.................... ......................................... FEATURE ARTICLE Doris J. Stiefel, DDS, MS; Edmond L. Truelove, DDS, MSD; Mae M. Chin, RDH, MEd; Lynn S. Mandel, PhD

Efficacy of chlorhexidine swabbing in oral health care for people with severe disabilities Chlorhexldine is effective when used as an oral rinse, but many dlsabled people cannot use such a prote col. A doubie-blind crossover study tested the eMcacy of applying chlorhexidine with a spongeswab, in a sample of 76 severely disabled adults, drawn from diverse rehabilitation settings. Two randomly assigned groups applied 1 0 mL 0.12%chlorhexidlne gluconate (PerldexTM ,Procter & Gamble) or 10mL placebo, using a "ToothetterM (Halbrand) once daily, 5 times per week for 1 0 weeks. All subjects received 1 0 mL 0.05 % NaF, applied simiiarly but separately from the test/placebo agent. Pre and posttrial measures included perceived level of function and oral status, that Is, DMFS, plaque, calculus, pocket depth, and tooth stain. The protocol received high levels of compliance and acceptance. Compared with placebo, swabbing with chlorhexidlne resulted In consistent, and, in part, significant Improvements in plaque, gingivitis, and periodontal pocket depth. Side effects of chiorhexidine, that is, tooth stain and calculus, were relativeiy mlnor. Perceived Improvements in dental health were associated with Improved physical health, appearance, and mouth odor. The results Indicate that chiorhexidine swabbing Is a useful oral disease preventive protocol for persons with disability.

oor oral hygiene, a high prevalence of periodontal disease and unmet restorative needs are characteristicfindings in severely disabled population^.'-^ For persons with disability for whom mechanical plaque removal is difficult, the use of antimicrobial agents, such as chlorhexidine gluconate and topical fluoride, appear particularly suited. Chlorhexidine is effective in dental prevention when used as an oral r i n ~ e .People ~ - ~ with severe disability who are unable to rinse the mouth and follow the usual protocol for use of an antimicrobial agent, however, require alternative application methods that facilitate compliance. This study tested chlorhexidine's efficacy in disabled groups using a sponge-swab to apply the agent. Outcome measures included the biological effectiveness of the procedures in reducing oral disease indicators; client and attendant satisfaction and compliance with the protocol in a variety of rehabilitation settings; and the impact of the oral disease preventive measures on functioning level, self-image, and social acceptability of the subjects.

P

Methods Subjects. A sample of 81 adults with severe physical and mental disabilities consented to complete the first of two clinical trials. Of this group, 76 persons participated for the entire 26-week period of the project. Table l presents a profile of the subjects who completed the study. The majority of participants (54%)had developmental disabilities, a large subgroup (42%)had acquired neuromuscular disorders and head injury, and three individuals (4%)had disabilities of different types. The

mean age of the subjects was 40.8 years. Participants were drawn from a variety of rehabilitation settings including independent living, group homes, long-term care facilities, and supported employment. Clinical protocol. The study followed a double-blind cross-over design. Two clinical trials of 10 weeks each were separated by a 6-week wash-out period. Subjects were randomly assigned to Group A (n = 37) test protocol, or Group B (n = 39) control protocol for Trial I. They were switched to the converse protocol for Trial 11; that is, Group A subjects received the placebo, and Group B subjects received the active agent. Subjects did not have a dental prophylaxis for 1 month or longer, Table 1.Profile of subjects.

Variable

Gender Male Female Primary disability Mental retardation Cerebral palsy Head injury Neuromuscular Psychiatric Sensory Other Rehabilitation settings Independent living Group homes Long-term care Supported employment

No. of subjects 46 30 19

21 21 11

2 7

1

17 8

46 5

Mean age: 40.8years; SD = 14.5.

Special Care in Dentistry, Voi l 2 No 2 1992 57

before the study or any time during the study, with the exception of three persons who had stain removed at the end of Trial I. Test subjects received 10 milliliters of 0.12%chlorhexidine (PeridexTM, Procter & Gamble) 1 time per day (5 times per week) for 10 weeks. Control subjects received 10 mL placebo according to the same schedule. All subjects, test and control, also received 10 mL 0.05% sodium fluoride (NaF) applied similarly at a separate time of day from the test or placebo agent, as an added preventive measure, and to standardize subjects with respect to topical fluoride use. Agents were dispensed in metered amounts, and were applied to the teeth with a spongeswab (ToothetteTM, Halbrand, Inc.). The procedure was done according to one of the following modes: by the subject independently (care level I) by the subject under supervision of a caregiver (care level 11) by a caregiver/nurse (care level 111) In all cases, compliance was monitored by a check-off form, completed by subjects and caregivers.

Assessments Dental, periodontal, and oral hygiene indices. Standard indices following the protocol of a National Institute of Dental Research National Survey of Adult Dental Health, and modified as previously reported, were used to determine decayed, missing, and filled surfaces (DMFS),calculus, gingivitis, periodontal pocket depth, and plaque le~els.~JO In addition, chlorhexidine staining of the teeth was assessed for the quadrants examined, using a scale of 0-3 to measure area of stain (0 = absent, 1 = 1/3 of surface, 2 = 2/3 of surface, 3 = > 2/3 of surface). Each subject received a total of four assessments: before and after Trial I, and before and after Trial 11. However, DMFS was only determined twice, at the beginning and end of the 26-week study. Attitudinal measures. Subjects and caregivers also completed a series of questionnaires and evaluations to determine their perceived level of dental health, general physical health, emo-

58 Special Care in Dentistry, V o l l 2 No 2 1992

tional condition, appearance, attitude toward dental health, quality of life, and the effects of their dental health on their ability to function. Assessment instruments included Likert-type scales, verbal ratings, and simplified drawings to portray emotions, adapted from “Dartmouth COOP Project Function Charts.”” Questionnaires were pilot tested on a sample of disabled individuals. Attitudinal evaluations were obtained before and after each of the clinical trials. At the end of each trial, the reaction by subjects and caregivers to use of the preventive agents was determined. Examiners. Examinations were conducted by a team of examiners. Two dentists (TIand ’ LL) measured DMFS; a dental hygienist (MC) performed oral hygiene and periodontal assessments, and a dentist (LL) and a dental hygientist (MC) administered the attitudinal surveys. The examiners were trained in the assessment protocol, and were calibrated until consistent before each clinical trial. Statisticalanalysis.Paired t-tests and Wilcoxon matched-pairs signedranked tests were used to compare baseline and post-trial observations for interval and ordinal data respectively. For independent samples (for example, placebo vs active agent), group t-tests were used with interval data and Mann-Whitney U was performed with ordinal data. For comparison of three groups, one-way analysis of variance (ANOVA)was used with interval data, and Kruskal-Wallis with ordinal data. Analysis of covariance (ANCOVA) was used to compare post-trial results for active agent vs placebo, taking into account baseline levels. Chi-square with Yates’ correction was used with nominal data.

Results Use of the preventive agent, 0.12% chlorhexidine (Peridex,Procter & Gamble) consistently improved oral health measures. Clinical measures The results are presented in Tables 2-4. Plaque. Both groups started with

very similar plaque levels at baseline. At the end of Trial I a significant decline in total plaque score ( p < .001) was noted for Group A (chlorhexidine), whereas plaque levels for Group B (placebo) tended to increase. By the end of the washout period of 6 weeks, plaque levels for Group A had returned almost to baseline values. Clinical Trial I1 showed a similar significant decrease in plaque for Group B, now using chlorhexidine ( p = .003),and no change for Group A, now on placebo. At the end of Trial I the plaque score for those using chlorhexidine was significantly lower than for those using placebo, (ANCOVA, p < .001). For Trial 11, intergroup differences in plaque score did not reach statistical significance. Gingivitis. In both Trials I and 11, gingivitis scores showed a similar improvement trend for the group using chlorhexidine, whereas gingivitis scores for those using placebo tended to increase. In Trial 11, pretrial vs posttrial differences in gingivitis scores were significant for those using chlorhexidine (p = .045).The difference between the groups with respect to the number of severely affected sites (rating 2 2) was statistically significant at the completion of Trial I (ANCOVA,p = .016). In general, gingivitis levels in Trial I1 tended to be higher than in Trial I. CaZculus. Calculus scores showed a similar increase with time for both groups. In Trial I, the increase in calculus score for subjects using chlorhexidine was statistically significant compared with baseline ( p = .03); these subjects also developed a significantly greater number of severely affected sites (rating 2 2). The difference between groups at post-Trial I, however, was not significant for either calculus score or number of severely involved sites. Calculus levels showed no significant changes in Trial 11. Periodontal pockets. Chlorhexidine use improved periodontal pocket depth, whereas the placebo use had no effect. Although statistically significant in Trial 11, both within and between groups ( p = .001 and p = .010, respectively), the magnitude of the change was actually very small, (mean of 0.26 millimeters). Moreover, the measures

Table 2. Clinical findings for Trial I: oral hygiene and periodontal disease.

Pre-Trial I Mean S D

Post-Trial I Mean S D

Pre-/Postp value

-

ANCOVA p value

Plaque score chlorhexidine

1.16

.72

-68

.60

< .001

placebo

1.19

.57

1.26

.65

.545

< .001

Plaque ## sites 2 2 chlorhexidine

5.39 5.25

2.24 3.45

< ,001

placebo

5.20 4.62

6.65 5.31

,088

< ,001

Gingivitis score chlorhexidine

1.64

.43

1.52

.47

.132

placebo Gingivitis # sites 2 2

1.65

.39

1.77

.42

.062

chlorhexidine

14.76 7.62

13.14 6.64

,157

placebo

15.21 7.49

16.61 7.17

.199

.016

Calculus score chlorhexidine

1.13

.66

1.32

.62

.030

placebo

1.16

.74

1.22

.68

.339

Calculus ## sites = 2 chlorhexidine

7.83 4.69

9.15 4.42

.026

placebo

7.90 5.30

8.27 4.95

,419

.164

Pocket depth (mm) chlorhexidine

2.56

.53

2.48

.43

.075

placebo

2.56

.49

2.52

.42

.455

.462

Stain ## sites chlorhexidine

_

_

3.23 4.60

placebo

_

_

.29 1.08

< .001

~

Group A: Chlorhexidine N = 37; Group B: Placebo N

indicated a reduction in "pseudo" pocket depth, rather than enhanced attachment levels. Tooth stain. In clinical Trials I and 11, stain on one or more teeth after chlorhexidine use was observed in 42% and 45%of subjects respectively. For Group A, at the end of Trial I, a mean of 3.23 sites with stain was noted; this was significantly higher than for Group B, the placebo group (p < .001). In Trial 11, Group B (now using chlorhexidine) also developed stain, but to a lesser degree, with a mean of 1.54 sites. The intergroup difference in stain at the conclusion of Trial I1 was not significant. Staining was mild to moderate in intensity (1.88 and 1.48 for Trials I and I1 respectively on a 3-point scale).Only three subjects requested special teeth cleaning at the end of Trial I, and none

= 39.

after Trial 11.

Dental status-DMFS. Because each 10-week trial was considered too brief a period to assess changes in DMFSI teeth, DMFS determinations were obtained only at baseline, and 26 weeks later, on completion of the study; no intergroup comparisons were made. While the results indicate an upward trend in all three variables, only the F component showed a significant increase (p =.04). Level of care A comparison by care level showed only limited differences (Table 4). Although plaque levels improved with chlorhexidine use for all three groups, the improvement was significant only for Group I, who applied the agent independently, and for Group 111, the most severely disabled, for whom the

agent was applied by a caregiver or nurse. Group 11, who applied the agents under supervision, developed significantlymore calculus compared with baseline and with the group USing placebo, (whereas, the other two groups showed no such increase). There were no differences in gingivitis and periodontal pocket depth between groups; all three modes of chlorhexidine application improved gingivitis and periodontal pocket depth. Overall, a high level of compliance with the protocol was reached, with a median rating of 89.4%of total applications achieved, and a mean of 84.3%. The time required to apply the preventive agent varied with the care level, the caregiver, and the disability of the individual. For subjects at care level 11, self-application under supervision, the mean time per application was 2.4 minutes, with a range of 0.5 to 15 minutes and a median of 2 minutes. For subjects who were severely and profoundly disabled and at care level 111, application by caregiver, the mean time ranged from < 0.5 to 4.1 minutes. Attitudlnal measures

Subjects' response to protocol. The reaction of subjects to the preventive protocol was generally highly favorable (Table 5). The agents' taste was acceptable to most participants, and was rated as good or very good by 44.1% for the active agent and 50% for the placebo; however, 16.9%rated taste of the active agent as bad, in contrast to less than 8.6%who rated the placebo negatively. Taste was the only variable for which a significant difference in reaction was noted between active agent and placebo (p < .05). The application method was considered easy or very easy by about 75%. More than 90% found the time required reasonable, and about 43% of the subjects were able to apply the agents independently. Two-thirds of those using chlorhexidine perceived no problem with teeth staining, and of those reporting a problem, less than 10%considered it a big problem. Gagging was not a serious problem for the majority in either group (74.2% and 79.7%,respectively). When asked whether they would

Special Care in Dentistry, Voi l 2 No 2 1992 59

Table 3. Clinical findings for Trial II: oral hyglene and periodontal dlsease status.

Post-Trial I1 Mean SD

Pre-Trial I1 Mean S D

Pre-/Postp value

ANCOVA p ziafue

Plaque score chlorhexidine

1.20

.62

.83

.60

.003

placebo

1.08

.65

1.08

.63

.688

Plaque # sites t 2 chlorhexidine

5.61 5.49

3.70 4.10

.017

placebo

4.34 4.59

4.62 4.47

.919

chlorhexidine

1.91

.43

1.73

-56

.045

placebo

1.76

.50

1.83

.53

.379 .068 .869

.114

Gingivitis score

Gingivitis # sites t 2 chlorhexidine

19.05 6.85

17.41 6.80

placebo

16.87 6.83

17.07 7.36

.361

Calculus score chlorhexidine

1.30

.68

1.37

.61

,368

placebo

1.40

.70

1.47

.61

.236

9.92 3.96 10.14 4.32

.089 .227

Calculus # sites = 2 chlorhexidine

9.00 4.83

placebo

9.64 4.86

.693

Pocket depth (mm) chlorhexidine

2.59

.62

2.33

.61

.001

placebo

2.55

.46

2.54

.60

.825

_ _

_ _

1.54 2.64

.010

Stain # sites chlorhexidine placebo

1.58 2.64

Group A: Placebo N = 37; Group B: Chlorhexidine N = 39.

Table 4. Effectlvenessof therapy by level of care.

Posi-Trial I1

I11

1.89+

2.83

3.61+

4.23

6.84

4.42

6.82

15.58

18.68

13.82

14.59

17.02

14.38

17.62

18.85

15.98

17.60

I

Pre-Trial I1

111

chlorhexidine

7.01

4.64

5.95

placebo

5.70

5.14

chlorhexidine

17.62

placebo

17.15

Level of Care*

I

Plaque # sites 2 2

Gingivitis # sites t 2

Calculus score

continue to use the preventive protocol if given the opportunity, 86.7%of subjects after chlorhexidine use and 82.5% of subjects after placebo use were either positive about the method or were willing to consider continued use, whereas 13.3%and 17.6%,respectively, responded negatively. Among the positive comments were remarks that the teeth looked or felt cleaner, and that using the agent was good for the teeth . Perception of health and function. Improvements in the preceding 4-week period in dental and physical health were reported by a significantly higher percentage of subjects at the end of Trial I as compared with baseline after chlorhexidine use (46%vs 14%,p = .005; and 29%vs 11%, p = .003, respectively) (Table 6). A similar positive trend was noted by the group using chlorhexidine in the effect of dental health on ability to do daily activities; that is, no subjects reported interference with daily activities as a result of dental problems at the end of Trial I (100% vs 86%). In contrast, the placebo group reported no significant changes. For Trial 11, neither the active nor placebo group perceived changes. Overall, improved dental health was positively correlated with the subjects feeling good about their teeth, and with improvements in appearance, smile, and mouth odor. Those subjects who reported good physical health tended not to have dental problems, to give quality of life a high rating, to report improvement in smile, and no adverse effects from the teeth. At the end of Trial I, caregivers perceived improvements in dental health and smile for those using active agent ( p < .05); an increased number of caregivers also reported feeling better about their patients’ teeth and gums, both for those using active agent ( p < .01) as well as those using placebo ( p < .05). No significant changes were noted in Trial I1 for either active agent or placebo groups.

chlorhexidine

11.97

6.60

9.52

11.42

8.57+ 10.09

placebo

11.40

7.14

9.81

12.10

7.53

10.28

chlorhexidine

2.41

2.53

2.71

2.12

2.38

2.54

Discussion

placebo

2.38

2.55

2.62

2.38

2.50

2.61

The study demonstrated the practical usefulness of applying an antimicrobial agent by means of a swabbing technique as a daily dental hygiene

Pocket depth (mm)

* Level of care: I = independent, N = 11; I1 = supervised, N = 34; 111= caregiver/nurse, N = 30. ANCOVA p < .05 +

60 Special Care In Dentistry, Vol 12 No 2 1992

Table 5. Subjects' reaction to preventive agents.

chlorhexidine, did not appear to be a serious deter% Subjects* rent to use of Peridex as adChlorhexidine Placebo ministered. Rating ( N = 63) ( N = 60) Of primary importance Negative Positive Negative Positive was the biological effectiveness of the protocol in the Taste' 16.9 44.1 8.6** 50.0 prevention of dental disease Ease of use 27.0 73.0 23.3 76.7 in a compromised populaTime 7.9 92.1 10.0 90.0 tion, even without prior Independent use 57.1 42.9 56.7 43.3 dental prophylaxis. The significant reduction achieved Continue to use 13.3 86.7 17.6 82.5 in plaque levels was particularly notable. Corrected for missing values. Neutral reactions omitted from table. ** p < .05. Although improvement in oral health indicators was consistent, the changes were Table 6. Subjects' perception of status. most pronounced in Trial I. A number of factors may acPerceived count for the differences in % Subjects improvement* by Group A: Pre-Trial I Post-Trial I p value' magnitude for Trials I and chlorhexidine 11. The study was of 26 (N = 28) weeks' duration, so by the time of completion, subjects Dental health 14 46 .005 had not had a dental prophylaxis for at least 30 Physical health 11 29 .003 weeks, and in many cases, Daily activities 86 100 .068 considerably longer. The (no difficulties) cross-over design also may have depressed the effecIn previous four-week period. 'Wilcoxon matched-pairs tiveness of the active agent in Trial I1 because subjects measure in people with severe disabili- using active agent in this phase of the study had used placebo before, and ties. This method has advantages over tended to start Trial I1 with higher other possible means of application, plaque and gingivitis scores than those such as toothbrushes, in that the swab is disposable, inexpensive, and a famil- who had used chlorhexidine, and who may still have demonstrated some iar oral hygiene aid in US long-term benefits from the active agent at the care facilities. end of a 6-week wash-out period. FurThe swabbing application method thermore, the chlorhexidine-induced of agents was appropriate for diverse side-effects of stain and increased callevels of care, from independence in culus formation carried over from oral hygiene to complete dependence Trial I may have obscured group difon caregivers. The more limited imferences in Trial 11. provements evidenced by persons with severe disability at Class I1 level Both subjects and caregivers perceived benefits from the preventive underscore the need for close superviprotocol. The relationships noted besion of daily oral hygiene to achieve tween dental health and improveoptimum benefits for persons who ments in appearance, mouth odor, strive for independence at this level of physical health and function, and befunction. tween physical health, absence of denThe positive response to the prototal pain, and quality of life support the col and the fact that cooperation of important role of oral health in the hasubjects and caregivers could be susbilitationlrehabilitation process. tained over a prolonged period indiClearly, oral health is a significant faccate the long-term potential of the tor in optimum health, function, and methods for disabled populations. Teeth stains and poor taste, side effects well-being in the individual with a disability. that are frequently associated with +

On the basis of the findings, swabbing with an antimicrobial agent such as chlorhexidine offers a rational approach to oral disease prevention in persons with severe disabilities. It is anticipated that by combining periodic professional dental prophylaxis with chlorhexidine applications, the therapeutic benefits of the agent can be substantially enhanced. In addition, the feasibility of reducing the frequency of application without loss in clinical effectiveness requires further study. Use of chlorhexidine for 10 weeks produced only minor side effects and was well-accepted by subjects and caregivers. The safety and efficacy of application of this protocol over longer periods of time, however, remain to be determined. Currently, Peridex is a prescription drug, and can be administered to dependent persons in longterm care facilities only by licensed staff, as opposed to nurses' aides, who generally are responsible for daily oral care. To ensure optimum use and cost effectiveness of a protocol involving oral disease, preventive agents such as Peridex, if proven safe and efficacious over time, will require changes in state regulations governing their use in group settings. Alternatively, the therapeutic effects of nonprescription antimicrobial agents to prevent oral disease in disabled groups warrant investigation. Contingent on corroborative findings from further studies, the present protocol supports the establishment of an antimicrobial dental preventive regimen as the standard of care for people with severe disabilities in residential and rehabilitation settings.

Conclusion A swabbing method of applying antimicrobial oral disease preventive agents, with, for example, chlorhexidine and sodium fluoride, was well-accepted by a sample of people with severe disabilities and their caregivers, and fostered independence in daily oral hygiene. When applied in this manner, 0.12% chlorhexidine gluconate was clinically effective. In contrast to placebo, chlorhexidine resulted in consistent, and in part, significant improvements in plaque, gingivitis, and periodontal

Special Care In Dentlstry, Vol 12 No 2 1992 61

pseudo-pocket depth. Side effects of chlorhexidine were relatively minor. Increased calculus formation was noted to a significant degree only in the first part of the study. Staining, although observed, was considered a substantial problem by less than 10% of the sample. Subjects and their caregivers perceived benefits from the protocol in terms of improved dental health, accompanied by improved physical health and appearance. Therapeutic benefits of chlorhexidine were demonstrated and sustained despite unfavorable conditions, that is, in the prolonged absence of dental prophylaxis, and under conditions of poor oral hygiene. It is postulated that with prior and continued dental prophylaxis, clinical effectiveness of swabbing with chlorhexidine would be enhanced. The method, therefore, has great potential for improving the oral health of people with disabilities. This study was supported by Grant #H133C80004 from the National Institute on Disability and Rehabilitation Research (NIDRR), US Department of Education. The informed consent of all participants in this investigation was obtained after the nature of

62 Special Care in Dentistry, V o l l 2 No 2 1992

the procedure and possible discomforts and risks had been fully explained, in accordance with the requirements of the Human Research Review Board, Department of Social and Health Services, State of Washington. The authors thank the clients and staff of the following facilities for their kind cooperation with this study: Center Park Apartments; Greenwood Home; Highline Care Center; Summit Inn,;United Cerebral Palsy Apartments and Residence, Seattle; Rocky Bay Health Care Facility, Gig Harbor; Snohomish Chalet-Delta Rehabilitation, Snohomish; Sumner Lodge, Sumner; and Work Opportunities, Lynnwood. Dr. Stiefel is associate professor, department of oral medicine, and director, Dental Education in Care of the Disabled (DECOD),University of Washington, SC-63, Seattle 98195. Dr. Truelove is associate professor and chair, department of oral medicine, and co-director, DECOD. Ms. Chin is clinical associate, department of oral medicine, University of Washington. Dr. Mandel is research associate, department of medical education, University of Washington. Address requests for reprints to Dr. Stiefel. 1. Thornton JB, Al-Zahid S, Campbell VA, Marchetti A, Bradley EL Jr. Oral hygiene levels and periodontal disease prevalence among residents with mental retardation at various residential settings. Special Care Dentist 9186-90,1989. 2. Minihan I‘M, Dean DH. Meeting the needs for health services of persons with mental retardation living in the community. Am J Public Health 801043-8,1989. 3. Stiefel DJ, Truelove EL, Menard TW, Anderson VK, Doyle PE, Mandel LS. A

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comparison of the oral health of persons with and without chronic mental illness in community settings. Special Care Dentist 106-12,1990. Girgis S. Dental health of persons with severe mentally handicapping conditions. Community Dent Oral Epidemiol13:18102,1985. Strauss R, Hairfield W, George M. Disabled adults in sheltered employment. An assessment of dental needs and costs. Am ] Public Health 75661-3,1985. Banting D, Bosma M, Bollmer B. Clinical effectiveness of a 0.12% chlorhexidine mouthrinse over two years. J Dent Res 68 (special issue):1716-8,1989. Briner W, Buckner R, Rebitski G, Manhart M, Banting D. Effect of two years’ use of 0.12% chlorhexidine on plaque bacteria. J Dent Res 68 (special issue):1719-21,1989. Fardal 0,Turnbull R. A review of the literature on use of chlorhexidine in dentistry. JADA 112:863-9,1986. Gjermo P. Chlorhexidine and related compounds. J Dent Res 68 (special issue):16028, 1989. Oral health of United States adults: the national survey of oral health in U.S. employed adults and seniors, 1985-1986; national findings. NIDR 1987; DHHS, NIH publication no. 87-2868. Nelson EC, Landgraf JM, Hays RD, Kirk JW, Wasson JH, Keller A, Zubkoff M. Dartmouth COOP proposal to develop and demonstrate a system to assess functional health status in physicians’ offices - final report. Department of Community and Family Medicine, Dartmouth Medical School, Hanover, NH, Oct. 1987.

Efficacy of chlorhexidine swabbing in oral health care for people with severe disabilities.

Chlorhexidine is effective when used as an oral rinse, but many disabled people cannot use such a protocol. A double-blind cross-over study tested the...
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