journal of dentistry 43 (2015) 297–308

Available online at www.sciencedirect.com

ScienceDirect journal homepage: www.intl.elsevierhealth.com/journals/jden

Review

Assessment of the effectiveness of mouthwashes in reducing cariogenic biofilm in orthodontic patients: A systematic review Matheus Melo Pithon a,*, Letı´cia Iandeyara Dantas Andrade Sant’Anna a, Felipe Carvalho Souza Baia˜o a, Roge´rio Lacerda dos Santos b, Raildo da Silva Coqueiro a, Lucianne Cople Maia c a

Department of Healthy, Southwest Bahia State University UESB, Jequie´, Bahia, Brazil Department of Health and Technology Rural, Federal University of Campina Grande, Patos, Paraı´ba, Brazil c Department of Pediatric Dentistry and Orthodontics, School of Dentistry, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil b

article info

abstract

Article history:

Objectives: The use of fixed orthodontic appliances makes it difficult to clean the teeth and accessories associated with it. For this reason, orthodontic patients have used oral antiseptics as coadjuvent means to reduce cariogenic plaque. The aim of this systematic review was to evaluate the effectiveness of oral antiseptics on the reduction of cariogenic plaque on orthodontic patients.

Received 12 January 2014 Received in revised form 3 December 2014 Accepted 12 December 2014

Keywords: Cariogenic plaque Mouthwash Mouth rinses Fixed appliance

Data: This review has been registered at PROSPERO – international prospective register of systematic reviews under the number CRD42013006857. Sources: A systematic review of the literature was conducted in the following electronic databases: Scopus, PubMed, Web of Science, Medline, Embase and Cochrane, Grey literature and Clinical Trials, without limitations on the year of publication or language. Clinical studies in patients with fixed orthodontic appliances, who were making use of oral mouthwashes in order to reduce cariogenic plaque, were included. Articles with patients using systemic drugs, syndromic patients, those using mouthwashes for other purposes and/or using different cleaning techniques, and clinical cases were excluded. After selection by title and abstract, potentially eligible articles were read in full. The methodological quality and risk of biases of articles included were evaluated according to the characteristics of the study, measurements and statistical analyses of the study. The methodological quality was classified as high, moderate or low. Study selection: The search identified 2716 articles, of which 15 met the inclusion criteria. Of these, 8 analyzed chlorhexidine-based mouthwashes, while in 1 article Cetylpyridinium was used; 1 analyzed the mouthwash containing sanguinaria; 1 the use of NaF; 2 articles the use of AmF/SnF2; 2 the use of Listerine1, 1 also analyzed the association between mouthwashes with octenidine and with PVP-I. Of the articles analyzed, 11 were classified as having high and 4 as having moderate methodological quality. Conclusion: There is evidence of effectiveness of the use of oral mouthwashes in the control of cariogenic plaque in patients with fixed orthodontic appliances. The orthodontists may suggest the use of oral antiseptics in the oral hygiene of their patients as coadjuvent means to reduce cariogenic plaque. Clinical significance: Given current evidence, orthodontists may prescribe mouthwash as an auxiliary method in the control of cariogenic biofilm in orthodontic patients.

# 2014 Elsevier Ltd. All rights reserved.

* Corresponding author at: Av. Ota´vio Santos, 395, sala 705, Centro Odontome´dico Dr. Altamirando da Costa Lima, Bairro Recreio, CEP 45020-750 Vito´ria da Conquista, Bahia, Brazil. Tel.: +55 7730842020; fax: +55 7734252062. E-mail address: [email protected] (M.M. Pithon). http://dx.doi.org/10.1016/j.jdent.2014.12.010 0300-5712/# 2014 Elsevier Ltd. All rights reserved.

298

1.

journal of dentistry 43 (2015) 297–308

Introduction

Patients under treatment with fixed orthodontic appliances are frequently incapable of effectively performing the mechanical oral hygiene methods, such as brushing and the use of dental floss.1 This leads to changes in the oral cavity, resulting in a reduction in pH and greater propensity for the formation of bacterial colonies responsible for the onset and progression of dental caries.2,3 As a result of the deficient oral hygiene, there is an accumulation of bacteria around the brackets, capable of causing gingival inflammation and demineralization of the hydroxyapatite crystals of tooth enamel, leading to the formation of caries lesions.4–7 Because of this difficulty, chemical agents, especially oral mouthwashes with active principles (such as chlorhexidine, sodium fluoride, AmF/SnF2 and Cetylpyridinium) have been prescribed as coadjuvent means for the reduction of cariogenic plaque in orthodontic patients.8 Mouth washes contain antimicrobial agents capable of altering bacterial membrane permeability, which contributes to its lysis, reduces cell metabolism and its ability to adhere to the tooth surface.9,10 However, there are still many controversies with respect to the real effects of these products on plaque reduction in orthodontic patients. From this perspective, the aim of the authors of the present study was to identify, by means of a systematic review of the literature, the scientific evidence that supports the use of oral mouthwashes to reduce plaque scores in patients who use labial fixed orthodontic appliances.

2.

Materials and methods

2.1.

Focused question

The present systematic review was conducted in order to answer the following focused question: Is there any scientific evidence of reduction in plaque scores when patients undergoing labial fixed appliance treatment use a mouthwash, in comparison with a control group that does not? This systematic review was performed according to Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement for reporting systematic reviews that evaluate health care interventions (MOHER, 2009). This review was registered with PROSPERO – international prospective register of systematic reviews under the number CRD42013006857.

2.2.

Search strategy

The methodology used in this systematic review was based on the PRISMA guidelines (www.prisma-statement.org). In order to identify relevant articles, without limitations on year of publication and language, a search was conducted in the following electronic databases: Scopus, PubMed, Web of Science, Medline, Embase, Cochrane, Controlled Trials. Grey literature (OpenGrey) was also consulted. The search strategy was suited to each database. The following descriptors/MeSH terms were used: mouthwashes, dental plaque, cariogenic, orthodontic appliances, remineralization, oral hygiene, dental

prophylaxis and the key words: cariogenic plaque, mouthwash, mouth rinses and fixed appliance. The details of the search strategy are presented in Table 1.

2.3.

Eligibility criteria of the articles

In order for articles to be selected for this review, they had to meet the following inclusion criteria: Be a controlled clinical study, conducted in orthodontic patients with labial fixed appliances; without age limit (P), with the use of oral mouthwashes (I), comparing the effects obtained by the different types of mouthwashes with a control group (C) on the reduction in plaque score (O). The initial selection was made by reading the titles and abstracts of the articles found. Studies with patients making use of systemic drugs, those who were syndromic, making use of oral mouthwashes for purposes other than the removal of dental plaque and/or making use of other techniques for its removal, but without the use of oral mouthwashes, were excluded from the present review. In addition, in vitro studies, case reports, reviews of the literature and editorials were also excluded. The articles of which the title and abstract did not present sufficient information were downloaded and analyzed in full in order to decide about their eligibility. Those that presented a title within the theme, but the abstract was not available, were also obtained and fully analyzed. Articles that appeared in a database searched more than once, were considered only once. Two researchers (L.I.D.A.S and F.C.S.B.) made the selections independently and the results were compared, with the purpose of avoiding discrepancies that could occur during data collection. If disagreements were found between the two evaluators as regards the inclusion or exclusion of any study, a third evaluator would be consulted (M.M.P.) in a consensus meeting in order to eliminate the discrepancies. The lists of references of selected articles were evaluated manually to verify whether there was any study that had not previously been pointed out by the searched databases. In cases in which additional data were necessary, the corresponding authors of the studies were contacted by e-mail, in order to clear up doubts as regards the eligibility criteria.

2.4.

Quality assessment and risk of bias

For an evaluation of the methodological quality of the articles included in the present systematic review, a scoring process was used in this study, modified from the one used by Baratieri et al.11 and Lagrave`reet al.,12 in which items D, E, F and G were suited to the requirements of the present review. With regard to item A there was a change in the maximum score: this was increased from 1 to 2 points due to its greater relevance, seeing that this item gives a complete description of the population, mean age and the participants’ condition. Items J and L were removed because they did not fit into the context of the research. The articles selected were then evaluated according to the characteristics of the study, measurements of the study and statistical analyses (Table 2). The criteria used for evaluating the characteristics of the study, such as the description of the selection criteria, comparison with control group, randomization declared, description of the adequate use of mouthwash and its composition, received the maximum score (1 point)

journal of dentistry 43 (2015) 297–308

299

Table 1 – Database and method of search. Database

Search strategy

PubMed

((((((mouthwashes AND dental plaque AND orthodontic appliances[MeSH Terms])) OR (mouthwashes AND oral hygiene AND remineralization AND biofilm[MeSH Terms])) OR (mouthwashes AND orthodontic appliances AND Dental Prophylaxis[MeSH Terms])) OR (orthodontic appliances AND remineralization AND dental prophylaxis[MeSH Terms])) OR (oral hygiene AND dental plaque AND mouthwashes)) OR (orthodontic appliances AND mouthwashes AND oral hygiene AND biofilm)

Scopus

(TITLE-ABS-KEY(mouthwashes AND ‘‘orthodontic appliances’’ AND dental plaque) OR TITLE-ABSKEY(‘‘orthodontic appliances’’ AND cariogenic AND (dental prophylaxis OR oral hygiene)) OR TITLE-ABSKEY(‘‘orthodontic appliances’’ AND cariogenic AND mouthwashes) OR TITLE-ABS-KEY(‘‘orthodontic appliances’’ AND mouthwahes AND biofilm) OR TITLE-ABS-KEY(‘‘orthodontic appliances’’ AND (‘‘dental prophylaxis’’ OR ‘‘oral hygiene’’)))

Web of Science

Topic = (mouthwashes AND orthodontic appliances) OR Topic = (orthodontic appliances AND (cariogenic OR dental plaque) AND (oral hygiene OR dental prophylaxis)) OR Topic = (mouthwashes AND orthodontic appliances AND (oral hygiene OR cariogenic OR biofilm))

Embase

‘Mouthwashes’/exp OR mouthwashes AND (‘orthodontic’/exp OR orthodontic) AND appliances OR (‘mouthwash’/ exp OR mouthwash AND (dental AND plaque OR cariogenic)) OR (‘orthodontic’/exp OR orthodontic AND appliance AND (biofilm AND (‘prophylaxis’/exp OR prophylaxis) OR ‘oral’/exp OR oral) AND (‘hygiene’/exp OR hygiene)) OR (appliance AND (dental AND plaque OR cariogenic) AND (‘mouthwashes’/exp OR mouthwashes) AND (‘orthodontic’/exp OR orthodontic) AND appliances AND remineralization)

Medline Complete (EBSCO)

TX (mouthwashes AND orthodontic appliances) OR TX (orthodontic appliances AND (dental plaque OR cariogenic)) OR TX (mouthwashes AND orthdontic appliances AND remineralization) OR TX (orthodontic appliances AND biofilm AND (dental prophylaxis OR oral hygiene)))

Cochrane

Mouthwashes AND orthodontic appliances or mouthwashes AND orthodontic appliances AND (dental plaque OR cariogenic) or orthodontic appliances AND biofilm AND (dental prophylaxis or oral hygiene)

Controlled-Trials

Mouthwashes AND orthodontic appliances

OpenGrey

Mouthwashes AND orthodontic appliances

when suitably filled out, otherwise no point was awarded. With regard to the description of the population, when the 3 items, age, sex and condition of the patient were mentioned, the criterion was considered completely fulfilled, and the

Table 2 – Protocol for qualitative score of methodology (maximum score, 13 pointsb). 1. Characterization of study (9) A. Adequate description of population (2) Items analyzed: age sex and condition of the patient: 2 points when all items were satisfied; 1 point when two items were satisfied; 0 point when one or no item was satisfied. B. Description of selection criteria (1)a C. Sample size (2) Item analyzed: number of participants: 2 points when there were 25 or more participants; 1 point when there were between 20 and 25 participants; 0 point when there were less than 20 participants. D. Comparison with control group (1)a E. Randomization declared (1)a F. Description of adequate use of mouth wash (1)a G. Description of mouth wash (1)a 2. Measurements of study (2) H. Methodology appropriate for objective of article (1)a I. Blinding of examiners and statistics (1)a 3. Statistical analysis (2) J. Statistical Test Suited to Data (1)a K. Presentation of p-value (1)a a Items B, D, E, F, G, H, I, J, K: 1 point when was satisfied; 0 point when was not satisfied. b High quality: 11–13 points, moderate quality from 6 to 10 points, low quality below 6 points.

maximum score was awarded (2 points), when only 2 were mentioned, half the score was awarded (partially fulfilled), and when only one or none of them were fulfilled, no score was awarded. As regards the amplitude of the sample, this was scored according to the number of participants, both in the control and group under treatment. Therefore, when there was a number over 25 the maximum score was awarded (1 point). Whereas for a number between 20 and 25 half the maximum score was awarded. No point was given for values lower than 20 participants, because it was considered that samples smaller than 20 are less relevant. A number of 25 individuals was established, based on the sample calculation made by Chen et al.14 According to these authors, 25 individual would be the minimum number required for conducting this type of study. Both the criteria for evaluation of the study measurements and the statistical analysis criteria were scored with a maximum score (1 point) if they were adequately fulfilled, and no point was awarded if the criterion was not fulfilled. The score ranged from 0 to 13, and the methodological quality of the studies was classified as high when the score ranged from 11 to 13, moderate from 6 to 10 and low when the score was lower than 6.

3.

Results

The search in the databases led to 2716 articles being found. By the titles and abstracts, the articles not related to the topic of this systematic review were excluded. Thus, 62 articles were selected. Duplicated articles were removed, so that 15 articles remained to be read in full, as they fulfilled the inclusion criteria. The flow chart (Fig. 1) illustrates the search results.

300

3.1.

journal of dentistry 43 (2015) 297–308

Quality assessment

Table 3 illustrates the classification of the articles analyzed and their scores. Of the 15 articles included, eleven were qualified as high methodological quality,13,26 while four as moderate methodological quality.3,23–26 Only Ogaard et al.22 did not make comparisons between the test and control groups (item D). Only the study of Dogan et al.23 did not receive any score in item E, because it was not a randomized study. Where the adequate description of the use of mouthwash was concerned (item F) only the study of Ousehal et al.3 received no score. With regard to description of the mouthwash, only Hannah et al.15 and Tufekci et al.21

obtained no score. In five the statistical examiners were not blinded, therefore they received no score.3,16,19,23,25 While 2 articles did not present statistical tests suited to the data,24,26 all presented the significance of the statistical analysis.

3.2.

Sample size

As regards sample size, 3 articles received score 0,23–25 i.e., they had fewer than 20 participants in their sample, 1 study15 had a sample size between 20 and 25 participants (score 1), while 11 articles2,13,14,16–22,26 had a sample consisting of over 25 participants (score 2).

Fig. 1 – Flow chart – results of searches.

301

journal of dentistry 43 (2015) 297–308

Table 3 – Protocol for qualitative scoring of methodology of articles analyzed. Author

A

B

C

D

E

F

G

H

I

J

K

Total

Pahwa, Kumar and Gupta (2011) Gehlen et al. (2000) Nelson-Filho et al. (2012) Ogaard et al. (1988) Ogaard et al. (2006) Hannah, Johnson and Kuftinec (1989) Anderson et al. (1997) Madle´naet al. (2012) Tufekci et al. (2008) Ousehalet al. (2011) Nelson-Filho et al. (2011a) Dogan et al. (2009) Chen et al. (2012) Gehlen et al. (2000) Nelson-Filho et al. (2011b)

2

1

2

1

1

1

1

1

1

1

1

13

High

1 1 1 1 2

1 1 1 1 1

0 2 2 2 1

1 1 1 0 1

1 1 1 1 1

1 1 1 1 1

1 1 1 1 0

1 1 1 1 1

0 1 1 1 1

1 1 0 1 1

1 1 1 1 1

9 12 11 11 11

Moderate High High High High

2 2 2 2 2 2 2 1 2

1 1 1 1 1 1 1 1 1

2 2 2 2 2 0 2 0 2

1 1 1 1 1 1 1 1 1

1 1 1 1 1 0 1 1 1

1 1 1 0 1 1 1 1 1

1 1 0 0 1 1 1 1 1

1 1 1 1 1 1 1 1 1

1 0 1 0 1 0 1 1 0

1 1 1 1 1 1 1 0 1

1 1 1 1 1 1 1 1 1

13 12 12 10 13 9 13 9 12

High High High Moderate High Moderate High Moderate High

3.3.

Types of mouthwash

With regard to the type of mouthwash used as treatment to reduce bacteriogenic plaque, 8 articles used chlorhexidinebased mouthwashes,3,13,17–19,23–25 2 prescribed Amf/SnF2,16,22 1 made use of octenidine,23 1 of Cetylpyridinium,20 1 sodium fluoride,26 2 used Listerine (essential oil),14,21 and Hannah et al. used sanguinaria.

3.4.

Quantity of mouthwash

For the quantity of mouthwash product used to perform each mouthwash, the measurements of 10 ml,16,24,25 15 ml,13,15 and 20 ml14,19,21 were related. The prescriptions described by the articles were 3 times a day,15 1 time at night,22,26 1 time a day,23 2 times at night and day,16,21,21 2 times a week.17–19 Ousehal et al.3 did not inform the prescription used in their study. An abstract about the description of the studies included and evaluated, explaining the characteristics of the participants – sample, age and condition – and the intervention of the treatment used – composition of the mouthwash, prescription and total time – is presented in Table 4. On the subject of oral hygiene technique, only three authors mentioned using the Bass technique or a modification of it,13,15,16 while 7 authors mentioned having given their patients oral hygiene instructions,14,18,19,21,23–26 without giving details about them, and only mentioned the frequency of performing the hygiene protocol.14,17–19,21–25 As far as the type of dentifrice was concerned, 3 used a fluoride-containing product (Colgate Ma´xima Protec¸a˜o Antica´ries, ColgatePalmolive Industria e Come´rcio, Sa˜o Paulo, Sa˜o Paulo, Brazil),17–19 while 2 used a paste containing AmF/SnF2 (Meridol),16,22 1 Viadent,15 2 Silicea,24,25 1 Crest Regular Flavour (Procter & Gamble, Cincinnati, Ohio, United States of America),13 and 5 did not mention the paste used.3,14,21,23,26

4.

Discussion

The efficiency of the use of fluoridated substances (gel, varnish, oral mouthwash) associated with fluoridated denti-

Quality

frices in comparison with the use of common dentifrice only by children and adolescents has been verified in a previous systematic review.27 However, a special group of patients deserves investigation and the search for evidence as regards the effectiveness of these auxiliary methods in cariogenic plaque control, namely orthodontic patients. With a view to filling this lack in the literature, the aim of the authors of this systematic review was to seek evidence with respect to the effectiveness of oral mouthwashes in the reduction of cariogenic plaque in patients undergoing therapy with labial fixed orthodontic appliances. In the selected studies, the plaque index measurement was performed in six teeth3,16,20,22 and the entire mouth.14,21,24,25 While some authors used other methods to calculate the plaque index, Hanna et al.,15 for example, analyzed 12 teeth, units 11–16 and 31–36. Ogaard et al.,26,28 after conducting the study period, extracted two premolars of the volunteer for analysis of the tooth enamel structure. Dogan et al.23 used saliva samples to check the mouthwash action against the bacteria. Analysis was performed of bonding an adhesive to 3 premolars,17 and to 2 premolars.17,18 With regard to the statistical test suitable for the data, 13 articles presented statistically significant results, with 8 of these having been qualified as high quality studies13–21 and 5 as having moderate quality.3,22–26 Due to the predominance of studies with populations presenting the age group between 11 and 25 years, the need for studies with populations of older age groups is perceived, considering that Boyd et al., based on their results, affirmed that adolescents are not as efficient in removing cariogenic plaque as adults, so that they accumulate more plaque, thus showing a higher plaque index than adults from the 9th to the 18th month of treatment ( p < 0.05). This concern is pertinent by virtue of the progressive increase in adult patients in the dental offices during the last few years.27

5.

Comparison with control group

Articles that had a control group using basic oral hygiene without the use of mouthwash and an experimental group using of some type of mouthwash revealed that the reduction in cariogenic plaque was higher in the test than in the control

302

journal of dentistry 43 (2015) 297–308

Table 4 – Description of studies included. Participants Author

Total

Intervention

Age (mean)

Condition

Composition of mouthwash, prescription and total time of treatment

Pahwa, Kumar and Gupta (2011)

TOTAL: 45 (25F/20M) CONTROL GROUP: Placebo. TEST GROUP 1: Cetylpyridinium. TEST GROUP 2: Tooth brushing.

11–25 years, mean 14.8

Complete initial levelling and alignment. Patient under fixed orthodontic treatment with supports on anterior teeth and bands on molars.

Prescription: 10 ml of mouthwash for 60 s used 30 min after breakfast and before going to sleep. Test mouthwash: Cetylpyridinium. Treatment: 1 month.

Gehlen et al. (2000)

TOTAL: 12 (8F/4M) CONTROL GROUP (7): Odol-med-3. TEST GROUP (5): Chlorhexidine.

Mean 14.1 years

Not mentioned.

Prescription: 10 ml of mouthwash twice a day (morning and night). Placebo mouthwash: CON, basic source of fluoride: Odol-med-31. Test mouthwash: 0.2% Chlorhexidine. Treatment: – Preliminary Phase: 2 weeks; – Test Phase A: 48 h; – Period of 5 days without use; – Test Phase B: 48 h; – Total: 23 days.

Nelson-Filho et al. (2012)

TOTAL: 35 CONTROL GROUP (18): Placebo mouthwash (58.8% F and 41.2% M). TEST GROUP (17): Use of chlorhexidine (44.5% F & 55.5% M).

14–22 years

Had good general health and had no antibiotics or oral antimicrobial antiseptics within 3 months before the study.

Prescription: 10 ml of test solution for 30 s, two times per week (Tuesdays and Fridays). Test mouthwash: 0.12% Chlorhexidine. Treatment: 30 days.

Orgaard et al. (1988)

TOTAL: 29 I: Effect on development of lesions: CONTROL GROUP (5): without use of F. TEST GROUP (5): 0.2% NaF solution. TEST GROUP 2 (4): Fluoride application. II. Effect on established lesions (10). III. Effect of debanding on established lesions (5).

11–14 years

Premolars must be removed as part of orthodontic treatment.

Prescription: Perform mouthwash using solution for 1 min every night after tooth brushing. Test mouthwash: 0.2% sodium fluoride (NaF) solution. Treatment: 4 weeks.

Orgaard et al. (2006)

TOTAL: 97 (62F/35M) TEST GROUP 1 (50): AmF/SnF2 (33 F and 17M). TEST GROUP 2 (47): NaF (29 F and 18M)

11–14 years

–

Prescription: Perform mouthwash every night after tooth brushing. Test mouthwash: A solution containing AmF/SnF2 (250 ppm of F, pH 4.0), throughout the entire treatment period.

Hannah, Johnson and Kuftinec (1989)

TOTAL: 24 (12F/12M) CONTROL GROUP: Use of toothpaste and oral mouthwash with placebo. TEST GROUP: Use of toothpaste and oral mouthwash with sanguinaria.

13.2–14.1 years

Be healthy. Without oral or systemic diseases, had no periodontal pockets deeper than 5 mm, and had not been on an antibiotic therapy regime for at least 3 months before study began. Individuals were prepared to use only mouth washing tooth paste and tooth brush provided by the investigator and agreed to follow the oral hygiene programme prescribed by the investigator.

Prescription: 15 ml of oral mouthwash for 30 s after brushing, three times a day. Test mouthwash: Mouthwash containing sanguinaria. Treatment: 8 months.

303

journal of dentistry 43 (2015) 297–308

Table 4 (Continued ) Participants Author

Total

Age (mean)

Intervention Condition

Composition of mouthwash, prescription and total time of treatment

Anderson et al. (1997)

TOTAL: 30 CONTROL GROUP: Placebo mouthwash TEST GROUP: Chlorhexidine

11–15 years

Under orthodontic treatment without systematic complications or use of medications that could interfere in oral tissues, present band on at least one molar per quadrant.

Prescription: 15 ml of mouthwash for 30 s, twice a day, after breakfast and before going to sleep. Test mouthwash: 0.2% chlorhexidine gluconate (Peridex, Proctor and Gamble). Treatment: 3 months.

Madle´na et al. (2012)

TOTAL: 40 (26F/14M) CONTROL GROUP (20): Use of dentifrice only. TEST GROUP (20): Brushing with dentifrice based on AmF/SnF2 and mouth washing with AmF/SnF2.

20.1  5.7 years

New orthodontic patients requiring therapy with fixed appliance, without use of antibiotics, immunosuppressants or other drugs in the previous 6 months, healthy oral or gingival flora, non-smokers.

Prescription: Brushing with dentifrice and mouthwash with 10 ml of mouthwash for 30 s. Test mouthwash: AmF/SnF2-based mouthwash (Meridol1). Treatment: 4 weeks.

Tufeckci et al. (2008)

TOTAL: 50 CONTROL GROUP (25): Brushing and use of dental floss; TEST GROUP (25): Brushing and use of dental floss and mouthwash.

16.6 years

Under orthodontic treatment without significant dental or medical history in the first 6 months.

Prescription: Mouthwash with 20 ml for 30 s 2 times a day, in addition to basic oral health care. Test mouthwash: Listerine Cool Mint1. Treatment: Evaluation in 3rd & 6th month of treatment.

Ousehal et al. (2011)

TOTAL: 84 (21M/65F) CONTROL GROUP (28): Brushing with manual brush. TEST GROUP 1 (28): Brushing with electric brush. TEST GROUP 2 (28): Manual brushing and use of mouthwash.

24% < 15 years 76% > 15 years

Use of multibracket orthodontic appliance in both arches, good general health and free of periodontal diseases.

Prescription: Not mentioned. Test mouthwash: Kin1 with 0.12% chlorhexidine without alcohol. Treatment: 1 month.

Nelson-Filho et al. (2011a)

TOTAL: 33 CONTROL GROUP (17): Use of placebo mouthwash. TEST GROUP (16): Use of antimicrobial mouthwash.

11–33 years

Both sexes, using fixed orthodontic appliance for at least 16 months. Present good general health and had not used antibiotic or antimicrobial mouthwashes within 3 months before the study.

Prescription: 10 ml of mouthwash for 30 s, twice a week. Test mouthwash: 0.12% chlorhexidine gluconate (Periogard, Colgate-Palmolive). Treatment: 30 days.

Dogan et al. (2009)

TOTAL: 18 (5M/13F)

12–16 years

Under orthodontic treatment, with good oral health, without receiving antibiotics or topical antiseptics in the previous 30 days, or present systemic disease that could alter the plaque or saliva composition.

Prescription: 15 ml of mouthwash for 30 s, once a day, during the morning. Test mouthwash: – Octenidine dihydrochloride; – 0.2% Chlorhexidine gluconate; – 7.5% complex polyvinylpyrrolidone-iodine. Treatment: 5 days for each mouthwash with interval of two weeks between each of them.

304

journal of dentistry 43 (2015) 297–308

Table 4 (Continued ) Participants Author

Total

Intervention

Age (mean)

Condition

Composition of mouthwash, prescription and total time of treatment

Chen et al. (2012)

TOTAL: 90 (47F/43M) CONTROL GROUP (30): Brushing and use of dental floss. TEST GROUP 1 (30): Use of essential oil-based mouthwash. TEST GROUP 2 (30): Use of two types of mouthwashes (A & B).

17.7  3.9 years

In use of fixed orthodontic appliance, over 13 years of age, non-smokers, healthy, preexistent gingivitis and without evidence of periodontitis.

Prescription: 20 ml of mouthwash for 30 s, twice a day. Test mouthwashes: Test 1: Listerine1 Tartar Control; Test 2: – Solution A: 5% umbuzeiro fruit extract; – Solution B: 2% sodium bicarbonate (perform mouthwash with solution A and afterwards with solution B). Treatment: 6 months.

Gehlen et al. (2000)

TOTAL: 12 (8F/4M) CONTROL GROUP (7): Placebo mouthwash. TEST GROUP (5): use of chlorhexidine.

11–13 years

Right-handed, without periodontal pathologies, fixed orthodontic appliance (archwire 016 in.) in maxillary arch in the last 6 months, and with elastic ligatures.

Prescription: 10 ml of mouthwash twice a day (morning and night). Placebo mouthwash: CON, basic source of fluoride: Odol-med-31. Test mouthwash: 0.2% Chlorhexidine Treatment: – Preliminary Phase: 2 weeks; – Test Phases A: 48 h; – Period of 5 days without use; – Test Phase B: 48 h; – Total: 23 days.

Nelson-Filho et al. (2011b)

TOTAL: 39 CONTROL GROUP (20): Placebo mouthwash. TEST GROUP (19): Chlorhexidine.

11–13 years

Both genders, caries-free, with complete dentition and undergoing orthodontic treatment with fixed appliance.

Prescription: 10 ml of mouthwash for 30 s, twice a week. Active mouthwash: 0.12% Chlorhexidine gluconate (Periogard1). Treatment: 30 days.

group.3,14,16,20,21,26 Ogaard et al. affirmed that with the use of mouthwashes, carious lesion development was retarded rather than inhibited, therefore the mouthwash acts only as a bacteriostatic agent. Whereas Pahwa et al.20 affirmed that the use of an oral mouthwash associated with mechanical cleaning resulted in a more effective reduction in cariogenic plaque than mechanical control alone. The results described by these authors reinforce the important participation of mouthwashes in bacterial control. Articles in which the control group was composed of subjects using placebo mouthwash, compared with those using mouthwashes containing active substances, revealed that the mouthwashes with active substances provided greater antimicrobial activity, consequently greater reduction in cariogenic plaque.13,17–19,24,25 Moreover, articles that made comparisons between two or more types of mouthwashes revealed differences in the results, demonstrating that different prescriptions and active principles have an influence on the final result of reduction in cariogenic plaque.14,15,22,23 Some studies have demonstrated that the participation in scientific studies could change the participants’ behaviour, and could lead to false-positive results; that is, the participants may feel motivated to perform a more satisfactory oral hygiene with a view to obtaining good results.29 However, in

no study included in this systematic review was anything mentioned about this problem.

6. Description of mouthwashes and prescription With regard to the effectiveness of the type of mouthwash, the majority of the authors affirmed that those based on chlorhexidine are effective in combatting the proliferation of plaque.13,17–19,24,25 Anderson et al. pointed out that the effectiveness was greater after 90 days of use. However, Nelson-Filho et al.17 found results that were not statistically significant ( p = 0.66) as regards the plaque index, in spite of having verified greater effectiveness of the mouthwash with active principle than the placebo. The results found by Nelson-Filho et al.17 could have been different if the evaluation had been made for period of 3 months, a period in which the mouthwashes demonstrated greater effectiveness in bacterial plaque reduction. With regard to these articles, Table 5 explains the methods of measurement, results followed by p-value and conclusion of the authors. Among the results presented by the studies with high methodological quality, the study of Tufekci et al.21 is

305

journal of dentistry 43 (2015) 297–308

Table 5 – Methods of measurement, results and authors’ conclusions. Author

Method of measurement

Result

Authors’ conclusions

Pahwa, Kumar and Gupta (2011)

Plaque index (Pl)

Mean alteration plaque index scores at end of one month: Control Group: 0.02286 Group with CHX: 0.214

The 0.07% Cetylpyridinium mouthwash was verified to be effective in reducing plaque index scores.

Gehlen et al. (2000)

PI

Preliminary Phase: PI = 1.3 ( p = 0.042 for control and 0.021 for test group) Phase T0 Control: PI = 0.9 Chlorhexidine: PI = 1.0 ( p = 0.032) Phase T1: Control: PI = 1.02 Chlorhexidine: PI = 0.44 ( p < 0.001) Phase T2: Control: PI = 2.27 Chlorhexidine: PI = 1.0 ( p < 0.001)

Washing with a 0.2% chlorhexidine solution significantly reduced the clinical plaque indices, plaque re-growth and microbial vitality in orthodontic patients.

Nelson-Filho et al. (2012)

PI

The experimental group had less dental plaque accumulation in comparison with the control group ( p = 0.0006)

The levels of A. actinomycetemcomitans were significantly lower in individuals who performed washing two times per week with a 0.12% chlorhexidine solution for 30 days.

Ogaard et al. (1988)

Microdensitometric technique

The difference between the values with the use of the mouthwash and the control group was statistically significant at the level p = 0.05 (t-test).

The use of the neutral mouthwash 0.2% NaF solution significantly retarded the development of lesion.

Ogaard et al. (2006)

Visible plaque index (VPI)

Statistically significant in VPI was found before bonding and on debonding for maxillary anterior teeth in the NaF Group. On bonding: p = 0.2, on debonding p between 0.2 and 0.25.

There was significantly less visible plaque on maxillary anterior teeth after using the 2 products AmF/SnF2.

Hannah, Johnson and Kuftinec (1989)

PI

In the active group there were 57% reductions in plaque. Differences between the active and placebo groups were statistically significant in favour of the active group for plaque ( p < 0.01)

The results were both statistically and clinically significant. The result suggested that the use of the sanguinaria mouthwash could greatly improve the oral hygiene and health of tissues in orthodontic subjects during a period of 6 months.

Anderson et al. (1997)

PI

After 3 months, there was a difference ( p > 0.05) between the plaque index values on the distal, mesial and tongue surfaces. A higher value was observed in the placebo group.

The results indicated that the use of chlorhexidine mouthwashes could be beneficial to orthodontic patients in maintaining better oral hygiene.

Madle´na et al. (2012)

PI

Beginning: PI = 1.27  0.52 4 weeks: PI = 1.32  0.42 ( p = 0.00)

The use of the AmF/SnF2–based mouthwash brought beneficial clinical effects as regards plaque accumulation during orthodontic therapy.

Tufekci et al. (2008)

PI

After 3 months Control: PI = 1.6 Listerine: PI < 1 After 6 months Control: PI > 2 Listerine: PI = 1 ( p < 0.001)

Daily use of Listerine in the oral hygiene regime was efficient in control of cariogenic biofilm.

306

journal of dentistry 43 (2015) 297–308

Table 5 (Continued ) Author

Method of measurement

Result

Authors’ conclusions

Ousehal et al. (2011)

PI

Reduction of 0.39 in PI ( p = 0 < 0.05)

Use of CHX- based oral mouthwash was efficient, however precautions must be taken as regards prolonged use.

Nelson-Filho et al. (2011a)

PI

Control: PI = 1.8 (0.9–2.1) Test: PI = 1.4 (1.0–2.0) ( p = 0.66)

Use of 0.12% Chlorhexidinegluconate-based mouthwashes was efficient in the reduction of pathogenic microorganisms in patients with fixed orthodontic appliances.

Dogan et al. (2009)

PI, Mitis Salivarius agar and Rogosa agar

OCT: PI = 0.07 (0–1.05) CHX: PI = 0.02 (0–0.75) PVP-I: PI = 0.02 (0–0.085) ( p < 0.01)

The use of OCT, for 5 days of use, was shown to be the most effective mouthwash with significant reduction in cariogenic bacteria.

Chen et al. (2012)

PI

EOM T1: PI = 1.61  0.45 T2: PI = 1.70  0.45 T3: PI = 1.69  0.50 FMM T1: PI = 1.66  0.47 T2: PI = 1.91  0.50 T3: PI = 1.66  0.40 NC T1: PI = 1.78  0.39 T2: PI = 1.87  0.48 T3: PI = 1.83  0.50 ( p > 0.05)

The use of both the mouthwash containing essential oil (EOM) and that based on the umbuzeiro fruit extract presented no significant alterations in the microbiological profile of the orthodontic patient.

Gehlen et al. (2000)

PI and Vital fluorescence

Preliminary Phase: PI = 1.3 ( p = 0.042 for control and 0.021 for test group) Phase T0 Control: PI = 0.9 Chlorhexidine: PI = 1.0 ( p = 0.032) Phase T1: Control: PI = 1.02 Chlorhexidine: PI = 0.44 ( p < 0.001) Phase T2: Control: PI = 2.27 Chlorhexidine: PI = 1.0 ( p < 0.001)

The return of cariogenic plaque was significantly reduced by the use of the 0.2% chlorhexidine mouthwash.

Nelson-Filho et al. (2011b)

PI and checkerboard DNA–DNA hybridization

The use of the mouthwash with chlorhexidine was shown to be more efficient than that of the control in the reduction of S. mutans.

S. mutans, S. sobrinus, L. casei and L. cidophilus were detected in metal bracket samples, with higher level of S. mutans and S. sobrinus, with the use of CHX significantly reducing the indices of S. mutans.

outstanding. This study confirms the efficacy of Listerine in the control of cariogenic plaque, by maintaining the plaque index (PI) around 1, whereas in the group cleaning with brushing and using dental floss, the plaque index showed an increase from 1.6 to PI > 2 ( p < 0.001). In their study, NelsonFilho affirmed that the use of 0.12% chlorhexidine gluconate for 30 s twice a day significantly reduced the level of Streptococcus mutans ( p = 0.03). The use of mouthwash with cetylpyridinium chloride twice a day for a month was shown to be effective in reducing the plaque when associated with basic oral hygiene in patients undergoing orthodontic treatment with fixed appliances, and also improved the periodontal health of these patients.9 When referring to the use of mouthwashes with essential oil

(Listerine1), Tufekci et al.21 affirmed that this was more efficient for plaque reduction than the method used in the control group (brush and floss); while Chen et al.14 affirmed that the results obtained did not differ from those obtained in the control group. As far as the oral mouthwash composed of NaF is concerned, according to Ogaard et al.,26 its efficiency can be affirmed. According to the above-mentioned authors, the use of the mouthwash with NaF retards caries development, however, the process is not completely inhibited. Moreover, some authors16,22 have found the use of AmF/ SnF2 to be efficient in cariogenic plaque reduction. Therefore, it may be inferred that this systematic review is of importance to clinical practice, because it points out the effectiveness of mouthwashes in reducing cariogenic plaque

journal of dentistry 43 (2015) 297–308

in orthodontic patients after their use for the period of 3 months. This allows orthodontists to indicate the use of these substances to patients as coadjuvent means of performing daily oral hygiene, with the goal of reducing cariogenic plaque, since this type of chemical control has also been shown to be effective when associated with other clinical practices.

7.

Conclusion

By conducting this systematic review, it could be inferred that:  There is some evidence showing that the use of oral mouthwashes reduces cariogenic plaque in patients with fixed orthodontic appliances.  The prescription most indicated for this situation is the use of the mouthwash twice a day, once before going to sleep and once in the morning, with quantities of mouthwash varying between 10 and 20 ml.  According to the data set out, it was observed that the use of mouthwashes based on chlorhexidine, octenidine, essential oil (Listerine1), Cetylpyridinium, NaF, and AmF/SnF2 were shown to be effective in the reduction of cariogenic plaque.  Further controlled and randomized clinical studies, with a longer period of study duration, larger sample size, and better definition of the control and test groups as regards gender of the participants are necessary to increase the strength of the evidence of the effects on the reduction of cariogenic plaque.

Acknowledgement The authors would like to thank National Council of Research (CNPq) for the financial support: Process numbers 302800/ 2012-3, 150919/2014-0 and 446013/2014-5.

references

1. Dills SS, Olshan AM, Goldner S, Brogdon C. Comparison of the antimicrobial capability of an abrasive paste and chemical-soak denture cleaners. Journal of Prosthetic Dentistry 1988;60:467–70. 2. Mota SM, Enoki C, Ito IY, Elias AM, Matsumoto MA. Streptococcus mutans counts in plaque adjacent to orthodontic brackets bonded with resin-modified glass ionomer cement or resin-based composite. Brazilian Oral Research 2008;22:55–60. 3. Ousehal L, Lazrak L, Es-Said R, Hamdoune H, Elquars F, Khadija A. Evaluation of dental plaque control in patients wearing fixed orthodontic appliances: a clinical study. International Orthodontics 2011;9:140–55. 4. Featherstone JD. The caries balance: the basis for caries management by risk assessment. Oral Health & Preventive Dentistry 2004;2(Suppl. 1):259–64. 5. Robinson C. Fluoride and the caries lesion: interactions and mechanism of action. European Archives of Paediatric Dentistry 2009;10:136–40. 6. Wolff MS, Larson C. The cariogenic dental biofilm: good, bad or just something to control? Brazilian Oral Research 2009;23(Suppl. 1):31–8.

307

7. Zachrisson BJ. A posttreatment evaluation of direct bonding in orthodontics. American Journal of Orthodontics 1977;71: 173–89. 8. Brightman LJ, Terezhalmy GT, Greenwell H, Jacobs M, Enlow DH. The effects of a 0.12% chlorhexidine gluconate mouthrinse on orthodontic patients aged 11 through 17 with established gingivitis. American Journal of Orthodontics and Dentofacial Orthopedics 1991;100:324–9. 9. Herrera D, Santos S, Ferrus J, Barbieri G, Trombelli L, Sanz M. Efficacy of a 0.15% benzydamine hydrochloride and 0.05% cetylpyridinium chloride mouth rinse on 4-day de novo plaque formation. Journal of Clinical Periodontology 2005;32:595–603. 10. Torres CRG, Kubo CH, Anido AA, Rodrigues JR. Agentes antimicrobianos e seu potencial de uso na Odontologia. Revista da Faculdade de Odontologia de Sa˜o Jose´ dos Campos 2000;3:43–52. 11. Baratieri C, Alves Jr M, de Souza MM, de Souza Araujo MT, Maia LC. Does rapid maxillary expansion have long-term effects on airway dimensions and breathing? American Journal of Orthodontics and Dentofacial Orthopedics 2011;140:146–56. 12. Lagravere MO, Major PW, Flores-Mir C. Long-term dental arch changes after rapid maxillary expansion treatment: a systematic review. Angle Orthodontist 2005;75:155–61. 13. Anderson GB, Bowden J, Morrison EC, Caffesse RG. Clinical effects of chlorhexidine mouthwashes on patients undergoing orthodontic treatment. American Journal of Orthodontics and Dentofacial Orthopedics 1997;111:606–12. 14. Chen Y, Wong RW, Seneviratne CJ, Hagg U, McGrath C, Samaranayake LP. The effects of natural compoundscontaining mouthrinses on patients with fixed orthodontic appliance treatment: clinical and microbiological outcomes. International Journal of Paediatric Dentistry 2012;23:452–9. 15. Hannah JJ, Johnson JD, Kuftinec MM. Long-term clinical evaluation of toothpaste and oral rinse containing sanguinaria extract in controlling plaque, gingival inflammation, and sulcular bleeding during orthodontic treatment. American Journal of Orthodontics and Dentofacial Orthopedics 1989;96:199–207. 16. Madlena M, Banoczy J, Gotz G, Marton S, Kaan Jr M, Nagy G. Effects of amine and stannous fluorides on plaque accumulation and gingival health in orthodontic patients treated with fixed appliances: a pilot study. Oral Health and Dental Management 2012;11:57–61. 17. Nelson-Filho P, Carpio-Horta KO, Andrucioli MC, Feres M, Bezerra da Silva RA, Garcia Paula-Silva FW, et al. Molecular detection of Aggregatibacter actinomycetemcomitans on metallic brackets by the checkerboard DNA–DNA hybridization technique. American Journal of Orthodontics and Dentofacial Orthopedics 2012;142:481–6. 18. Nelson-Filho P, Olmedo LY, Andrucioli MC, Saraiva Mda C, Matsumoto MA, de Queiroz AM, et al. Use of the checkerboard DNA–DNA hybridisation technique for in vivo detection of cariogenic microorganisms on metallic brackets, with or without use of an antimicrobial agent. Journal of Dentistry 2011;39:513–7. 19. Nelson-Filho P, Valdez RM, Andrucioli MC, Saraiva MC, Feres M, Sorgi CA, et al. Gram-negative periodontal pathogens and bacterial endotoxin in metallic orthodontic brackets with or without an antimicrobial agent: an in-vivo study. American Journal of Orthodontics and Dentofacial Orthopedics 2011;140:e281–7. 20. Pahwa N, Kumar A, Gupta S. Short term clinical effectiveness of a 0.07% cetylpyridinium chloride mouth rinse in patients undergoing fixed orthodontic appliance treatment. Saudi Dental Journal 2011;23:135–41. 21. Tufekci E, Casagrande ZA, Lindauer SJ, Fowler CE, Williams KT. Effectiveness of an essential oil mouthrinse in

308

22.

23.

24.

25.

journal of dentistry 43 (2015) 297–308

improving oral health in orthodontic patients. Angle Orthodontist 2008;78:294–8. Ogaard B, Alm AA, Larsson E, Adolfsson U. A prospective, randomized clinical study on the effects of an amine fluoride/stannous fluoride toothpaste/mouthrinse on plaque, gingivitis and initial caries lesion development in orthodontic patients. European Journal of Orthodontics 2006;28:8–12. Dogan AA, Cetin ES, Hussein E, Adiloglu AK. Microbiological evaluation of octenidine dihydrochloride mouth rinse after 5 days’ use in orthodontic patients. Angle Orthodontist 2009;79:766–72. Gehlen I, Netuschil L, Berg R, Reich E, Katsaros C. The influence of a 0.2% chlorhexidine mouthrinse on plaque regrowth in orthodontic patients. A randomized prospective study. Part I: Clinical parameters. Journal of Orofacial Orthopedics 2000;61:54–62. Gehlen I, Netuschil L, Georg T, Reich E, Berg R, Katsaros C. The influence of a 0.2% chlorhexidine mouthrinse on plaque

26.

27.

28.

29.

regrowth in orthodontic patients. A randomized prospective study. Part II: Bacteriological parameters. Journal of Orofacial Orthopedics 2000;61:138–48. Ogaard B, Rolla G, Arends J, ten Cate JM. Orthodontic appliances and enamel demineralization. Part 2. Prevention and treatment of lesions. American Journal of Orthodontics and Dentofacial Orthopedics 1988;94:123–8. Bagga DK. Adult orthodontics versus adolescent orthodontics: an overview. Journal of Oral Health & Community Dentistry 2010;4:42–7. Alvarenga P, Palma P, Goncalves AP, Baiao N, Fernandes RM, de Varennes A, et al. Assessment of chemical, biochemical and ecotoxicological aspects in a mine soil amended with sludge of either urban or industrial origin. Chemosphere 2008;72:1774–81. Meyer ACA, Tera TM, Ito CYK, Kerbauy WD, Jardini MAN. Clinical and microbiological evaluation of the use of a toothpaste containing chlorhexidine 1%. Revista de Odontologia 2007;36:255–60.