ORAL HEALTH EVIDENCE-BASED PRACTICE PROGRAM
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Title Chlorhexidine Mouth Rinse Twice a Day Is at Least as Effective as Dental Floss in Reducing Plaque Buildup
Clinical Question In adult patients, does regular tooth brushing with adjunctive dental floss more effectively reduce plaque index as compared to regular tooth brushing with adjunctive chlorhexidine mouth rinse?
Clinical Bottom Line In adult patients, chlorhexidine mouth rinse is at least as effective as dental floss as an adjunct to regular tooth brushing in reducing plaque index. This is supported by two randomized control trials conducted in India, which showed that use of chlorhexidine mouth rinse resulted in clinically significant reductions in plaque indices as compared to dental floss. Prescription of chlorhexidine mouth rinse is within the capability of the average dental practitioner, likely to be accepted by the average patient, and should be considered in situations where flossing and proper tooth brushing are not sufficient.
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 25478436Arora/201445 dental students (19-25 years old)Randomized Controlled Trial
Key resultsIn this 3-way crossover study, significantly greater reductions from the baseline plaque indices (based on the Turesky modification of the Quigly-Hein Index) were observed when the subjects used 0.12% chlorhexidine mouth rinse twice daily as an adjunct to tooth brushing (baseline: 0.67 ± 0.07, third follow-up: 0.21 ± 0.03, p < 0.001) as compared to using flossing as an adjunct to tooth brushing (baseline: 0.68 ± 0.05, third follow-up: 0.40 ± 0.06, p < 0.001). The difference of 0.19 seen in the mean comparison of the plaque indices between subjects who used 0.12% chlorhexidine twice daily as compared to dental floss was seen as significant (p < 0.001) with chlorhexidine mouth rinse being more effective.
#2) 24478951Mythri/2011157 subjects (12-74 years old)Randomized Controlled Trial
Key resultsIn this study, the authors implemented an “at least as good as” method of comparing mouth rinses to flossing. They found that significantly greater reductions from the baseline plaque indices (based on the Turesky-Gilmore-Glickman modification of the Quigly-Hein Index) were observed when the subjects used 0.2% chlorhexidine mouth rinse twice daily as an adjunct to tooth brushing (baseline: 2.35 ± 0.48, 6-month follow-up: 1.81 ± 0.03, p < 0.05, 18.53% reduction versus tooth brushing alone) as compared to using flossing as an adjunctive to tooth brushing (baseline: 2.31 ± 0.50, 6-month follow-up: 2.21 ± 0.49, p < 0.05, 0.12% reduction versus tooth brushing alone).
Evidence Search ("chlorhexidine"[MeSH Terms] OR "chlorhexidine"[All Fields]) AND ("plaque, amyloid"[MeSH Terms] OR ("plaque"[All Fields] AND "amyloid"[All Fields]) OR "amyloid plaque"[All Fields] OR "plaque"[All Fields] OR "dental plaque"[MeSH Terms] OR ("dental"[All Fields] AND "plaque"[All Fields]) OR "dental plaque"[All Fields]) AND ("dental devices, home care"[MeSH Terms] OR ("dental"[All Fields] AND "devices"[All Fields] AND "home"[All Fields] AND "care"[All Fields]) OR "home care dental devices"[All Fields] OR ("dental"[All Fields] AND "floss"[All Fields]) OR "dental floss"[All Fields])
Comments on
The Evidence
Validity: The studies by Arora and Mythri were both randomized controlled trials; however, while the study by Arora was double-blinded, the study by Mythri was single-blinded (observer). Compliance issues may be a concern; in particular, the study by Arora had dental students as subjects whom tend to be more concerned with their oral health than the general public. The study by Mythri attempted to minimize compliance issues by instructing the subjects to chart their compliance while the study by Arora had no means to verify compliance. The subjects in both studies were also provided adequate general hygiene instructions and given oral hygiene products to minimize confounding factors. Perspective: While both studies suggest that using chlorhexidine mouth rinse is an effective alternative to flossing, I found it concerning that the study by Arora suggested that flossing as an adjunct to tooth brushing may be no more effective than tooth brushing alone. I speculate this is due to the fact that the subjects were dental students who may adhere to more effective tooth brushing habits thus making it difficult to apply the results to the general public. Ultimately, more studies with larger samples sizes need to be conducted in order to verify the results from these two studies. Furthermore, while plaque index was the measure used in these studies, I believe gingival index may be more clinically applicable to determine whether the mouth rinses can appreciably lessen the chances of gingivitis.
Applicability Chlorhexidine mouth rinse offers an easier, albeit slightly more expensive, alternative to flossing, which may see better compliance in patients who either refuse to floss or are incapable of flossing due to lack of manual dexterity. However, concerns arose in the study by Mythri where a few patients communicated stained teeth and a metallic taste as a result of using chlorhexidine mouth rinse. It is also important to note that both studies were conducted in India where the patient oral health needs may differ from the patients in your office thus making it harder to generalize the results universally.
Specialty/Discipline (Public Health) (General Dentistry) (Periodontics)
Keywords Dental Floss, Floss, Chlorhexidine, Mouth Rinse, Plaque, Plaque Index
ID# 3138
Date of submission: 02/27/2017spacer
E-mail mominrm@livemail.uthscsa.edu
Author Rehman M. Momin
Co-author(s)
Co-author(s) e-mail
Faculty mentor/Co-author Suman N. Challa
Faculty mentor/Co-author e-mail Challas@uthscsa.edu
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?)
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