLE 2
Thickness of plaque (total scores): summary oj results Ana!ysis of variance Plaque score at examination 1
Before meals
After meals
Placebo first (n = 24) Active first ( n = 26) Placebo first (n=24) Active first (n =26)
2
3
2v3
3v4
2v4
F-ratio
t
t
t
4
Mean 11.13
9.54
9.46 (P) 8.46(A)
s.d.
3.80
4.83
4.51
4.50
Mean 10.88
9.69
8.92 (A)
8.85 (P)
s.d.
4.18
4.15
3.79
4.65
Mean 10.58
8.96
8.54(P)
5.79(A)
s.d.
4.14
4.08
3.73
3.65
Mean 9.50
9.08
7.04(A)
7.96(P)
s.d.
4.26
3.96
3.76
4.16
A
=
score after rinsing with active mouthwash
P
=
score after rinsing with placebo mouthwash
To investigate this reduction more closely the buccal and lingual plaque scores at examinations 1 and 2 were considered separately. Paired t-tests were again performed and this analysis indicated a significant difference (P
