Efficacy of adjunctive anti-plaque chemical agents: a systematic review and network meta-analyses of the Turesky modification of the Quigley and Hein plaque index

Investigation of the inter-rater reliability of three different plaque indices used in patients with fixed orthodontic appliances

BACKGROUND/OBJECTIVES

To analyze the inter-rater reliability of three different plaque indices with regard to raters' orthodontic experience.

MATERIALS/METHODS

The study analyzed 50 photographs of patients with maxillary and mandibular multibracket appliances (MB), captured via Digital Plaque Imaging Analysis (DPIA) for plaque assessment. Three indices - the modified Turesky index (TQH index), Attin index, and modified bonded bracket index (mBB index) were used. Fourteen evaluators with varying orthodontic experience levels (four with limited, five with moderate, and five with extensive experience) assessed the images.

RESULTS

The highest agreement among the evaluators in terms of ICC was obtained using the Attin index and the mBB index. The TQH index yielded the poorest agreement among evaluators. Orthodontic experience had no significant effect on inter-rater reliability. The evaluators with little orthodontic experience scored best in agreement with the Attin index, and the evaluators with much orthodontic experience scored best with the Attin and mBB indices. No difference was observed between the three plaque indices among the evaluators with moderate orthodontic experience.

LIMITATIONS

Consistent classification of subjects into the same oral hygiene category by multiple raters using a plaque index was difficult. Consequently, calibration of raters in practice may lead to a more unanimous classification of patients into the same oral hygiene category. A disadvantage of the classification of plaque values into oral hygiene categories was posed by the category boundaries. These resulted in two plaque indices being less consistent than was the case in reality.

CONCLUSIONS/IMPLICATIONS

We recommend the use of an orthodontic plaque index (Attin index) or a combined dental and orthodontic plaque index (mBB index) in patients with an MB. The TQH index, considered the international standard plaque index, is less appropriate for application in these patients. Training and calibration of evaluators are of great importance when applying conventional plaque indices.

Essential oils mouthwash with or without alcohol in relation to effect on parameters of plaque and gingivitis: A systematic review and meta-analysis

AIM

The primary aim was to systematically assess the available literature on the effect of an essential oils mouthwash without alcohol (EOalc-) compared to an essential oils mouthwash with alcohol (EOalc+) on plaque scores and parameters of gingival health. The secondary aim was to evaluate user appreciation.

MATERIALS AND METHODS

The MEDLINE-PubMed and Cochrane-CENTRAL databases were searched to identify eligible studies published up to and including March 2024. Papers comparing the effectiveness of EOalc- and EOalc+ were included. The quality was assessed. A descriptive analysis and a meta-analysis were performed.

RESULTS

After screening, seven papers were found to be eligible. The descriptive analysis demonstrates a significant difference in plaque scores in favour of EOalc+. This is confirmed by the meta-analyses of plaque scores in non-brushing and brushing studies (DiffM = 0.40; 95% CI [0.27; 0.53], p < 0.00001 and DiffM = 0.05; 95% CI [0.01; 0.10], p = 0.01, respectively). This finding is also supported by the sub-analysis of brands. The meta-analyses of bleeding and gingival scores in brushing studies did not show significant differences between products. For user appreciation, the difference found was for taste perception in favour of EOalc- (DiffM = 1.63; 95% CI [0.72; 2.55], p = 0.0004).

CONCLUSION

When an EO-mouthwash is used in non-brushing or brushing situations, with small to moderate certainty, EOalc- provided less effect regarding plaque control than EOalc+. For bleeding and gingival index there is weak certainty for no difference. In terms of the taste perception EOalc- seems more appreciated.

Randomised-crossover clinical trial on the substantivity of a single application of a gel containing chlorhexidine and o-cymen-5-ol on the oral biofilm and saliva

BACKGROUND

No clinical trials have evaluated the antimicrobial activity and substantivity of gel formulations containing chlorhexidine (CHX) and cymenol.

OBJECTIVE

To compare the in situ antimicrobial effect and substantivity of a new 0.20% CHX + cymenol gel (test) with the current 0.20% CHX gel formulation (control) on salivary flora and dental plaque biofilm up to seven hours after a single application.

METHODS

A randomised-crossover clinical trial was conducted with 29 orally healthy volunteers participating in the development of Experiments 1 (saliva) and 2 (dental plaque biofilm). All subjects participated in both experiments and were randomly assigned to receive either the test or control gels. Samples were collected at baseline and five minutes and one, three, five, and seven hours after a single application of the products. The specimens were processed using confocal laser scanning microscopy after staining with the LIVE/DEAD® BacLight™ solution. Bacterial viability (BV) was quantified in the saliva and biofilm samples. The BV was calculated using the DenTiUS Biofilm software.

RESULTS

In Experiment 1, the mean baseline BV was significantly reduced five minutes after application in the test group (87.00% vs. 26.50%; p < 0.01). This effect was maintained throughout all sampling times and continued up to seven hours (40.40%, p < 0.01). The CHX control followed the same pattern. In Experiment 2, the mean baseline BV was also significantly lower five minutes after applying the test gel for: (1) the total thickness of biofilm (91.00% vs. 5.80%; p < 0.01); (2) the upper layer (91.29% vs. 3.94%; p < 0.01); and (3) the lower layer (86.29% vs. 3.83%; p < 0.01). The reduction of BV from baseline was observed for the full-thickness and by layers at all sampling moments and continued seven hours after application (21.30%, 24.13%, and 22.06%, respectively; p < 0.01). Again, the control group showed similar results. No significant differences between test and control gels were observed in either saliva or dental plaque biofilm at any sampling time.

CONCLUSIONS

A 0.20% CHX + cymenol gel application demonstrates potent and immediate antimicrobial activity on salivary flora and de novo biofilm. This effect is maintained seven hours after application. Similar effects are obtained with a 0.20% CHX-only gel.

The efficacy and safety of an enzyme-containing lozenge for dental biofilm control-a randomized controlled pilot trial

OBJECTIVES

To evaluate the effect of daily use of a multiple-enzyme lozenge on de novo plaque formation, on gingivitis development, and on the oral microbiome composition.

METHODS

This trial with two parallel arms included 24 healthy adults allocated to the Active (n = 12) or Placebo (n = 12) group. Subjects consumed one lozenge three times daily for seven days, and no oral hygiene procedures were allowed. Differences in de novo plaque accumulation between a baseline period, and one and seven days of intervention were assessed by the Turesky-modification of the Quigley-and-Hein-Plaque-Index (TM-QHPI). The development of gingivitis after seven days of intervention was assessed by the Gingival Index (GI). Plaque and saliva samples were collected at baseline and after seven days of intervention, and evaluated by 16S rRNA gene sequencing.

RESULTS

All subjects completed the study, and no adverse events were reported. After one day, the average TM-QHPI was significantly lower in the Active than in the Placebo group, as compared to baseline (p = 0.012). After 7 days, average TM-QHPI values did not differ significantly between groups (p = 0.37). GI values did not increase during the intervention period, with no difference between groups (p = 0.62). Bacterial richness increased in both plaque and saliva samples over a seven-day oral hygiene-free period, with a statistically significant difference for the saliva samples (p = 0.0495) between groups.

CONCLUSIONS

A multiple-enzymes lozenge decreased the build-up of de novo plaque after one day and slowed down the process of species increment in saliva. The lozenge may be an adjunct to regular mechanical plaque removal.

CLINICAL SIGNIFICANCE

Dental plaque is the main cause of caries, gingivitis, and periodontitis. The search for therapeutic adjuncts to mechanical plaque removal that have no harmful effects on the oral microbiome is important. Treatment with multiple plaque-matrix degrading enzymes is a promising non-biocidal approach to plaque control.

Case Report on Caries Assessment Using Intraoral Scanner Compared with Bitewing Radiographs

Dental caries remains one of the main reasons patients seeing their dentist. They either show up for preventive measures, diagnostics, or treatment of present caries lesions. To date, diagnostics are performed visually, supported by using bitewing radiographs. While radiographic diagnostics should only be performed on a biannual basis, and some caries process will not be seen with visual diagnostics, there remains a lack in regular checkups. Therefore, different technical applications can be used for regular diagnostics. One of those is the near-infrared imaging (NIRI) technology. In this case report, a patient presented with incipient caries lesions. These lesions were diagnosed visually, radiographically, and using NIRI. After diagnosis of incipient caries lesions, the patient was advised to use a hydroxyapatite toothpaste and a hydroxyapatite gel for the remineralization of the lesions and prevention of caries progression. The patient was followed up for 6 months with regular checkups in between. Visual diagnostics and NIRI were used to detecting the caries progress. After 6 months, bitewing radiographs were used in addition. In this clinical investigation we were able to show for the first time that NIRI and bitewing radiographs are able to detect and follow incipient caries lesions. Additionally, this study highlights that hydroxyapatite-containing oral care products are able to arrest and remineralize the caries process.

Comparative evaluation of the effect of impregnated retraction cord versus laser on gingival attachment level and pain perception following retraction for subgingival margins - A prospective, split-mouth, controlled, clinical study

AIM

To evaluate and compare the effect of impregnated retraction cord vs Laser on gingival attachment level and pain perception following retraction for subgingival margins.

SETTINGS AND DESIGN

Many methods for achieving and measuring the amount of gingival retraction in fixed prosthodontic work have been advocated. Though the gingival attachment level is crucial in Periodontology, the literature available regarding the effect of these retraction methods on the same is scarce. Hence, this clinical study was designed to compare the pain perception and amount of gingival recession when impregnated cord and laser were used for retraction.

MATERIALS AND METHODS

In 40 subjects (age range of 20 to 40 years) with single missing maxillary incisor, the abutments were prepared with subgingival margins, to receive a full coverage metal-ceramic fixed dental prosthesis. The gingiva was retracted on one of the abutments with impregnated retraction cord and on the other with diode laser. Gingival attachment levels were compared at six sites per abutment using superimposition of digital scans, preoperative and four weeks after cementation of final prosthesis.

STATISTICAL ANALYSIS USED

Statistical analysis of the data for gingival recession was done using t-test. Pain perception was analysed with Chi-square test. Pain perception by patients following retraction was compared with VAS scale.

RESULTS

The average values of gingival recession on buccal side were 0.61 mm and 0.38 mm and on the palatal side were 0.58 mm and 0.35 mm for impregnated retraction cord and laser respectively. The P values of <0.01 indicated a highly significant difference between the two groups. Intragroup comparison did not show significant differences between various sites. Pain and discomfort produced by cord method was moderate in comparison with mild/no pain with diode laser and the difference was highly significant.Conclusion: Retraction cord produced more gingival recession than the diode laser, which was statistically highly significant on both buccal and palatal aspects of the teeth. Patients experience with diode laser technique was less painful in comparison with retraction cord method.

The effect of a multicomponent oral care regimen on gingival inflammation: A randomized controlled clinical trial

BACKGROUND

Oral care regimens can be explored to improve oral health in patients with gingivitis. This study aimed to evaluate the efficacy of a multicomponent oral care regimen with a dual zinc plus arginine (DZA) toothpaste and cetylpyridinium chloride with zinc lactate (CPC + Zn) mouthwash in reducing gingival bleeding in patients with gingivitis.

METHODS

This randomized clinical trial included 94 participants with gingivitis who were randomized into two groups: the DZA/CPC + Zn group, which used a 1450-ppm fluoride toothpaste containing 0.96% zinc plus 1.5% arginine and a fluoride-containing mouthwash with 0.075% CPC and 0.28% zinc lactate, and the control group, which used a 1450-ppm fluoride toothpaste and a placebo mouthwash for 6 months. All participants were examined by a blinded examiner who measured the gingival index, plaque index, and gingival severity index. Data were analyzed using paired t test, independent t test, and analysis of covariance (ANCOVA).

RESULTS

Both groups presented statistically significant reductions in all clinical parameters compared to baseline. The DZA/CPC + Zn group exhibited significantly greater reductions in gingival index, gingival severity index, proximal gingival index, plaque index and proximal plaque index compared to the control group at 1, 3, and 6 months. Furthermore, DZA/CPC + Zn significantly decreased the percentage of patients with generalized gingivitis over a 6-month follow-up period. However, differences between the DZA/CPC + Zn and the control groups were not maintained after both groups established similar regimens with fluoride toothpaste.

CONCLUSION

The multicomponent oral care regimen consisting of DZA toothpaste and CPC + Zn mouthwash is effective in reducing gingival inflammation and supragingival biofilm in patients with gingivitis.

Effects of three orthodontic retainers on periodontal pathogens and periodontal parameters

The objective of this study was to compare and evaluate the changes in periodontal pathogens and periodontal status within 6 months of wearing three orthodontic retainers, namely, vacuum-formed retainer (VFR), Hawley retainer (HR), and lingual fixed retainer (LR). In total, 48 patients who underwent orthodontic treatment with ordinary metal brackets were divided into VFR, HR, and LR groups (n = 16 per group). Saliva samples were collected at the time of debonding (T0) and after 1 month (T1), 3 months (T2), and 6 months (T3). Porphyromonas gingivalis (Pg) and Aggregatibacter actinomycetemcomitans (Aa) were quantitatively analyzed using real-time PCR. Gingival index (GI), plaque index (PLI), and probing depth (PD) were measured at the four time points to evaluate changes in periodontal state. SPSS20.0 software was used to analyze the data, and P < 0.05 was considered statistically significant. The trial was registered at the Chinese Clinical Trial Registry (ChiCTR2300073704), the registration was retrospective. Compared to baseline (T0) values, Pg, Aa, GI, PLI, and PD were significantly decreased in all three groups 1 month after wearing the retainer (p < 0.05). Significant differences were observed in Aa at T3 among the three groups, whereby the HR group exhibited significantly better results compared to the VFR and LR groups (p < 0.05). Differences were found among the three groups' Porphyromonas gingivalis at T3, and the HR group was significantly better than the VFR and LR groups (P < 0.05). From T1 to T2, GI, PLI, and PD of the three groups tended to be stable, however differences were observed at T3, with the PLI and PD of the HR group being the lowest among the three groups (p < 0.05). Regardless of the type of retainer used, the periodontal condition of patients was significantly improved after removal of the metal brackets. After 6 months of retainer use, the Hawley retainer was superior to vacuum-formed retainer and lingual fixed retainer with regard to Pg, Aa, and periodontal clinical parameters.

Effectiveness of Mouthwashes in Managing Oral Diseases and Conditions: Do They Have a Role?

Antimicrobial mouthwashes are considered to reduce dental plaque biofilm and thus the potential to prevent plaque-induced oral diseases, particularly periodontal diseases. The effectiveness of mouthwashes relates to this antiplaque role, as well as, their tooth-whitening potential and ability to mask/mange malodour (halitosis). There is also a growing interest in the use of mouthwashes as an adjunctive measure in post surgical and post-dental care, while the COVID-19 pandemic has given a new lease of life to mouthwashes as an oral antispetic that may be useful in reducing the oral viral load. The mode of action of mouthwashes varies, depending on their active ingredients, concentrations, and mode and frequency of use, as does their potential effectiveness. This article aims to provide a narrative overview of the evidence of the effectiveness of the most widely used mouthwashes in managing oral diseases, oral conditions, and adjunctive care roles.

Mouthwashes: Implications for Practice

This is the concluding article in the supplement on the role of mouthwashes in oral care, which summarises the current guidelines across the globe regarding their acceptable adjunctive use for managing caries, gingivitis, and periodontal disease. Based on moderate evidence for clinical effectiveness, most current guidelines suggest fluoride mouthwashes for the management of dental caries, and chlorhexidine for the management of periodontal diseases. However there still appears to be gaps in the literature underpinning these recommendations. Importantly, all evidence supports such mouthwash use "adjunctively," alongside mechanical oral hygiene measures. Other antimicrobial mouthwashes such as essential oils and cetylpyridinium chloride may also be clinically effective against plaque and gingivitis, but there is a current lack of robust evidence of natural mouthwashes to recommend their adjunctive use. The authors of the current review are of the view that mouthwashes may not be of much value in those with good periodontal health or low caries risk. The reasons for this are, the potential i) risks of allergic reactions, ii) dysbiosis of the oral microbiota, iii) emergence of antimicrobial resistance, and iv) deleterious effects on the environment. There is, however, much empirical research needed on mouthwashes, particularly in vivo research derived through clinical trials. Thus, dental practitioners need to keep abreast of the evidence base on the current, and the emerging, over-the-counter mouthwashes, and pay heed to the consensus views emanating from systematic reviews, as well as international guidelines on mouthwashes.

Supra and subgingival application of antiseptics or antibiotics during periodontal therapy

Periodontal diseases (gingivitis and periodontitis) are characterized by inflammatory processes which arise as a result of disruption of the balance in the oral ecosystem. According to the current S3 level clinical practice guidelines, therapy of patients with periodontitis involves a stepwise approach that includes the control of the patient's risk factors and the debridement of supra and subgingival biofilm. This debridement can be performed with or without the use of some adjuvant therapies, including physical or chemical agents, host modulating agents, subgingivally locally delivered antimicrobials, or systemic antimicrobials. Therefore, the main aim of this article is to review in a narrative manner the existing literature regarding the adjuvant application of local agents, either subgingivally delivered antibiotics and antiseptics or supragingivally applied rinses and dentifrices, during the different steps in periodontal therapy performed in Europe.

Chlorhexidine gel topical application ameliorates inflammatory bone loss in experimental periodontitis

OBJECTIVES

This study aimed to evaluate the impact of chlorhexidine (CHX) gel on inflammation-induced periodontal tissue destruction, osteoclastogenesis, subgingival microbiota, and on the modulation of the RANKL/OPG as well as inflammatory mediators during bone remodeling in vivo.

MATERIALS AND METHODS

Ligation- and LPS injection-induced experimental periodontitis were created to investigate the effect of topical application of CHX gel in vivo. Alveolar bone loss, osteoclast number and gingival inflammation was evaluated by micro-CT, histological, immunohistochemistry and biochemical analysis. The composition of the subgingival microbiota was characterized by 16S rRNA gene sequencing.

RESULTS

Data shows significant decreases in the alveolar bone destruction in rats from ligation-plus-CHX gel group compared to ligation group. In addition, significant decreases in the number of osteoclasts on bone surface and the protein level of receptor activator of nuclear factor κB ligand (RANKL) in gingival tissue were observed in rats from ligation-plus-CHX gel group. Moreover, data shows significantly decreased inflammatory cell infiltration and decreased expression of cyclooxygenase (COX-2) and inducible NO synthase (iNOS) in gingival tissue from ligation-plus-CHX gel group versus ligation group. Assessment of the subgingival microbiota revealed changes in rats with CHX gel application treatment.

CONCLUSION

HX gel presents protective effect on gingival tissue inflammation, osteoclastogenesis, RANKL/OPG expression, inflammatory mediators, and alveolar bone loss in vivo, which may have a translational impact on the adjunctive use in the management of inflammation-induced alveolar bone loss.

Revisiting Oral Antiseptics, Microorganism Targets and Effectiveness

A good oral health status is mostly dependent on good oral hygiene habits, which knowingly impacts systemic health. Although controversial, chemical oral antiseptics can be useful in adjunct use to mechanical dental plaque control techniques in the prevention and management of local and overall health and well-being. This review aims to revisit, gather and update evidence-based clinical indications for the use of the most popular oral antiseptics, considering different types, microorganism targets and effectiveness in order to establish updated clinical recommendations.

Defining in vitro topical antimicrobial and antibiofilm activity of epoxy-tigliane structures against oral pathogens

Background

Peri-implantitis has become an inexorable clinical challenge in implantology. Topical immunomodulatory epoxy-tiglianes (EBCs), derived from the Queensland blushwood tree, which induce remodeling and resolve dermal infection via induction of the inflammasome and biofilm disruption, may offer a novel therapeutic approach.

Design

In vitro antimicrobial activity of EBC structures (EBC-46, EBC-1013 and EBC-147) against Streptococcus mutans, Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis in minimum inhibitory concentration, growth curve and permeabilization assays were determined. Antibiofilm activity was assessed using minimum biofilm eradication concentration (MBEC) experiments. Biofilm formation and disruption assays were analyzed using confocal laser scanning microscopy, scanning electron microscopy and direct plate counting.

Results

The observed antimicrobial efficacy of the tested compounds (EBC-1013 > EBC-46 > EBC-147) was directly related to significant membrane permeabilization and growth inhibition (p < 0.05) against planktonic S. mutans and P. gingivalis. Antibiofilm activity was evident in MBEC assays, with S. mutans biofilm formation assays revealing significantly lower biomass volume and increased DEAD:LIVE cell ratio observed for EBC-1013 (p < 0.05). Furthermore, biofilm disruption assays on titanium discs induced significant biofilm disruption in S. mutans and P. gingivalis (p < 0.05).

Conclusions

EBC-1013 is a safe, semi-synthetic, compound, demonstrating clear antimicrobial biofilm disruption potential in peri-implantitis.

Methodological quality of network meta-analysis in dentistry: a meta-research

This meta-research aimed to provide an overview of the methodological quality and risk of bias of network meta-analyses (NMA) in dentistry. Searches for NMA of randomized clinical trials with clinical outcomes in dentistry were performed in databases up to January 2022. Two reviewers independently screened titles/abstracts, selected full texts, and extracted the data. The adherence to PRISMA-NMA reporting guideline, the AMSTAR-2 methodological quality tool, and the ROBIS risk of bias tool were assessed in the studies. Correlation between the PRISMA-NMA adherence and the AMSTAR-2 and ROBIS results was also investigated. Sixty-two NMA studies were included and presented varied methodological quality. According to AMSTAR-2, half of the NMA presented moderate quality (n = 32; 51.6%). The adherence to PRISMA-NMA also varied. Only 36 studies (58.1%) prospectively registered the protocol. Other issues lacking of reporting were data related were data related to the NMA geometry and the assessment of results consistency, and the evaluation of risk of bias across the studies. ROBIS assessment showed a high risk of bias mainly for domains 1 (study eligibility criteria) and 2 (identification and selection of studies). Correlation coefficients between the PRISMA-NMA adherence and the AMSTAR-2 and ROBIS results showed moderate correlation (rho < 0.6). Overall, NMA studies in dentistry were of moderate quality and at high risk of bias in several domains, especially study selection. Future reviews should be better planned and conducted and have higher compliance with reporting and quality assessment tools.

Europe's contribution to the evaluation of the use of systemic antimicrobials in the treatment of periodontitis

This narrative review celebrates Europe's contribution to the current knowledge on systemically administered antimicrobials in periodontal treatment. Periodontitis is the most frequent chronic noncommunicable human disease. It is caused by dysbiotic bacterial biofilms and is commonly treated with subgingival instrumentation. However, some sites/patients do not respond adequately, and its limitations and shortcomings have been recognized. This has led to the development of alternative or adjunctive therapies. One is the use of antimicrobials to target bacteria in subgingival biofilms in the periodontal pocket, which can be targeted directly through the pocket entrance with a locally delivered antibiotic or systemically by oral, intravenous, or intramuscular methods. Since the early 20th century, several studies on systemic antibiotics have been undertaken and published, especially between 1990 and 2010. Europe's latest contribution to this topic is the first European Federation of Periodontology, S3-level Clinical Practice Guideline, which incorporates recommendations related to the use of adjuncts to treat stage I-III periodontitis. Understanding the etiopathogenesis of periodontal diseases, specifically periodontitis, has influenced the use of systemic periodontal antibiotic therapy. Randomized clinical trials and systematic reviews with meta-analyses have demonstrated the clinical advantages of adjunctive systemic antimicrobials. However, current recommendations are restrictive due to concerns about antibiotic misuse and the increase in microbial antibiotic resistance. European researchers have contributed to the use of systemic antimicrobials in the treatment of periodontitis through clinical trials and by providing rational guidelines. Nowadays, European researchers are exploring alternatives and directing clinical practice by providing evidence-based guidelines to limit the use of systemic antimicrobials.

A randomised controlled trial evaluating the impact of oral health advice on gingival health using intra oral images combined with a gingivitis specific toothpaste

OBJECTIVES

Does a complex intervention of oral hygiene advice (OHA) delivered with intra-oral scanner images, anti-gingivitis toothpaste and motivational reminders, improve oral health more than a standard of care control arm of fluoride toothpaste, with OHA without scanner images?

METHODS

Adult participants with pre-existing gingivitis were randomised to intervention or control. Following enrolment, baseline and each subsequent visit (V) (3-weeks, V2; 3-months, V3; 6-months, V4) followed the same schedule. Bleeding on Probing (BOP) was assessed and Intra Oral Scan IOS(1) recorded. Plaque was disclosed, scored and re-scanned (IOS(2)). The intervention group received OHA with IOS images, control group receiving OHA without IOS images. Participants brushed with their allocated toothpaste (fluoride, control; anti-gingivitis, intervention), IOS(3) was recorded. Between visits participants brushed with their allocated toothpaste, intervention group received motivational reminders.

RESULTS

BOP scores from baseline were significantly improved in the intervention group compared to control at all visits for all surfaces (p<0.001); differences at V4 were 0.292 (all), 0.211 (buccal/labial) and 0.375 (lingual/palatal). Plaque scores from baseline pre-brushing to each visit pre- and post-brushing also favoured the intervention group, the difference always significant on lingual/palatal surfaces (p<0.05), significant for all but pre-brushing-V4 (p<0.05) on all surfaces, but only significant for pre-brushing-V3 (p<0.05) buccally/labially. Differences from baseline to post-brushing at V4 were: 0.200 (all), 0.098 (buccal/labial) and 0.291 (lingual/palatal).

CONCLUSION

A complex intervention comprising OHA delivered with IOS-images, anti-gingivitis toothpaste and motivational reminders improved gingival health more than existing standard of care-OHA together with a standard fluoride toothpaste over a 6-month period.

CLINICAL SIGNIFICANCE STATEMENT

Intra-oral scans (IOS) are now frequently used in general dental practice for a variety of purposes. IOS use, in combination with motivational texts and an anti-gingivitis toothpaste, could be further deployed to promote oral hygiene behaviour change in patients and improve gingival health, in a cost-effective manner.

Effect of interproximal home oral hygiene on clinical parameters and inflammatory biomarkers in patients receiving periodontal maintenance

BACKGROUND

The purpose of this 6-week, single-blinded, randomized clinical trial was to determine if the use of an interproximal brush, with or without a tracking device, is more effective than an oral irrigator in improving interproximal probing depth (PD), clinical attachment level (CAL), plaque index (PI), gingival index (GI), bleeding on probing (BOP), and inflammatory markers.

METHODS

Seventy-six patients with Stages III-IV, Grade B periodontitis and a 5-7 mm posterior interproximal PD with BOP were randomized: (1) interproximal brush alone (IB; n = 26), (2) interproximal brush with tracking device (TD; n = 23), (3) oral irrigator (OI; n = 27). Participants used devices once daily for 6 weeks. Clinical measurements (PD, CAL, PI, BOP, GI) and gingival crevicular fluid (GCF) samples were collected at baseline and 6 weeks.

RESULTS

All groups showed a significant reduction in PD and CAL (≥1.1 mm, p < 0.0001) and improvement in BOP (≥56%, p < 0.0001) and GI (≥82%, p < 0.001) at the experimental site with no differences among groups. The IB and IB+TD groups showed a significant reduction in PI (≥0.9, p ≤ 0.01). Interleukin (IL)-1β was reduced in all groups (p = 0.006), but IB+TB more than OI (p ≤ 0.05). IL-10 was reduced among all groups (p = 0.01), while interferon-gamma significantly increased (p = 0.01) in all groups.

CONCLUSIONS

IB and OI improved clinical parameters of PD and CAL and reduced inflammatory markers (BOP, GI, GCF IL-1β). IB had better interproximal plaque reduction. Tracking did not significantly improve clinical parameters compared with the IB and OI groups, suggesting future modifications are needed.

Systematic Review and Meta Analysis of the Relative Effect on Plaque Index among Pediatric Patients Using Powered (Electric) versus Manual Toothbrushes

Although many randomized controlled trials (RCT) have evaluated the efficacy of powered or electric toothbrushes compared with manual or traditional toothbrushes to remove biofilm and plaque, only one systematic review has been published for pediatric patients. The primary objective of this study was to perform a systematic review and meta analysis for this population. Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) protocol, N = 321 studies were initially identified. Three independent, blinded abstract reviews were completed resulting in a total of n = 38/322 or 11.8% for the final analysis (n = 27 non-orthodontic, n = 11 orthodontic studies). Meta analysis of these outcome data have revealed a strong reduction in plaque index scores among pediatric patients using electric toothbrushes of approximately 17.2% for non-orthodontic patients and 13.9% for orthodontic patients. These results provide strong clinical evidence for recommending electric toothbrushing to pediatric patients, as well as those patients undergoing orthodontic therapy and treatment.

Effects of sugar-free polyol chewing gums on gingival inflammation: a systematic review

OBJECTIVES

A systematic review of published data was conducted with the aim of assessing the effects of sugar-free polyol chewing gums on gingival inflammation.

MATERIALS AND METHODS

Electronic and hand searches were performed to find clinical studies concerning the effects of sugar-free chewing gums on gingival scores. Prospective randomized controlled clinical trials published between 1971 and 2021 were included in the review.

RESULTS

The initial search identified 46 erythritol, 102 xylitol, 23 sorbitol, and nine maltitol chewing gum articles. After applying inclusion and exclusion criteria, seven xylitol chewing gum studies, one sorbitol, and one maltitol chewing gum study with either high or fair quality were reviewed. In five out of the seven xylitol studies, xylitol gum decreased gingival scores. In two studies, xylitol decreased gingival scores compared to a polyol gum, and in three studies compared to no gum/gum base. As for sorbitol and maltitol, only sorbitol gum chewing showed a small decrease in gingival scores compared to the controls.

CONCLUSIONS

Habitual xylitol gum chewing may reduce gingival inflammation. The low number of studies and their heterogeneity provide clear indications that the effects of sugar-free polyol chewing gums on gingival inflammation need further, well-controlled studies.

CLINICAL RELEVANCE

Sugar-free chewing gums, especially xylitol gum, may function as adjuncts to toothbrushing for reducing gingival inflammation, but the evidence so far is inconclusive.

Evidence on the Use of Mouthwash for the Control of Supragingival Biofilm and Its Potential Adverse Effects

Antimicrobial mouthwash improves supragingival biofilm control when used in conjunction with mechanical removal as part of an oral hygiene routine. Mouthwash is intended to suppress bacterial adhesion during biofilm formation processes and is not aimed at mature biofilms. The most common evidence-based effects of mouthwash on the subgingival biofilm include the inhibition of biofilm accumulation and its anti-gingivitis property, followed by its cariostatic activities. There has been no significant change in the strength of the evidence over the last decade. A strategy for biofilm control that relies on the elimination of bacteria may cause a variety of side effects. The exposure of mature oral biofilms to mouthwash is associated with several possible adverse reactions, such as the emergence of resistant strains, the effects of the residual structure, enhanced pathogenicity following retarded penetration, and ecological changes to the microbiota. These concerns require further elucidation. This review aims to reconfirm the intended effects of mouthwash on oral biofilm control by summarizing systematic reviews from the last decade and to discuss the limitations of mouthwash and potential adverse reactions to its use. In the future, the strategy for oral biofilm control may shift to reducing the biofilm by detaching it or modulating its quality, rather than eliminating it, to preserve the benefits of the normal resident oral microflora.

Effect of Oral Health Education Using a Mobile App (OHEMA) on the Oral Health and Swallowing-Related Quality of Life in Community-Based Integrated Care of the Elderly: A Randomized Clinical Trial

This study investigated the effect of oral health education using a mobile app (OHEMA) on the oral health and swallowing-related quality of life (SWAL-QoL) of the elderly population in a community-based integrated care project (CICP). Forty elderly individuals in the CICP were randomized into intervention and control groups. OHEMA provided information on customized oral health care management, oral exercises, and intraoral and extraoral massage methods for 50 min/session, once a week, for 6 weeks. Pre- and post-intervention surveys assessed the unstimulated salivary flow rate, subjective oral dryness, tongue pressure, and SWAL-QoL, which were analyzed using ANCOVA and repeated measures ANOVA. In the intervention group, tongue pressure increased significantly from pre- (17.75) to post-intervention (27.24) (p < 0.001), and subjective oral dryness decreased from pre- (30.75) to post-intervention (18.50). The unstimulated salivary flow rate had a higher mean score in the intervention group (7.19) than in the control group (5.04) (p < 0.001). The SWAL-QoL significantly improved from pre- (152.10) to post-intervention (171.50) in the intervention group (p < 0.001) but did not change significantly in the control group (p > 0.05). OHEMA appears to be a useful tool for oral health education for the elderly as it improved the SWAL-QoL, with increased tongue pressure and reduced oral dryness.

Are adjunctive therapies effective in reducing gingivitis and plaque?

Data sources PubMed, CENTRAL, Scopus and Cochrane electronic databases were used as the data sources for the systematic review. All randomised control trials that reviewed antiseptics published up to and including 26 February 2019 were included. A manual search of reference lists of the selected studies was conducted, including information from previous systematic reviews conducted by the same authors.Study selection Two trained and calibrated reviewers screened titles and abstracts that investigated the efficacy of adjuncts to mechanical plaque control, in systematically healthy patients aged 18 years or older with dental plaque biofilm-induced gingivitis, in an intact periodontium (GP) or in patients previously treated for periodontitis with gingival inflammation (PP_GI). Studies with at least one test group and a control group were included, where changes from baseline up to six months in gingival or bleeding indices was the primary outcome.Data extraction and synthesis Data was extracted by three reviewers and reported outcomes extracted at baseline, six months and the longest to follow-up visit. Meta-analysis was conducted for six-month data on antiseptics investigating gingival indices, bleeding indices and plaque indices. Studies were compared via mean treatment effect, calculated for baseline to six months, and analysed using weighted mean differences (WMD) or standardised mean differences (SMD). Statistical heterogeneity was assessed using Cochran's Q and I squared statistic. Study-specific estimates were pooled using the random-effect model and meta-regression analysis performed. Sensitivity analysis was performed to assess the contribution of each study to the evidence and Begg's rank correlation test utilised to assess publication bias.Results Following screening of 1,101 articles, 70 were included in quantitative synthesis. Adjuncts yielded statistically significant reductions in gingival index, plaque index and plaque. Meta-regression analysis showed use of mouth rinses resulted in greater reductions in plaque when compared with dentifrices, whereas antiseptic agents were similarly effective in reducing gingivitis in plaque in patients with GP and PP_GI.Conclusions Based on the present evidence, adjunctive antiseptics in mouth rinses and dentifrices demonstrate statistically significant reductions in gingival, bleeding and plaque indices, when used in adjunct to mechanical plaque control. Clinical significance must be interpreted with caution due to the heterogeneity among studies included and significant publication bias.

Effects of Octenidine on the Formation and Disruption of Dental Biofilms: An Exploratory In Situ Study in Healthy Subjects

Dental biofilms are highly structured, complex multispecies communities that, if left untreated, lead to severe oral complications such as caries and periodontal diseases. Therefore, antibiofilm agents are often recommended for both preventive and therapeutic measures. However, biofilm management can be challenging due to the low sensitivity of biofilms to antimicrobial treatments. Octenidine dihydrochloride (OCT) is a highly effective antibacterial agent. Because the OCT antibiofilm efficacy has not been studied in situ, this exploratory crossover study aimed to evaluate the effects of OCT mouth rinsing on biofilm formation and on the disruption of mature biofilms. Moreover, a comparison to the gold-standard chlorhexidine (CHX) was conducted. The biofilms were formed intraorally by 5 healthy volunteers on enamel specimens fixed to acrylic splints. For biofilm formation analysis, OCT, CHX, or water rinses were applied for 30 s every 12 h. The samples evaluation took place at 24-and 48-h time points. For biofilm disruption analysis, sample assessment was performed before and directly after the first OCT or CHX rinse on 48-h mature biofilms. A second rinse was carried out 12 h later. The last assessment was applied to 72-h mature biofilms. The biofilms were analyzed by fluorescence microscopy and transmission electron microscopy. The results showed OCT significantly reducing biofilm formation and bacterial vitality in situ. Simultaneously, the biofilm thickness was strongly decreased. Moreover, a single application of OCT to a 48-h mature biofilm induced substantial biofilm disruption. In addition, the efficacy of OCT compared favorably to CHX. These findings show that OCT rinses prevent biofilm formation and disrupt preexisting mature biofilms formed by healthy subjects. This work suggests that OCT might be used for dental biofilm management as a part of the medical treatment of oral diseases. Future studies with a larger subject heterogeneity and number are needed to confirm the observed OCT effects.

Mechanical plaque removal of periodontal maintenance patients: A systematic review and network meta-analysis

AIM

This systematic review synthesizes the available clinical evidence concerning efficacy of mechanical oral hygiene devices in periodontal maintenance patients.

MATERIAL AND METHODS

Three databases were searched up to October 2019 for clinical trials conducted in adult patients in periodontal maintenance which evaluated the effect of toothbrushes or an interdental device on plaque removal and parameters of periodontal diseases. Descriptive analysis and network meta-analysis (NMA) were performed.

RESULTS

Sixteen eligible publications, including 17 relevant comparisons, were retrieved. Four out of five comparisons found no clinical difference between a manual and power toothbrush. Of the interdental cleaning devices, the interdental brushes (IDBs) reduced plaque scores more effectively than a manual toothbrush alone. For the oral irrigator, two out of three comparisons indicated a positive effect on gingivitis scores, and probing pocket depth. The NMA demonstrated that for plaque removal the adjuvant use of IDBs was significantly more effective than the manual toothbrush alone. For the reduction of gingival inflammation, no product ranked higher than the manual toothbrush.

CONCLUSION

Due to the scarcity of studies that met the inclusion criteria for each of the oral hygiene devices and the low certainty of the resultant evidence, no strong "evidence-based" conclusion can be drawn concerning any specific oral hygiene device for patient self-care in periodontal maintenance.

Efficacy of adjunctive therapies in patients with gingival inflammation: A systematic review and meta-analysis

AIM

To evaluate the efficacy of adjunctive therapies in reducing gingivitis and plaque by means of a systematic review of randomized clinical trials (RCTs).

MATERIAL AND METHODS

A search protocol was designed to identify 6-month RCTs that investigated the efficacy of adjuncts to mechanical plaque control on gingivitis and plaque. Following screening, relevant information was extracted, and quality and potential risk of bias were estimated. Mean treatment differences were calculated to obtain standardized mean differences and weighted mean differences (SMD and WMD) as appropriate.

RESULTS

Meta-analyses included 70 studies of adjunctive antiseptics. Compared with mechanical plaque control alone, adjuncts yielded statistically significant reductions in gingival index (n = 72; SMD = -1.268; 95% CI [-1.489; -1.047]; p < .001; I²  = 96.2%), bleeding (%) (n = 26, WMD=-14.62%; 95% CI [-18.01%; -11.23%]; p < .001; I²  = 95.1%), plaque index (n = 93, SMD = -1.017; 95% CI [-1.194; -0.840]; p < .001; I²  = 95.3%) and plaque (%) (n = 23; WMD = -18.20%; 95% CI [-24.00%; -12.50%]; p < .001; I²  = 96.9%). Mouthrinses resulted in greater reductions in per cent plaque compared with dentifrices (meta-regression, coefficient = 13.80%; 95% CI [2.40%; 25.10%]; p = .020). The antiseptic agents were similarly effective in reducing gingivitis and plaque in patients with dental plaque-induced gingivitis (intact periodontium) or previously treated periodontitis with gingival inflammation.

CONCLUSION

Adjunctive antiseptics in mouthrinses and dentifrices provide statistically significant reductions in gingival, bleeding and plaque indices.

BSP implementation of European S3 - level evidence-based treatment guidelines for stage I-III periodontitis in UK clinical practice

OBJECTIVES

To adapt the supranational European Federation for Periodontology (EFP) S3-Level Clinical Practice Guideline for treatment of periodontitis (stage I-III) to a UK healthcare environment, taking into account the views of a broad range of stakeholders, and patients.

SOURCES

This UK version is based on the supranational EFP guideline (Sanz et al., 2020) published in the Journal of Clinical Periodontology. The source guideline was developed using the S3-level methodology, which combined the assessment of formal evidence from 15 systematic reviews with a moderated consensus process of a representative group of stakeholders, and accounts for health equality, environmental factors and clinical effectiveness. It encompasses 62 clinical recommendations for the treatment of stage I-III periodontitis, based on a step-wise process mapped to the 2017 classification system.

METHODOLOGY

The UK version was developed from the source guideline using a formal process called the GRADE ADOLOPMENT framework. This framework allows for the adoption (unmodified acceptance), adaptation (acceptance with modifications) and the de novo development of clinical recommendations. Using this framework and following the S3-process, the underlying systematic reviews were updated and a representative guideline group of 75 delegates from 17 stakeholder organisations was assembled into three working groups. Following the formal S3-process, all clinical recommendations were formally assessed for their applicability to the UK and adoloped accordingly.

RESULTS AND CONCLUSION

Using the ADOLOPMENT protocol, a UK version of the EFP S3-level clinical practice guideline was developed. This guideline delivers evidence- and consensus-based clinical recommendations of direct relevance to the dental community in the UK.

CLINICAL SIGNIFICANCE

The aim of S3-level guidelines is to combine the evaluation of formal evidence, grading and synthesis with the clinical expertise of a broad range of stakeholders to form clinical recommendations. Herein, the first major international S3-level guideline in dentistry, the EFP guideline, was implemented for direct clinical applicability in the UK healthcare system.

Effect of adjunctive diode laser in the non-surgical periodontal treatment in patients with diabetes mellitus: a systematic review and meta-analysis

This study aimed to systematically review and analyze the present randomized clinical trials (RCTs) regarding the clinical efficacy of a diode laser (DL) adjuvant to scaling and root planning (SRP) in patients with chronic periodontitis (CP) who have diabetes mellitus (DM). Five databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trails, Web of Science, and Chinese BioMedical Literature Databases) were searched. A meta-analysis was implemented to evaluate periodontal parameters including probing depth (PD) and clinical attachment level (CAL) as primary outcomes. Hemoglobin A1c (HbA1c), plaque index (PI), and the gingival index (GI) were also observed as secondary outcomes. Independent scanning of 239 papers resulted in 9 RCTs. Moderate evidence demonstrated that the test groups showed significant benefits for PD reduction, CAL gain, and HbA1c reduction after 3 and 6 months. Significant differences in PI and GI reduction were not found except for GI reduction within 1 month. The collective evidence suggested that the DL with SRP had significant improvements in clinical results compared to SRP alone. Based on our results, the DL could be a recommended therapy for patients with CP who have DM.

Antiplaque and antigingivitis efficacy of cetylpyridinium chloride with zinc lactate compared with essential oil mouthrinses: Randomized clinical trial

BACKGROUND

The authors of this study aimed to evaluate the clinical antiplaque and antigingivitis effects of 3 oral hygiene regimens: toothbrushing with standard fluoride toothpaste and manual toothbrush and using a mouthrinse containing cetylpyridinium chloride, zinc lactate, and fluoride (CPC + Zn + F) in an alcohol-free base; toothbrushing with standard fluoride toothpaste and manual toothbrush and using a mouthrinse containing essential oils (EO) in an alcohol-free base; and toothbrushing with manual toothbrush and standard fluoride toothpaste and manual toothbrush (control).

METHODS

The participants (N = 120) were randomly assigned to study groups and followed the assigned regimens twice daily for 6 weeks. The participants were examined by a calibrated examiner for the Quigley-Hein plaque index (Turesky modification) and Löe-Silness gingival index at baseline, week 4, and week 6. Statistical analyses were performed separately for plaque and gingival indexes by means of analysis of variance, paired t test, and analysis of covariance (α = 0.05).

RESULTS

At week 4, the CPC + Zn + F group presented additional reductions in dental plaque compared with EO and control groups of (21.4% [P < .001] and 31.4% [P < .001], respectively). After 6 weeks, these values were 26.7% (P < .001) and 44.8% (P < .001), respectively. For Löe-Silness gingival index, additional reduction in the CPC + Zn + F group compared with EO were 10.6% (P < .001) and 13.7% (P < .001) at 4 and 6 weeks, respectively. Compared with control, these reductions were 13.6% (P < .001) and 17.8% (P < .001), respectively.

CONCLUSIONS

The regimen including a mouthrinse containing CPC + Zn + F presented higher antiplaque and antigingivitis effects than EO and control regimens.

PRACTICAL IMPLICATIONS

A mouthrinse containing CPC + Zn + F is an effective protocol for the control of dental plaque and gingivitis.

Current uses of chlorhexidine for management of oral disease: a narrative review

OBJECTIVES

Chlorhexidine (CHX) is a commonly used antiseptic mouthwash, used by dental practitioners and the public, due to its antimicrobial effects. The aim of this article was to provide a narrative review of current antimicrobial uses of CHX relevant to dentistry in the context of oral diseases, highlighting need for further studies to support its safe and appropriate use.

STUDY SELECTION, DATA AND SOURCES

Randomised controlled trials, systematic reviews and national (UK and US) guidelines were consulted where available, with search terms for each subject category entered into MEDLINE, PubMed, Google Scholar and the Cochrane database.

RESULTS

Some evidence existed to support adjunctive short-term use of CHX to manage dental plaque, and reduce clinical symptoms of gingivitis, dry socket, as well as reduce aerosolisation of bacteria. However, use must be weighed alongside the less desirable effects of CHX, including extrinsic staining of teeth, antimicrobial resistance to antiseptic agents and the rare, but fatal, allergic reactions to CHX. Conversely, evidence for the effectiveness of chlorhexidine to manage or prevent periodontitis, dental caries, necrotising periodontal diseases, peri-implantitis, and infections associated with extraction and aerosolised viruses remains less certain.

CONCLUSIONS

The use of CHX in dentistry and oral healthcare continues to be widespread and thus it is important that dental practitioners understand that, based on its differential mechanisms of action on different microbes, appropriate clinical and dental use of CHX should be oral disease specific. However, further scientific and clinical research is required before full recommendations can be made.

Efficacy of adjunctive photodynamic therapy and lasers in the non-surgical periodontal treatment: A Bayesian network meta-analysis

BACKGROUND

Photodynamic therapy (PDT) and lasers have been widely applied in non-surgical treatments in recent decades; however, their efficacy is not known. The objective of this study was to compare adjunctive PDT, different lasers, and scaling and root planning (SRP) in the management of chronic periodontitis.

METHODS

Randomized clinical trials (RCTs) assessing adjunctive PDT, different lasers, and SRP were identified. Relevant data were extracted, and the quality and risk of bias were evaluated. Network meta-analyses were performed to analyze clinical attachment level (CAL) outcomes.

RESULTS

Forty-four studies, including 10 types of adjuncts, were included. PDT + SRP and PDT + diode laser (DL)+SRP were significantly more efficient than SRP at the 3-month and 6-month follow-up. Adjunctive potassium-titanyl-phosphate (KTP) laser showed significantly more CAL gains than SRP at 6 months. The most effective adjunctive treatment at 3 months was PDT + DL (60 %) and at 6 months was KTP laser (71 %).

CONCLUSIONS

PDT + DL + SRP and PDT + SRP were found to be preferentially recommended methods. KTP + SRP was significantly superior to SRP at the 6-month follow-up. However, further investigations are necessary.

Sulfated vizantin causes detachment of biofilms composed mainly of the genus Streptococcus without affecting bacterial growth and viability

BACKGROUND

Sulfated vizantin, a recently developed immunostimulant, has also been found to exert antibiofilm properties. It acts not as a bactericide, but as a detachment-promoting agent by reducing the biofilm structural stability. This study aimed to investigate the mechanism underlying this activity and its species specificity using two distinct ex vivo oral biofilm models derived from human saliva.

RESULTS

The biofilm, composed mainly of the genus Streptococcus and containing 50 μM of sulfated vizantin, detached significantly from its basal surface with rotation at 500 rpm for only 15 s, even when 0.2% sucrose was supplied. Expression analyses for genes associated with biofilm formation and bacterial adhesion following identification of the Streptococcus species, revealed that a variety of Streptococcus species in a cariogenic biofilm showed downregulation of genes encoding glucosyltransferases involved in the biosynthesis of water-soluble glucan. The expression of some genes encoding surface proteins was also downregulated. Of the two quorum sensing systems involved in the genus Streptococcus, the expression of luxS in three species, Streptococcus oralis, Streptococcus gordonii, and Streptococcus mutans, was significantly downregulated in the presence of 50 μM sulfated vizantin. Biofilm detachment may be facilitated by the reduced structural stability due to these modulations. As a non-specific reaction, 50 μM sulfated vizantin decreased cell surface hydrophobicity by binding to the cell surface, resulting in reduced bacterial adherence.

CONCLUSION

Sulfated vizantin may be a candidate for a new antibiofilm strategy targeting the biofilm matrix while preserving the resident microflora.

Limited antimicrobial efficacy of oral care antiseptics in microcosm biofilms and phenotypic adaptation of bacteria upon repeated exposure

Objectives

The aims of this study were to investigate the antimicrobial efficacy of antiseptics in saliva-derived microcosm biofilms, and to examine phenotypic adaption of bacteria upon repeated exposure to sub-inhibitory antiseptic concentrations.

Methods

Saliva-derived biofilms were formed mimicking caries- or gingivitis-associated conditions, respectively. Microbial compositions were analyzed by semiconductor-based 16S rRNA sequencing. Biofilms were treated with CHX, CPC, BAC, ALX, and DQC for 1 or 10 min, and colony forming units (CFU) were evaluated. Phenotypic adaptation of six selected bacterial reference strains toward CHX, CPC, and BAC was assessed by measuring minimum inhibitory concentrations (MICs) over 10 passages of sub-inhibitory exposure. Protein expression profiles were investigated by SDS-PAGE.

Results

Both biofilms showed outgrowth of streptococci and Veillonella spp., while gingivitis biofilms also showed increased relative abundances of Actinomyces, Granulicatella, and Gemella spp. Antiseptic treatment for 1 min led to no relevant CFU-reductions despite for CPC. When treated for 10 min, CPC was most effective followed by BAC, ALX, CHX, and DQC. Stable adaptations with up to fourfold MIC increases were found in E. coli toward all tested antiseptics, in E. faecalis toward CHX and BAC, and in S. aureus toward CPC. Adapted E. coli strains showed different protein expression as compared with the wildtype strain.

Conclusion

Antiseptics showed limited antimicrobial efficacy toward mature biofilms when applied for clinically relevant treatment periods. Bacteria showed phenotypic adaptation upon repeated sub-inhibitory exposure.

Clinical relevance

Clinicians should be aware that wide-spread use of antiseptics may pose the risk of inducing resistances in oral bacteria.

Efficacy of a 0.03% chlorhexidine and 0.05% cetylpyridinium chloride mouth rinse in reducing inflammation around the teeth and implants: a randomized clinical trial

OBJECTIVES

To evaluate the efficacy of a 0.03% chlorhexidine (CHX) and 0.05% cetylpyridinium chloride (CPC) mouth rinse, as an adjunct to professional plaque removal (PPR) and mechanical hygiene, in the treatment of peri-implant mucositis (PiM) and gingivitis.

MATERIAL AND METHODS

Patients displaying PiM in, at least, one implant were included in this randomized, double-blinded, clinical trial. Subjects received PPR (at baseline and 6-month visits) and were instructed to rinse, twice daily, during 1 year with the tested mouth rinse or a placebo. Clinical and patient-reported outcomes were recorded at baseline and 6 and 12 months.

RESULTS

Fifty-four patients were included in the study and 46 attended the final visit. In the teeth and implants with inflammation, a higher reduction in BOP was observed in the test group. Statistically significant differences between groups were only observed in the lingual sites of the teeth with gingivitis (mean difference = 11.96%; 95% confidence interval [1.09; 22.83]; p = 0.03). Overall, compliance and satisfaction were good, even though staining were higher for the test group (p < 0.05).

CONCLUSIONS

The combined use of mechanical debridement with a 0.03% CHX and 0.05% CPC mouth rinse may have adjunctive benefits in the management of gingivitis, and it is associated with a higher degree of staining.

CLINICAL RELEVANCE

The control of gingivitis can be improved, after professional mechanical debridement, with toothbrushing and the supplementary use of a 0.03% CHX and 0.05% CPC mouth rinse at home.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03533166.

Treatment of stage I-III periodontitis-The EFP S3 level clinical practice guideline

BACKGROUND

The recently introduced 2017 World Workshop on the classification of periodontitis, incorporating stages and grades of disease, aims to link disease classification with approaches to prevention and treatment, as it describes not only disease severity and extent but also the degree of complexity and an individual's risk. There is, therefore, a need for evidence-based clinical guidelines providing recommendations to treat periodontitis.

AIM

The objective of the current project was to develop a S3 Level Clinical Practice Guideline (CPG) for the treatment of Stage I-III periodontitis.

MATERIAL AND METHODS

This S3 CPG was developed under the auspices of the European Federation of Periodontology (EFP), following the methodological guidance of the Association of Scientific Medical Societies in Germany and the Grading of Recommendations Assessment, Development and Evaluation (GRADE). The rigorous and transparent process included synthesis of relevant research in 15 specifically commissioned systematic reviews, evaluation of the quality and strength of evidence, the formulation of specific recommendations and consensus, on those recommendations, by leading experts and a broad base of stakeholders.

RESULTS

The S3 CPG approaches the treatment of periodontitis (stages I, II and III) using a pre-established stepwise approach to therapy that, depending on the disease stage, should be incremental, each including different interventions. Consensus was achieved on recommendations covering different interventions, aimed at (a) behavioural changes, supragingival biofilm, gingival inflammation and risk factor control; (b) supra- and sub-gingival instrumentation, with and without adjunctive therapies; (c) different types of periodontal surgical interventions; and (d) the necessary supportive periodontal care to extend benefits over time.

CONCLUSION

This S3 guideline informs clinical practice, health systems, policymakers and, indirectly, the public on the available and most effective modalities to treat periodontitis and to maintain a healthy dentition for a lifetime, according to the available evidence at the time of publication.

Is the oral cavity relevant in SARS-CoV-2 pandemic?

Objectives

Recent scientific evidences suggest a relevant role of the oral cavity in the transmission and pathogenicity of SARS-CoV-2.

Methods

A literature search was performed in PubMed, up to April 30, 2020, focusing on SARS-CoV-2, COVID-19, oral cavity, and antimicrobial agents.

Results

Oral viral load of SARS-CoV-2 has been associated with the severity of COVID-19, and thus, a reduction in the oral viral load could be associated with a decrease in the severity of the condition. Similarly, a decrease in the oral viral load would diminish the amount of virus expelled and reduce the risk of transmission, since (i) during the first 10 days, the virus mainly accumulates at the nasal, oral, and pharyngeal area; (ii) the number of angiotensin-converting enzyme (ACE2) receptor is greater in the salivary glands as compared with the lungs; and (iii) salivary droplets represent the most relevant transmission route. To reduce the oral viral load, antiseptic agents may be used, although the evidence on its efficacy is indirect and weak.

Conclusions

Antiseptic mouth rinses, such as those containing cetylpyridinium chloride or povidone-iodine, may be able to decrease the severity of COVID-19 by reducing oral viral load in infected subjects and decreasing the risk of transmission by limiting viral load in droplets, generated in normal life, or in aerosols, produced during dental procedures. Well-designed clinical and preclinical research must be conducted to support these hypotheses.

Clinical relevance

Antiseptic mouth rinses may help in decreasing the severity of COVID-19 and in reducing the risk of transmission.

Efficacy of a novel post-foaming dental gel on gingival inflammation: A randomized controlled clinical trial

BACKGROUND

A pilot randomized controlled clinical trial was performed to evaluate the efficacy of a post-foaming dental gel containing cetylpridinium chloride (CPC), hydrogen peroxide (H₂ O₂ ), sodium bicarbonate, and antioxidants on periodontal/oral health.

METHODS

Individuals with gingivitis or mild-moderate periodontitis (n=36) were included and randomly assigned to Group 1 and 2 with foaming gel loaded on a mouthpiece with a light source and controlled warming heat built-in unit or on a toothbrush, respectively, in addition to regular twice-daily brushing. Group 3 served as control with twice daily brushing and further assigned split-mouth to Group 3a-un-flossed and Group 3b-flossed. Gingival index (GI) and bleeding on probing (BOP) were evaluated in addition to plaque index (PI), pocket depth, and clinical attachment level at days 14, 28, 42 (treatment), and 60 (maintenance). Subgingival plaque microbial profiles and gingival crevicular fluid (GCF) cytokine levels were determined by DNA-DNA hybridization and multiplexing assays, respectively. Exploratory analyses included esthetic outcomes: changes in tooth color and levels of volatile sulfur compounds in breath. Statistical analyses were conducted using ANOVA with a post hoc analysis of Fisher's LSD.

RESULTS

Use of post-foaming gel in both test groups resulted in significant changes in GI and BOP at Day 42 compared to control and un-flossed control (P<0.05). Device-enhanced foaming gel significantly reduced the PI in Group 1 at Day 42 compared to control and un-flossed control (P=0.02; P=0.007, respectively). GCF IL-6 and TNF-α levels were significantly reduced in Group 2 compared to control (P_IL-6 =0.01, P_TNF-α =0.02). Post-foaming gel resulted in greater reductions in periodontopathogens, whereas health-associated species remained stable. Despite cessation of adjunct treatments, Group 1 and 2 continued having reduced levels of GI, BOP, and PI at Day 60 (P<0.05).

CONCLUSIONS

The novel post-foaming dental gel improves oral health by reducing gingival inflammation at the local site in addition to better esthetic outcomes.

Clinical and Microbiological Evaluation of Brazilian Red Propolis Containing-Dentifrice in Orthodontic Patients: A Randomized Clinical Trial

Aim

To evaluate the efficacy of dentifrice containing brazilian red propolis (BRP) in adolescents under orthodontic treatment. Materials and Methods. This is a randomized, double-blind, clinical trial. A total of 92 participants free from caries were randomized into 2 groups; the first received fluoride dentifrice, and the second received fluoride dentifrice incorporated with BRP. The gingival bleeding index (GBI) was recorded, and saliva was collected on the baseline (D0) and after 28 days (D28) for microbiological analysis. Data from GBI and Colony Forming Units (CFU) (log₁₀) were expressed as mean and standard deviation.

Results

The two groups reduced GBI significantly, with no difference in the intergroup analysis. In the intragroup analysis, it was observed that G2 (p < 0.001) had a significant reduction for Gram-negative bacteria, while there was significance (p < 0.001) had a significant reduction for Gram-negative bacteria, while there was significance (S. mutans bacteria, it was observed that only G2 had a statistically significant reduction (p < 0.001) had a significant reduction for Gram-negative bacteria, while there was significance (p < 0.001) had a significant reduction for Gram-negative bacteria, while there was significance (.

Conclusions

Dentifrice containing BRP demonstrated better clinical and microbiological activity. Future studies are needed to better identify effects to establish the use of dentifrice containing propolis in biofilm control.

Effect of herbal mouthrinses on dental plaque formation and gingival inflammation: A systematic review

To evaluate the effect of herbal mouthrinses as an adjuvant to oral hygiene on dental plaque and gingival inflammation in subjects with gingivitis. Searches were conducted in the PubMed/MEDLINE, Cochrane-CENTRAL, EMBASE, Web of Science, LILACS/BIREME, Clinical Trials Registry and grey literature for Randomised Clinical Trials (RCTs) published up to April 2018 without language restrictions. From 4,013 paper found, 20 studies met the eligibility criteria and were included. The herbal mouthrinses achieved significant reductions in dental plaque and gingival inflammation compared to placebo rinses. Five herbal products (Camelia sinensis, Azadirachta indica, Anacardium occidentale Linn, Schinus terebinthifolius and Curcuma longa) showed better results than chlorhexidine in dental plaque and gingival inflammation reductions. However, the unclear risk of bias of most included RCTs precludes definitive conclusions. Therefore, it is necessary to improve the design of future RCT in other reduced potential bias that may affect the degree of precision of treatment outcomes in order to evaluate the effect size and clinical relevance of herbal mouthrinses.

Evidence-based strategy for dental biofilms: Current evidence of mouthwashes on dental biofilm and gingivitis

Therapeutic mouthwash (MW) is an adjunctive tool along with a regular oral hygiene routine of daily tooth brushing and daily flossing. Previous systematic reviews have demonstrated that it is effective against dental biofilm and gingival inflammation, for prevention of dental caries, and for managing one's bad breath condition according to the active ingredients. MWs prevent the microorganisms from bacterial adhesion that corresponds to the initial step in biofilm formation. This review summarized the current state of evidence such as anti-biofilm, anti-gingivitis and cariostatic properties of MWs by evaluating systematic reviews from the past six years. The anti-biofilm property has been proven to be effective, with strong evidence of three main clinical efficacies. The most commonly studied active agent was chlorhexidine gluconate (CHX), followed by essential oil (EO) and cetylpyridinium chloride. All the systematic reviews are in complete agreement that CHX and EO provide statistically significant improvements in terms of plaque and gingival indices. These effects have held up over the years as the number of studies has increased. While the use of fluoride MW is proven to be effective in improving the oral health of both children and adults, the quality of evidence is still regarded as low.

Efficacy of adjunctive anti-plaque chemical agents in managing gingivitis: A systematic review and network meta-analyses

AIM

The aim of this network meta-analysis (NMA) was to compare the efficacy of different oral hygiene products for chemical biofilm control, in 6-month home-use, randomized clinical trials (RCTs), in terms of changes in gingival index (GI).

MATERIAL AND METHODS

Six-month RCTs assessing GI were identified and screened for inclusion. Relevant information was extracted, and quality and potential risk of bias were estimated. Mean differences between baseline and end were calculated to obtain standardized mean differences (SMDs). NMA protocols were applied to assess direct and indirect comparisons among products using Löe & Silness GI, modified GI and gingival severity index.

RESULTS

Fifty-three papers were included, 19 studies for mouth rinses, 32 for dentifrices, comprising data from 5,775 and 2,682 subjects, respectively. When ranking treatments, similar results were observed for all tested dentifrices, with the lowest effect observed for sanguinarine and baking soda. For mouth rinses, essential oils, triclosan-copolymer, chlorhexidine (at concentrations ≥ 0.10%) and cetylpyridinium chloride (>0.05%) demonstrated the greatest effect.

CONCLUSION

Although NMA revealed significant differences when comparing placebo versus some active agents, when comparing among active agents, no differences were found for dentifrices, while mouth rinses containing essential oils showed the greatest effect on GI scores.

The efficacy of baking soda dentifrice in controlling plaque and gingivitis: A systematic review

OBJECTIVE

To test the efficacy of a dentifrice containing baking soda (BS), compared with dentifrice without BS for controlling plaque and gingivitis.

MATERIALS AND METHODS

MEDLINE-PubMed and Cochrane-CENTRAL were searched. The inclusion criteria were randomized controlled clinical trials including healthy participants aged 18 years or older. Studies were selected that compared the effect of toothbrushing with a dentifrice with and without BS on the clinical parameters of plaque and gingivitis. Data were extracted from the selected studies, and a meta-analysis was performed.

RESULTS

The search retrieved 21 eligible publications. Among these papers, 43 comparisons were provided, with 23 involving a single-use design and 20 being evaluations with a follow-up. Negative controls were found, or positive controls for which various active ingredients had been used. The included studies showed a moderate overall potential risk of bias and considerable heterogeneity. The meta-analysis of plaque scores from the single-brushing experiments showed that BS dentifrice (BS-DF) was associated with significantly better outcomes than the negative control dentifrices (DiffM -0.20; P < 0.0001; 95% CI: [-0.27; -0.12]) or the positive control dentifrices (DiffM -0.18; P < 0.0001; 95% CI: [-0.24; -0.12]). This finding was only confirmed in studies that used a follow-up design as compared to a negative control (DiffM -0.19; P = 0.01; 95% CI: [-0.34; -0.04]). The indices of gingival bleeding also improved when the comparison was a negative control (DiffM -0.08; P = 0.02; 95% CI: [-0.16; -0.01] and (DiffM -0.13; P < 0.001; 95% CI: [-0.18; -0.08]. However, for the gingival index scores, the meta-analysis did not reveal any significant differences.

CONCLUSION

BS-DF showed promising results with respect to plaque removal in single-use studies. However, the finding was partially substantiated in follow-up studies. Studies that assessed bleeding scores indicated that a small reduction can be expected from BS, relative to a control product.

Plaque control and reduction of gingivitis: The evidence for dentifrices

This paper focuses on plaque control and the management of gingivitis in adults and summarizes the evidence of commercially available dentifrices as gathered from existing systematic reviews. Three internet sources were used to search for appropriate papers (up to and including February 2017). The search strategy was designed to include any systematic review published on dentifrices that also included an evaluation of plaque and gingivitis scores. Characteristics of the individual reviews, such as methodological aspects, quantitative data and conclusions, were extracted. The potential risk of bias was estimated and the acquired evidence was graded. Independent screening of 205 unique reviews resulted in 10 published and eligible systematic reviews. One publication evaluated the mechanical contribution of dentifrice to plaque removal. Eight papers were identified that evaluated the efficacy of a proposed single active ingredients, of which two reviewed more than one potentially active ingredient. One study compared two active ingredients. This meta-review appraised the current state of evidence and found that toothbrushing with a standard fluoride dentifrice does not provide an added effect for the mechanical removal of dental plaque. Evidence suggests that compared with a standard dentifrice, those containing triclosan or stannous fluoride have benefits with respect to gingival health and control of dental plaque.

Changes in plaque and gingivitis levels after tooth bleaching: A systematic review

OBJECTIVES

The primary aim of this systematic review was to evaluate the effect of external tooth-bleaching products on plaque indices and to compare it to a placebo or a negative control.

METHODS

A protocol was developed aimed to answer the next focused question: What is the effect of tooth bleaching compared to no treatment or a placebo, in subjects without periodontitis aged ≥18 years in the levels of plaque and gingivitis? Two electronic databases were used as sources in the search for studies satisfying the inclusion criteria: (a) The National Library of Medicine (MEDLINE via PubMed); (b) Cochrane Central Register of Controlled Trials.

RESULTS

Only randomized controlled trials were included. The initial search found 382 potential publications. Seven of them were finally included, and six were used in the meta-analyses. The use of bleaching products showed higher reductions in plaque (n = 6; standardized mean difference [SMD] = 0.47; 95% confidence interval [CI] = 0.06, 0.88; P < 0.001) and gingivitis indices (n = 4; SMD = 0.47; 95% CI = 0.22, 0.73; P < 0.001), when compared to a control group (no treatment or placebo).

CONCLUSIONS

External tooth bleaching is associated with statistically significant short-term reductions in plaque and gingivitis indices. However, no data were available to evaluate long-term effects.

Salivary arginase activity after mechanical-chemical therapy

Abstract Introduction Salivary components can be used as biomarkers for diagnosing and monitoring oral diseases. There is evidence that one potential biomarker, arginase, is associated with the inflammatory processes of periodontal disease, and its enzymatic activity is reduced according to the improvement in the clinical parameters after treatment. Objective The present study aimed to evaluate the salivary arginase activity in gingivitis and periodontitis patients treated with full-mouth mechanical procedures combined with the adjunctive use of essential oils or chlorhexidine mouthwash, respectively. Material and method Twenty-six gingivitis and 16 periodontitis patients received complete periodontal examinations at the baseline and 3 months after therapy, in which the periodontal probing depth, clinical attachment loss, plaque index, and gingival index measurements were taken. At these same appointments, the salivary total protein level and salivary arginase activity were also established via spectrophotometry. Result There were improvements in all of the clinical parameters (p < 0.05) evaluated from the baseline to 3 months in both groups. In addition, the salivary arginase activity and total protein levels were reduced after the gingivitis treatment. Conclusion Similar to the clinical results, both therapeutic protocols positively affected the salivary arginase activity; however, further studies are necessary to clarify its potential as a salivary biomarker for periodontal monitoring.

Critical quality evaluation of network meta-analyses in dental care

OBJECTIVE

Network meta-analysis (NMA) is a new method to compare the effects of multiple treatments in dental care. We examined whether published NMA follow the key methodological reporting recommendations, the PRISMA Extension Statement.

DESIGN

Collection of published systematic reviews with NMA in dental care DATA SOURCES: MEDLINE, EMBASE, and Web of Science searched from inception to May 1, 2017.

STUDY SELECTION

All NMA published in dental journals comparing the clinical efficacy of three or more interventions with and without closed loops.

DATA EXTRACTION AND SYNTHESIS

NMA reporting was assessed according to the PRISMA Extension checklist. We assessed the reporting of general components (27 items) and key NMA methodological components (5 new items, S 1-5) of the systematic review process of NMA in dental care.

RESULTS

Among 85 identified articles, 21 NMA (16 used the Bayesian statistical approach, and 5 the frequentist approach) were included. Overall, among 21 articles, 15 (71%) reports of NMA in dental care did not describe in detail the network regarding S1-5 based on the PRISMA Extension. Problem areas include exploring the geometry of the network (S1), assessment of insistency (S2) in the method section, presentation of network structure (S3), summary of network geometry (S4), exploration for inconsistency (S5) in the result section, risk of bias across studies, protocol registrations, and additional analysis.

CONCLUSIONS

The quality of NMA reporting was low in the dental field. An NMA with inadequate reporting reduces the end-user's confidence on the quality of the reported results. The PRISMA Extension guideline is relatively new and should be used more extensively to improve reporting practices in the field of dental care.

Nonsurgical and surgical treatment of periodontitis: how many options for one disease?

Treatment of periodontitis aims at preventing further disease progression with the intentions to reduce the risk of tooth loss, minimize symptoms and perception of the disease, possibly restore lost periodontal tissue and provide information on maintaining a healthy periodontium. Therapeutic intervention includes introduction of techniques to change behavior, such as: individually tailored oral-hygiene instructions; a smoking-cessation program; dietary adjustment; subgingival instrumentation to remove plaque and calculus; local and systemic pharmacotherapy; and various types of surgery. No single treatment option has shown superiority, and virtually all types of mechanical periodontal treatment benefit from adjunctive antimicrobial chemotherapy. Periodontal treatment, because of the chronic nature of periodontitis, is a lifelong commitment to intricate oral-hygiene techniques, which, when properly implemented, will minimize the risk of disease initiation and progression.

The plaque and gingivitis inhibiting capacity of a commercially available mouthwash containing essential oils and ethyl lauroyl arginate. A randomized clinical trial

OBJECTIVE

A commercially available mouth rinse with ethyl lauroyl arginate and essential oils claims to have better antimicrobial properties than the traditional essential oil products. The aim of this study was to compare the plaque and gingivitis inhibiting effect of the commercial product containing essential oils with ethyl lauroyl arginate with one placebo and one negative control in a modified experimental gingivitis model.

MATERIALS AND METHODS

In three groups of healthy volunteers, experimental gingivitis was induced and monitored over 21 d, simultaneously treated with the commercial test solution, 21.6% hydro-alcohol solution and sterile water, respectively. The maxillary right quadrant of each individual received mouthwash only, whereas the maxillary left quadrant was subject to both rinsing and mechanical oral hygiene. Compliance and side effects were monitored at d 7, 14, and 21. Plaque and gingivitis scores were obtained at baseline and d 21.

RESULTS AND CONCLUSION

Although the commercial product containing essential oils with ethyl lauroyl arginate performed statistically significantly better regarding average plaque scores on all surfaces combined than the placebo (p = .018) and negative control (p = .003) when no mechanical tooth cleaning was performed, the product still left the patient with enough plaque to cause gingivitis and thus seemed of questionable clinical benefit to the patient. ClinicalTrials.gov Identifier is NCT02884817.