Accepted: 30 May 2017

DOI: 10.1111/idh.12299

ORIGINAL ARTICLE

Assessment of efficacy of two chlorhexidine mouthrinses on

oral hygiene and gingival health in adolescents wearing two
types of orthodontic brackets

S Jurišić1 | Ž Verzak2 | G Jurišić1 | H Jurić2

1
Private Practice, Dental Polyclinic Jurišić,
Mostar, Bosnia and Herzegovina Abstract
2
Paediatric Dentistry Department, School Objective: To investigate the efficacy of two formulations of chlorhexidine 0.2%
of Dental Medicine, University of Zagreb,
(CHX) mouthrinses in terms of oral hygiene and gingival health status in adolescents
Zagreb, Croatia
with fixed orthodontic appliances wearing two different types of brackets during
Correspondence
18 weeks.
Sanja Jurišić, Dental Polyclinic Jurišić, Mostar,
Bosnia and Herzegovina. Study population and methodology: Eighty subjects were randomly divided into two
Email: [email protected]
equal groups according to brackets type: (i) metal-­stainless steel, (ii) ceramic. Four
weeks after the placement of the fixed orthodontic appliances the subjects from each
group were randomly allocated into two equal subgroups and were provided with two
different mouthrinses for 14 days: (i) alcohol-­free CHX, (ii) CHX with antidiscoloration
system (CHX-­ADS). Assessment was carried out according to gingival index (GI) and
oral hygiene index-­simplified (OHI-­S) performed prior to the placement of the appli-
ance (t1), 6 weeks (t2), and 18 weeks (t3) after the placement. To analyse the data, two-­
way mixed model MANOVA. Pearson correlations, one-­way ANOVA and Independent
Samples t test were conducted.
Results: Statistically significant decrease in GI and OHI-­S indices after 6 weeks and
then increase after 18 weeks for all groups was found. Both GI and OHI-­S values were
lower in subjects wearing ceramic brackets, with statistically significant difference for
GI after the usage of the mouthrinse for 14 days, at t2 (P<.05).
Conclusion: The results revealed that the ceramic brackets as well as usage of CHX-­
ADS resulted in improved gingival status.

KEYWORDS
chlorhexidine, gingival index, mouthrinse, oral hygiene, orthodontic bracket

1 | INTRODUCTION aesthetics during orthodontic treatment, it is essential to identify

possible variations in the dental plaque retention on different bracket
Multibracket orthodontic appliances increase dental plaque retention materials in order to decrease the risk of possible side effects of the
and make oral hygiene more difficult for patients.1 It is hard to effec- therapy.6 Plaque in association with fixed appliances can result in clini-
tively educate patients to reduce plaque solely by mechanical means cal problems, like demineralization of the adjacent enamel and gingival
as mechanical methods of plaque removal require motivation, man- inflammation.7,8 Oral hygiene is the most effective means of prevent-
2
ual dexterity and dedication. This is especially evident with fixed or- ing plaque accumulation, also controlling gingivitis and periodontal
thodontic appliances.3-5 Since the popularity of ceramic brackets has disease.9 Orthodontists usually recommend scrupulous maintaining
grown during the last few years due to increased demand for superior oral hygiene during therapy.10 Several antimicrobial agents have been

Int J Dent Hygiene. 2017;1–6. wileyonlinelibrary.com/journal/idh © 2017 John Wiley & Sons A/S. | 1
Published by John Wiley & Sons Ltd
2 | JURIŠIĆ et al.

incorporated in mouthrinses as adjuncts to daily plaque control and

Orthodontic patients
are more beneficial than only mechanical brushing.11 Chlorhexidine (n=87)
(CHX) mouthrinse, as antimicrobial agent is considered the gold stan- Excluded (n=7)

Enrollment
dard in preventing the dental plaque formation and gingival inflam- - Not meeting inclusion criteria
- antibiotic intake (n=4)
mation due to its antigingivitis effects.12 It is a cationic composition - Refused to participate (n=3)
that can bind to bacterial plaque, enamel hydroxyapatite and mucous
membranes.13 Some studies have shown that CHX has side effects,
like extrinsic tooth and tongue staining.14 In recent times in dental
clinical practice, there has also been an advanced version of CHX with Randomized (n=80)
antidiscoloration system (CHX-­ADS). Besides maintaining its antisep-
tic qualities, ­CHX-­ADS avoids the side effect of staining.15
The aim of this study was to investigate the effectiveness of two
chlorhexidine mouthrinses on oral hygiene and gingival health status Metalic brackets Ceramic brackets
(n=40) (n=40)

Allocation
of adolescents wearing two different types of orthodontic brackets.
The first null hypothesis was that two mouthrinses show no differ-
ences in the effectiveness of reducing gingival signs of inflammation CHX CHX- CHX CHX-
and improving oral hygiene during the period of 18 weeks. The sec- (n=20) ADS (n=20) ADS
(n=20) (n=20)
ond null hypothesis of the study was that stainless steel and ceramic
­brackets show no influence on gingival and oral health status.

Follow up t1, t2, t3 t1, t2, t3 t1, t2, t3 t1, t2, t3

2 | STUDY POPULATION AND (n=20) (n=20) (n=20) (n=20)
METHODOLOGY

Eighty-­seven subjects with indications for fixed orthodontic treatment

from Dental Polyclinic participated in this prospective clinical study. Analyzed Analyzed Analyzed Analyzed
Analysis

The subjects had to fulfil the following criteria: good general health, (n=20) (n=20) (n=20) (n=20)
no antibiotic intake or use of antibacterial mouthrinses in the previ-
ous 3 months, no periodontal disease (no periodontal probing depth
FIGURE 1 Consort diagram
>4 mm; bleeding on probing frequency <20%) and non-­smoking. To
determine the periodontal condition, all the subjects were assessed
by clinical periodontal examination using periodontal probe (973/ CA, USA) by random choice (Figure 1). All archwires were ligated using
CP12, Carl Martin GmbH, Solingen, Germany). Seven subjects were stainless steel ligatures (Dentaurum GmbH, Ispringen, Germany).
excluded because they did not meet the inclusion criteria (four used Four weeks after the placement of the fixed orthodontic appliance
antibiotics at the time and three refused to participate). In total 80 the subjects from each bracket group were randomly allocated into
subjects were included (61 girls, 19 boys; aged 11-­18 years, mean age two equal subgroups and were provided with two different mouth-
14.2±1.4 years). rinses for use during the next 14 days. Within each bracket group 20
Before the treatment and at every visit, the patients were given subjects received a conventional, alcohol-­free chlorhexidine solution
oral hygiene instructions. Verbal instruction and physical demon- (0.2% CHX; Parodontax extra 0.2; GlaxoSmithKline Consumer Health
stration were provided on how to carry out effective oral hygiene care, Brentford, UK), 20 subjects received a chlorhexidine solu-
close to the brackets and ligatures, and how to use dental floss for tion with antidiscoloration system (0.2% CHX-­ADS; Curasept ADS
cleaning spaces around the brackets, between the teeth and under 220, Curaprox; Kriens, Switzerland). Ten millilitres of each mouthrinse
the archwires using a model. All instructions were given by the same was used twice daily. The subjects were instructed to avoid eating and
experienced investigator. The subjects were instructed to use manual drinking for 30 minutes after mouthrinse usage.16
and interdental tooth brushes and floss twice daily. The study was ap- The following parameters were measured as follows:
proved by the Ethical Committee of the Medical Health Centre, Dental
Polyclinic Jurišić (protocol no 011.2014.), and a written consent was 1. gingival status—using the gingival index—Löe and Silness (GI)
obtained from the participants and their parents. for each tooth with brackets17
Total of 80 subjects considered for standard orhtodontic treatment 2. oral hygiene status—using the oral hygiene index-simplified (OHI-S)
(metalic brackets) were randomly divided into two groups according examining standard six tooth surfaces (facial surfaces of the first mo-
to brackets types: 40 subjects received metal-­stainless steel brackets lars in the right and left maxilla, the lingual surfaces of the first molars
(Ortho Classic, McMinnville, Oregon, USA; Mini Twin, OR, USA), and in the right and left sides of the mandible; the facial surfaces of the
40 subjects received ceramic brackets (3M Unitec; Clarity, Monrovia, maxillary right central incisor and mandibular left central incisor).18
JURIŠIĆ et al. | 3

The mean values for OHI-­s and GI were calculated. All clinical mea- T A B L E 1 Two-­way mixed model MANOVA for GI and OHI-­S:
surements were performed by the same examiner at three time points: (i) within-­and between-­subjects effects
prior to the placement of the fixed orthodontic appliance (t1), (ii) 6 weeks CHX CHX-­ADS
after the placement of the fixed orthodontic appliance (after 14 days of
N Mean SD N Mean SD
rinsing) (t2), and (iii) 18 weeks after the placement of the fixed orthodon-
tic appliance (t3). The data were analysed by spss 23.0 software (SPSS Inc, Metalic brackets
Chicago, IL, USA). As all variables were found to be normally distributed GI t1 20 0.46* 0.32 20 0.44* 0.27
according to one-­way Kolmogorov-­Smirnov test; parametric tests were GI t2 20 0.34* 0.26 20 0.28* 0.12
used in further statistical analysis (P>.05). GI t3 20 0.37* 0.21 20 0.35* 0.15
Two-­way mixed model MANOVA [group (bracket, mouthrinse)×- OHI-­S t1 20 0.75**,† 0.39 20 0.72**,† 0.42
time point (t1, t2, t3)] was applied to determine the effect of the dif-
OHI-­S t2 20 0.54**,† 0.23 20 0.45**,† 0.22
ferent type of orthodontic brackets and different mouthrinses on GI
OHI-­S t3 20 0.65**,† 0.43 20 0.51**,† 0.20
and OHI-­S. Pearson correlations were performed between all depen-
Ceramic brackets
dent variables together with testing of covariance matrices. Series of
GI t1 20 0.38* 0.22 20 0.35* 0.16
follow-­up ANOVAs were then performed to determine differences in
GI t2 20 0.25* 0.10 20 0.09* 0.06
GI and OHI-­S between three testing times together with Bonferroni
corrections for multiple comparisons. Between-­subjects t test was GI t3 20 0.35* 0.22 20 0.33* 0.25
,† ,†
used to compare mean GI and OHI-­S values between the two types OHI-­S t1 20 0.68** 0.32 20 0.64** 0.39
,† ,†
of chlorhexidine mouthrinses and the two types of orthodontic OHI-­S t2 20 0.42** 0.20 20 0.36** 0.20
brackets. OHI-­S t3 20 0.68**,† 0.30 20 0.45**,† 0.25

*Within MANOVA significance F=7.64; df=2; P<.05.

**Within MANOVA significance F=16.11; df=2; P<.05.
3 | RESULTS
†
Within MANOVA significance F=5.316; df=2; P<.05.

From 87 subjects participating in the study 80 subjects met inclusion No significant differences in GI and OHI-­S values in ceramic brack-
criteria (61 girls, 19 boys; aged 11-­18 years, mean age 14.2±1.4 years) ets groups using CHX were found. However, between the measure-
and participated in the study. Changes in the values of GI and OHI-­S ments a decreasing trend at t2 followed by an increasing trend at the
were observed, and it was noticed that the changes observed de- t3 were also seen (P>.05). At the same time, GI and OHI-­S values in
pended on the type of orthodontic brackets and different mouthrinses the ceramic brackets groups using CHX-­ADS at different time points
at definite points of time (0, 6 and 18 weeks) after insertion of the significantly differed (F=9.539; df=2; P=.000, F=4.445; df=2; P=.016;
orthodontic appliances. respectively).
Pearson correlations revealed a meaningful pattern of correlations
amongst most of the dependent variables. Covariance matrices be-
tween the groups were assumed to be equal for the purposes of the 4 | DISCUSSION
MANOVA.
A statistically significant MANOVA effect was obtained using During orthodontic treatment, an increased accumulation of plaque
Pillais’ Trace test for within subject factor time point for GI (Table 1; may be found around the brackets due to inadequate oral hygiene,
P<.05). Also statically significant MANOVA effect was obtained using as is often the case in pubertal young people.19 Clinical studies have
same Pillais’ Trace test for within subject factor time point and within shown an increase in biofilm formation combined with an ecological
subject factors time*mouthrinse (Table 1; P<.05). change of the microbial profile after orthodontic brackets insertion.20
Mean values of gingival and oral hygiene parameters (GI and OHI-­S) In this study, gingival status, as well as oral hygiene maintenance was
within the two different orthodontic brackets and the type of mouth- analysed in adolescent orthodontic patients wearing different types
rinse used in the study are presented in Table 1. Significantly lower GI of brackets. As mentioned above, problems concerning habits and at-
value at second time point for all bracket types and mouthrinses after titudes in dental hygiene in orthodontic subjects have already been
the usage of the mouthrinse was found (t2; 6 weeks later) (t=2.313; reported.21-23 Therefore, this study group was divided to explore the
df=78; P=.023). The results of the comparison of the measurements at differences in GI and OHI-­S values between adolescents wearing or-
all three time points in each subgroup showed a decreasing trend for thodontic appliances with two different orthodontic brackets types.
both parameters evaluated in the study at t2 and an increasing trend The results of this study revealed lower values of both investigated
at t3. The time changes for the evaluated GI and OHI-­S parameters in parameters in the ceramic brackets group with significantly lower GI
both groups and subgroups are also shown in Table 1. value at second time point, after the usage of the mouthrinse (P<.05;
In the ceramic brackets group, the mean GI values were signifi- Table 1).
cantly lower in the subjects using CHX-­ADS mouthrinse (t=2.849; The second interesting item in the study was the format of the
df=38; P=.046). study, which was constructed for orthodontic patients wearing their
4 | JURIŠIĆ et al.

appliances for a long period of time and using a mouthrinse during gingival fluids on antimicrobial properties of CHX.35,37 The results of
the testing period. Therefore, GI and OHI-­S were measured at three this study revealed lower GI and OHI-­S in the subjects using CHX-­
time points. The first measurement was taken prior to the placement ADS mouthrinse in both orthodontic brackets groups and in case of
of the fixed orthodontic appliance. Following the orthodontic check GI in ceramic brackets this difference even reached the level of signifi-
up at 4 weeks, the subjects were given a mouthrinse. The second cance proving that the superior version of conventional CHX improves
set of measurements was taken 14 days after using the mouthrinse ­gingival health (P<.05; Table 1).
or 6 weeks after the appliance placement. The third measurement An interesting finding was the specific trend in GI and OHI-­S values
was taken 18 weeks after the appliance placement to assess the over the observed period of time. At t2 (6 weeks following appliance
overall effect of the mouthrinse on gingival health and oral hygiene. placement) both evaluated parameters reached their lowest values
24
According to Ristic et al. the period of 3 months after the appliance immediately after the use of mouthrinse, but at the end of the study
placement has been determined as a period with highest prevalence at t3 (18 weeks after the placement of the orthodontic appliance) the
of oral microbiota in orthodontic patients followed by decrease in values were higher. However, not higher than the initial measurements
the next 3 months. Therefore, two different mouthrinses during that at t1 (Table 1). This finding can be attributed to the fact that the use
period were used to see if they could prevent or reduce the dental of both CHX mouthrinses had an impact on the reduction in gingival
plaque formation and gingival inflammation and maintain gingival inflammation and an increased oral hygiene. The observed trend was
health. To avoid the influence of different ligation method (elastomeric seen in all investigated groups and subgroups, but GI and OHI-­S values
rings that can promote significant retention of biofilm and change the in ceramic group using CHX-­ADS statistically differed at t2 indicating
gingival conditions) in this study all the brackets were ligated using that CHX-­ADS acted more efficiently on plaque reduction as well as
­metal-­stainless steel ligatures.25 on gingival inflammation reduction (P<.05; Table 1). This indicates that
After dividing the study group into two types of orthodontic brack- there are multicausal issue associated with different conditions in the
ets, the effectiveness of two different chlorhexidine mouthrinses on oral cavity that have an impact upon the effectiveness of the mouth-
gingival health and oral hygiene was investigated. Therefore, each rinses. Therefore, the first null hypothesis was rejected. Hence, further
group of subjects was divided into two equal subgroups using CHX scientific research is needed for a better understanding of this clinical
and CHX-­ADS. CHX is one of the most commonly prescribed antisep- condition.
tic agents in the dental field. It has been found to be effective in dental The second null hypothesis about no influence of metal-­stainless
26,27
practice in most studies. It has a long-­lasting antibacterial activity steel or ceramic brackets on gingival and oral health status was also
with a broad-­spectrum of action, and it has been shown to reduce rejected because we found lower GI and OHI-­S values in subjects
plaque, bleeding and gingival inflammation.28 One of the most fre- wearing ceramic brackets. In the ceramic group, there were statisti-
quent side effects of the conventional CHX is the appearance of stains cally significant lower GI values at t2 in those using CHX-­ADS (P<.05;
on the teeth and mucous membranes, which particularly disturbs the Table 1). This can be attributed to the fact that the bracket material
patient. The subject of particular interest was the comparison of ef- particularly, the stainless steel, affected the adhesion of bacterial
ficiency of conventional CHX and CHX-­ADS. Debatable results have species and plaque accumulation. Lin et al.38 referred to corrosion of
been found in terms of plaque control with CHX enriched with ADS. stainless steel brackets and showed that the bracket surface alters its
29
The results of Li et al. proved no superior effect on oral hygiene characteristics over time due to the wear from food and drink, oral
in subjects using CHX-­ADS. The study performed by Marelli et al.30 hygiene. Some studies showed a higher plaque affinity to stainless
proved clinical efficacy of ADS in the reduction of tooth staining, with steel brackets, and this is in accordance with findings of this study.
no loss of antiplaque activity with respect to the CHX mouthrinses. Eliades et al.39 discovered that the critical surface tension and total
The results of Solis et al.31 showed no statistically significant differ- work of adhesion of metal-­stainless steel brackets are higher com-
ences in gingival indices among groups that have rinsed with conven- pared with ceramic or plastic brackets, which a causes an increased
tional CHX and CHX-­ADS. Some other authors have proved the same plaque-­retaining capacity. Lindel et al.40 showed that with respect
32 33
findings. Cortellini et al. showed that CHX-­ADS was as effective to long-­term biofilm formation, ceramic brackets appear to exhibit
as CHX in reducing signs of gingival inflammation in the post-­surgical ­advantageous material properties.
early healing phase. Bevilacqua et al.34 concluded the same in their We investigated group of subjects with higher incidence of plaque
study. Arweiler et al.35 presented that conventional CHX showed su- accumulation and causal gingival inflammation due to the orthodontic
periority in inhibiting plaque re-­growth and reducing bacterial vitality appliances. Higher efficiency of CHX-­ADS in this study was confirmed
36
compared with CHX-­ADS. On the other hand, Graziani et al. in their in subjects wearing ceramic brackets, which proved to have better
study proved that the conventional CHX appeared more effective in ­material properties.
terms of plaque reduction, but CHX-­ADS showed a higher control of In this study, we have used two types of brackets and mouthrinses
gingival inflammation. Their reasonable explanation is that CHX-­ADS usually prescribed and used in everyday dental practice.
qualitatively changes dental plaque. The results of this study can sup- The limitation of this study was the lack of other periodontal pa-
port their possible explanation. Some authors attributed their findings rameters as well as specific bacterial counts, the staining scores and
to the difference in chemical contents of these two agents (CHX-­ADS different orthodontics appliances that could be included in further
contains ascorbic acid and sodium metabisulfite) and the effect of study.
JURIŠIĆ et al. | 5

2. DePaola LG, Overholser CD, Meiller TF, Minah GE, Niehaus C.

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