Chlorhexidine mouthwash as an adjunctive treatment for gingival health

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dc.contributor.author James, Patrice
dc.contributor.author Worthington, Helen V.
dc.contributor.author Parnell, Carmel
dc.contributor.author Harding, Máiréad
dc.contributor.author Lamont, Thomas
dc.contributor.author Cheung, Andrea
dc.contributor.author Whelton, Helen
dc.contributor.author Riley, Philip
dc.date.accessioned 2018-05-11T12:05:09Z
dc.date.available 2018-05-11T12:05:09Z
dc.date.issued 2017-03-31
dc.identifier.citation James, P., Worthington, H. V., Parnell, C., Harding, M., Lamont, T., Cheung, A., Whelton, H. and Riley, P. (2017) 'Chlorhexidine mouthwash as an adjunctive treatment for gingival health', Cochrane Database of Systematic Reviews, 3, CD008676 (248pp). doi: 10.1002/14651858.CD008676.pub2 en
dc.identifier.issued 3 en
dc.identifier.startpage 1 en
dc.identifier.endpage 248 en
dc.identifier.issn 1469-493X
dc.identifier.uri http://hdl.handle.net/10468/6085
dc.identifier.doi 10.1002/14651858.CD008676.pub2
dc.description.abstract Background: Dental plaque associated gingivitis is a reversible inflammatory condition caused by accumulation and persistence of microbial biofilms (dental plaque) on the teeth. It is characterised by redness and swelling of the gingivae (gums) and a tendency for the gingivae to bleed easily. In susceptible individuals, gingivitis may lead to periodontitis and loss of the soft tissue and bony support for the tooth. It is thought that chlorhexidine mouthrinse may reduce the build-up of plaque thereby reducing gingivitis. Objectives: To assess the effectiveness of chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for the control of gingivitis and plaque compared to mechanical oral hygiene procedures alone or mechanical oral hygiene procedures plus placebo/control mouthrinse. Mechanical oral hygiene procedures were toothbrushing with/without the use of dental floss or interdental cleaning aids and could include professional tooth cleaning/periodontal treatment. To determine whether the effect of chlorhexidine mouthrinse is influenced by chlorhexidine concentration, or frequency of rinsing (once/day versus twice/day). To report and describe any adverse effects associated with chlorhexidine mouthrinse use from included trials. Search methods: Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 28 September 2016); the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8) in the Cochrane Library (searched 28 September 2016); MEDLINE Ovid (1946 to 28 September 2016); Embase Ovid (1980 to 28 September 2016); and CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to 28 September 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. Selection criteria: We included randomised controlled trials assessing the effects of chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for at least 4 weeks on gingivitis in children and adults. Mechanical oral hygiene procedures were toothbrushing with/without use of dental floss or interdental cleaning aids and could include professional tooth cleaning/periodontal treatment. We included trials where participants had gingivitis or periodontitis, where participants were healthy and where some or all participants had medical conditions or special care needs. Data collection and analysis: Two review authors independently screened the search results extracted data and assessed the risk of bias of the included studies. We attempted to contact study authors for missing data or clarification where feasible. For continuous outcomes, we used means and standard deviations to obtain the mean difference (MD) and 95% confidence interval (CI). We combined MDs where studies used the same scale and standardised mean differences (SMDs) where studies used different scales. For dichotomous outcomes, we reported risk ratios (RR) and 95% CIs. Due to anticipated heterogeneity we used random-effects models for all meta-analyses. Main results: We included 51 studies that analysed a total of 5345 participants. One study was assessed as being at unclear risk of bias, with the remaining 50 being at high risk of bias, however, this did not affect the quality assessments for gingivitis and plaque as we believe that further research is very unlikely to change our confidence in the estimate of effect. Gingivitis: After 4 to 6 weeks of use, chlorhexidine mouthrinse reduced gingivitis (Gingival Index (GI) 0 to 3 scale) by 0.21 (95% CI 0.11 to 0.31) compared to placebo, control or no mouthrinse (10 trials, 805 participants with mild gingival inflammation (mean score 1 on the GI scale) analysed, high-quality evidence). A similar effect size was found for reducing gingivitis at 6 months. There were insufficient data to determine the reduction in gingivitis associated with chlorhexidine mouthrinse use in individuals with mean GI scores of 1.1 to 3 (moderate or severe levels of gingival inflammation). Plaque: Plaque was measured by different indices and the SMD at 4 to 6 weeks was 1.45 (95% CI 1.00 to 1.90) standard deviations lower in the chlorhexidine group (12 trials, 950 participants analysed, high-quality evidence), indicating a large reduction in plaque. A similar large reduction was found for chlorhexidine mouthrinse use at 6 months. Extrinsic tooth staining: There was a large increase in extrinsic tooth staining in participants using chlorhexidine mouthrinse at 4 to 6 weeks. The SMD was 1.07 (95% CI 0.80 to 1.34) standard deviations higher (eight trials, 415 participants analysed, moderate-quality evidence) in the chlorhexidine mouthrinse group. There was also a large increase in extrinsic tooth staining in participants using chlorhexidine mouthrinse at 7 to 12 weeks and 6 months. Calculus: Results for the effect of chlorhexidine mouthrinse on calculus formation were inconclusive. Effect of concentration and frequency of rinsing There were insufficient data to determine whether there was a difference in effect for either chlorhexidine concentration or frequency of rinsing. Other adverse effects: The adverse effects most commonly reported in the included studies were taste disturbance/alteration (reported in 11 studies), effects on the oral mucosa including soreness, irritation, mild desquamation and mucosal ulceration/erosions (reported in 13 studies) and a general burning sensation or a burning tongue or both (reported in nine studies). Authors' conclusions: There is high-quality evidence from studies that reported the Löe and Silness Gingival Index of a reduction in gingivitis in individuals with mild gingival inflammation on average (mean score of 1 on the 0 to 3 GI scale) that was not considered to be clinically relevant. There is high-quality evidence of a large reduction in dental plaque with chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for 4 to 6 weeks and 6 months. There is no evidence that one concentration of chlorhexidine rinse is more effective than another. There is insufficient evidence to determine the reduction in gingivitis associated with chlorhexidine mouthrinse use in individuals with mean GI scores of 1.1 to 3 indicating moderate or severe levels of gingival inflammation. Rinsing with chlorhexidine mouthrinse for 4 weeks or longer causes extrinsic tooth staining. In addition, other adverse effects such as calculus build up, transient taste disturbance and effects on the oral mucosa were reported in the included studies. en
dc.description.sponsorship Health Research Board (Cochrane Fellowship Scheme, Ireland); National Institute for Health Research (Cochrane Infrastructure funding to Cochrane Oral Health) en
dc.format.mimetype application/pdf en
dc.language.iso en en
dc.publisher John Wiley & Sons, Ltd. en
dc.rights © 2017, The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. This review is published as a Cochrane Review in the Cochrane Database of Systematic Reviews 2017, Issue 3. Cochrane Reviews are regularly updated as new evidence emerges and in response to comments and criticisms, and the Cochrane Database of Systematic Reviews should be consulted for the most recent version of the Review. en
dc.subject Gingivitis en
dc.subject Plaque en
dc.subject Mouthwash en
dc.subject Extrinsic tooth staining en
dc.title Chlorhexidine mouthwash as an adjunctive treatment for gingival health en
dc.type Review en
dc.internal.authorcontactother Patrice James, Oral Health & Development, University College Cork, Cork, Ireland. +353-21-490-3000 Email: p.james@ucc.ie en
dc.internal.availability Full text available en
dc.date.updated 2018-04-30T08:58:50Z
dc.description.version Published Version en
dc.internal.rssid 392326225
dc.contributor.funder Health Research Board en
dc.contributor.funder National Institute for Health Research en
dc.contributor.funder Cochrane Oral Health Global Alliance, United Kingdom
dc.description.status Peer reviewed en
dc.identifier.journaltitle Cochrane Database of Systematic Reviews en
dc.internal.copyrightchecked Yes en
dc.internal.licenseacceptance Yes en
dc.internal.IRISemailaddress p.james@ucc.ie en


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