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Comparative Effectiveness of Toothbrushing, Flossing and Mouthrinse Regimens on Plaque and Gingivitis: A 12-week virtually supervised clinical trial
Abstract
Purpose:Various mechanical and chemotherapeutic methods are used to control dental plaque accumulation and prevent or reduce gingivitis. The purpose of this 12-week clinical trial was to investigate the effects of various combinations of supervised mechanical and chemotherapeutic regimens on the prevention and reduction of plaque, gingivitis, and gingival bleeding.Methods:Volunteers presenting with some evidence of gingivitis and no severe periodontitis were randomized into four groups: brush only (BO); brush/rinse (BR); brush/floss (BF); brush/floss/rinse (BFR) for this examiner-blinded clinical trial. Toothbrush, toothpaste, floss and a mouthrinse containing a fixed combination of four essential oils (EO) and training/instructions were provided to participants as per their assigned group. Participants performed their regimen at home, under virtual supervision, once each weekday; the second daily and weekend uses were unsupervised. Assessments included oral hard and soft tissue, plaque, gingivitis, and gingival bleeding (weeks 4, 12); probing depth and bleeding on probing (week 12).Results:Of 213 enrolled participants, 209 completed the study. After 12 weeks, plaque, gingivitis, and gingival bleeding were significantly reduced in groups BR (35.8%, 50.8%, and 71.0% respectively, p<0.001) and BFR (32.8%, 54.1%, and 78.2% respectively, p<0.001) compared to BO. After 12 weeks, gingivitis and gingival bleeding were significantly reduced in the BF group (9.2%, p=0.013 and 17.5%, p=0.003, respectively), however there were no significant reductions in plaque in the BF group as compared to the BO group (p=0.935).Conclusions:Oral care regimens that included a mouthrinse containing a fixed combination of four EOs (BR and BFR), demonstrated statistically significantly reduced plaque, gingivitis, and gingival bleeding as compared to BO and BF after 12 weeks. The BF regimen statistically significantly reduced gingivitis and gingival bleeding but did not statistically significantly reduce plaque compared to BO after 12 weeks.
... When used as an adjunct to daily mechanical oral hygiene, an alcohol-containing mouthrinse with a fixed combination of four essential oils (EOs) has a long history of demonstrated clinical reductions in plaque, gingivitis, and gingival bleeding [4,5] and has performed favorably when compared to flossing in two recent 3-month clinical trials [6,7]. An alcohol-free EO mouthrinse also performed similarly to an alcohol-containing mouthrinse in 6-month clinical trials [8,9]. ...
... This 12-week clinical trial investigated the effects of brushing with a sodium monofluorophosphate toothpaste, plus virtually supervised flossing, and/or using EOcontaining mouthrinse regimens [22] on the microbiota of supragingival and subgingival plaque. While clinical reports of superior plaque control by mouthrinses compared to flossing are on the rise [6,7,[36][37][38][39], there is paucity of information on how plaque biofilms are affected by mechanical and chemotherapeutic means of intervention, including how constituent bacterial species and their microbial ecology respond over time. ...
... Interestingly, these subgingival plaque vPCR results were also observed in the clinical endpoint measures of bleeding and inflammation as assessed using the interproximal and whole-mouth mean EBI and MGI scores [22] which provides support for the importance of mechanical flossing controlling subgingival plaque in synergy with mouthrinsing. This finding also supports other previous studies that demonstrated clinical improvements in gingival inflammation and bleeding scores despite poor plaque reduction by flossing [6,7,[36][37][38][39] and sheds light on how specific oral care regimens differentially affect distinct communities of the oral microbiome. Further quantitative research is required to understand the ability of different oral care regimens and products to reach not only subgingival plaque but also other oral surfaces, such as the gingiva, cheeks, tongue, oropharynx, and saliva. ...
Background
Translational microbiome research using next-generation DNA sequencing is challenging due to the semi-qualitative nature of relative abundance data. A novel method for quantitative analysis was applied in this 12-week clinical trial to understand the mechanical vs. chemotherapeutic actions of brushing, flossing, and mouthrinsing against the supragingival dental plaque microbiome. Enumeration of viable bacteria using vPCR was also applied on supragingival plaque for validation and on subgingival plaque to evaluate interventional effects below the gingival margin.
Methods
Subjects with gingivitis were enrolled in a single center, examiner-blind, virtually supervised, parallel group controlled clinical trial. Subjects with gingivitis were randomized into brushing only (B); brushing and flossing (BF); brushing and rinsing with Listerine® Cool Mint® Antiseptic (BA); brushing and rinsing with Listerine® Cool Mint® Zero (BZ); or brushing, flossing, and rinsing with Listerine® Cool Mint® Zero (BFZ). All subjects brushed twice daily for 1 min with a sodium monofluorophosphate toothpaste and a soft-bristled toothbrush. Subjects who flossed used unflavored waxed dental floss once daily. Subjects assigned to mouthrinses rinsed twice daily. Plaque specimens were collected at the baseline visit and after 4 and 12 weeks of intervention. Bacterial cell number quantification was achieved by adding reference amounts of DNA controls to plaque samples prior to DNA extraction, followed by shallow shotgun metagenome sequencing.
Results
286 subjects completed the trial. The metagenomic data for supragingival plaque showed significant reductions in Shannon-Weaver diversity, species richness, and total and categorical bacterial abundances (commensal, gingivitis, and malodor) after 4 and 12 weeks for the BA, BZ, and BFZ groups compared to the B group, while no significant differences were observed between the B and BF groups. Supragingival plaque vPCR further validated these results, and subgingival plaque vPCR demonstrated significant efficacy for the BFZ intervention only.
Conclusions
This publication reports on a successful application of a quantitative method of microbiome analysis in a clinical trial demonstrating the sustained and superior efficacy of essential oil mouthrinses at controlling dental plaque compared to mechanical methods. The quantitative microbiological data in this trial also reinforce the safety and mechanism of action of EO mouthrinses against plaque microbial ecology and highlights the importance of elevating EO mouthrinsing as an integral part of an oral hygiene regimen.
Trial registration
The trial was registered on ClinicalTrials.gov on 31/10/2022. The registration number is NCT05600231.
... A recently published study by Milleman et al. has demonstrated that under virtual supervision, oral care regimens that included four essential oils (EOs) alcoholcontaining mouthrinse (in combination with brushing or with brushing and flossing) significantly reduced supragingival plaque, gingivitis and gingival bleeding as compared to toothbrushing only or brushing and flossing after 12 weeks [7]. In that study, a virtually supervised brushing and flossing regimen was not significantly different from brushing only after 12 weeks in the reduction of supragingival plaque. ...
... As the Milleman et al. study [7] tested only an EO alcohol-containing mouthrinse, further research was warranted on EO non-alcohol containing mouthrinses for those patient populations unable to use alcohol-containing mouthrinses for various reasons such as children under 12, individuals experiencing alcohol dependence, people with strong taste preferences and those holding certain religious beliefs [8]. An EO non-alcohol containing mouthrinse is manufactured and marketed by Johnson & Johnson Consumer (JJC) since 2011 to provide an alternative to consumers. ...
... Subject selection was as described in Milleman et al. [7] with the following exceptions: due to a microbiome component of the current study, subjects were required to refrain from use of probiotic drinks/supplements for one week prior to and throughout the study; and subjects were to have abstained from chemotherapeutic antiplaque/anti-gingivitis products for four weeks prior to the start of the current study rather than two weeks as in Milleman, et al. Additionally, the age requirement was 18 years and above for this study, as compared with 18-60 years in Milleman, et al., due to COVID-19 risk factors at the time of that study. ...
Background
To investigate the effects of combinations of mechanical (brushing and flossing) and chemotherapeutic regimens which included essential oils (EO) non-alcohol and alcohol-containing mouthrinses compared to brushing only in the prevention and reduction of plaque, gingivitis, and gingival bleeding.
Methods
This was a randomized, virtually supervised, examiner blind, controlled clinical trial. Following informed consent and screening, subjects (N = 270) with gingivitis were randomly assigned to one of the following regimens: (1) Brush Only (B, n = 54); (2) Brush/Rinse (EO alcohol-containing mouthrinse) (BA, n = 54); (3) Brush/Rinse (EO non-alcohol containing mouthrinse) (BZ, n = 54); (4) Brush/Floss (BF, n = 54); (5) Brush/Floss/Rinse (EO non-alcohol containing mouthrinse) (BFZ, n = 54). Unflavored waxed dental floss (REACH unflavored waxed dental floss), and fluoridated toothpaste (Colgate Cavity Protection) were used. Examinations included oral hard and soft tissue, plaque, gingivitis, gingival bleeding, probing depth and bleeding on probing.
Results
After 12 weeks, both BA and BZ and the BFZ group were superior in reducing interproximal plaque (30.8%, 18.2%, 16.0%, respectively), gingivitis (39.0%, 36.9%, 36.1%, respectively), and bleeding (67.8%, 73.6%, 79.8%, respectively) compared to B. The BF group did not provide significant reductions in interproximal plaque but did reduce interproximal gingivitis (5.1%, p = 0.041) at Week 4 and bleeding at Weeks 4 and 12 (34.6%, 31.4%, p < 0.001 respectively) compared to B. The BFZ group did not significantly reduce interproximal plaque, gingivitis or bleeding compared to BZ.
Conclusions
This study demonstrated that the addition of EO non-alcohol containing mouthrinse to the manual toothbrushing and flossing regimen further reduces plaque, gingivitis and bleeding showing that addition of EO mouthrinses (alcohol or non-alcohol containing) to the oral hygiene regimen provides sustained reductions in plaque to help maintain gingival health after a dental prophylaxis. Dental professional recommendation of the addition of an EO non-alcohol containing mouthrinse to daily oral hygiene routines of brushing or brushing and flossing should be considered to aid supragingival plaque control and improve gingivitis prevention.
Study registry number
NCT05600231.
... Nesse contexto, produtos naturais, principalmente os derivados de plantas medicinais, têm sido vistos como fontes abundantes de novos compostos biologicamente ativos, de maior potência, eficácia e segurança, como também de custo mais baixo e melhor tolerados pelos pacientes (HOTWANI; BALIGA; SHARMA, 2014; FREIRES; ROSALEN, 2016). Na odontologia, uma das aplicações mais estudadas para esses produtos tem sido justamente no manejo das doenças infecciosas bucais (LOBO et al., 2014;FREIRES;ROSALEN, 2016 Alshehri et al., 2017;Bosma et al., 2022;Castro et al., 2018;Charugundla et al., 2015;Cortelli et al., 2014;Cortelli et al., 2018;Luís et al., 2018;Lynch et al., 2018;Máximo et al., 2020;Milleman et al., 2022a;Milleman et al., 2022b;Newman et al., 2022;Raslan et al., 2015;Valør et al., 2018;Yaneva et al., 2022 Artigos Encontrados (n=100) Pubmed: ALSHEHRI; ALSHAIL; ALSHEHRI, 2017;CASTRO et al., 2018;CORTELLI et al., 2018;LYNCH et al., 2018;VALØR et al., 2018;ANUSHA et al., 2019;KAMATH et al., 2020;MACHOROWSKA-PIENIĄZEK et al., 2021;TAALAB et al., 2021;MILLEMAN et al., 2022ª;MILLEMAN et al., 2022b;NEWMAN et al., 2022;YANEVA et al., 2022). Araújo et al. (2021), em que se avaliou a eficácia de um spray para prótese dentária e de um enxaguante contendo OE de Cinnamomum zeylanicum (Canela) a 0,5 mg/Ml. ...
... Nesse contexto, produtos naturais, principalmente os derivados de plantas medicinais, têm sido vistos como fontes abundantes de novos compostos biologicamente ativos, de maior potência, eficácia e segurança, como também de custo mais baixo e melhor tolerados pelos pacientes (HOTWANI; BALIGA; SHARMA, 2014; FREIRES; ROSALEN, 2016). Na odontologia, uma das aplicações mais estudadas para esses produtos tem sido justamente no manejo das doenças infecciosas bucais (LOBO et al., 2014;FREIRES;ROSALEN, 2016 Alshehri et al., 2017;Bosma et al., 2022;Castro et al., 2018;Charugundla et al., 2015;Cortelli et al., 2014;Cortelli et al., 2018;Luís et al., 2018;Lynch et al., 2018;Máximo et al., 2020;Milleman et al., 2022a;Milleman et al., 2022b;Newman et al., 2022;Raslan et al., 2015;Valør et al., 2018;Yaneva et al., 2022 Artigos Encontrados (n=100) Pubmed: ALSHEHRI; ALSHAIL; ALSHEHRI, 2017;CASTRO et al., 2018;CORTELLI et al., 2018;LYNCH et al., 2018;VALØR et al., 2018;ANUSHA et al., 2019;KAMATH et al., 2020;MACHOROWSKA-PIENIĄZEK et al., 2021;TAALAB et al., 2021;MILLEMAN et al., 2022ª;MILLEMAN et al., 2022b;NEWMAN et al., 2022;YANEVA et al., 2022). Araújo et al. (2021), em que se avaliou a eficácia de um spray para prótese dentária e de um enxaguante contendo OE de Cinnamomum zeylanicum (Canela) a 0,5 mg/Ml. ...
Introdução: O uso de antimicrobianos é muitas vezes necessário no manejo das doenças infecciosas bucais. Infelizmente, essas drogas ocasionam com frequência efeitos colaterais desagradáveis, sendo o mais grave a resistência microbiana. Nesse contexto, produtos derivados de plantas surgem como fontes abundantes de novos compostos biologicamente ativos, de maior potência, eficácia e segurança. Na odontologia, uma das aplicações mais estudadas para esses produtos tem sido justamente no manejo das doenças infecciosas bucais. Objetivo: Realizar um levantamento dos ensaios clínicos que avaliaram a eficácia de produtos derivados de plantas no controle do biofilme ou na prevenção e/ou tratamento das principais doenças infecciosas bucais. Metodologia: Foram selecionados 28 artigos, por meio de busca eletrônica nas bases MEDLINE/PubMed, SciELO e Web of Science. Foram incluídos ensaios clínicos realizados em humanos, em língua inglesa, publicados entre 2014 e 2023, e que avaliassem a eficácia de produtos derivados de plantas no controle de biofilmes bucais ou na prevenção/tratamento da cárie dentária, doenças periodontais, candidíase bucal ou herpes labial. Resultados e Discussão: O enxaguante bucal, composto por óleos essenciais ou seus componentes isolados, foi o principal produto testado. Quanto à finalidade, a maior parte dos estudos avaliou a eficácia dos produtos no controle do biofilme ou tratamento das doenças periodontais, principalmente gengivite. Em resumo, a maioria dos estudos encontrou eficácia para os produtos testados quando os comparou a um tratamento padrão ou a algum placebo. Conclusão: As evidências aqui encontradas apontam que produtos derivados de plantas têm potencial para representar terapias eficazes na prevenção e tratamento de doenças infecciosas bucais.
... (32) Recent studies continue to affirm the benefits of mouth rinses in reducing plaque and bacteria, emphasizing their role in maintaining oral hygiene. (33,34) The current study revealed that only about 18,5 (286 out of 1 542) of the schoolchildren utilized mouth rinse. This result is consistent with an international survey conducted across 20 countries revealed that only 12,8 % of children consistently used mouthwash. ...
Introduction: Oral health is vital for overall well-being, especially in childhood, as early habits influence lifelong dental health. This survey aims to evaluate oral hygiene habits and patterns among schoolchildren in Saudi Arabia. Methods: The survey utilized a school-based, point-in-time analysis conducted from October 15 to December 15, 2024. Participants were selected using a pure random sampling method to ensure a representative group of schoolchildren. Each participant completed an anonymous, detailed survey on oral hygiene habits, including tooth brushing, flossing, toothbrush ownership, and sharing toothbrushes with family members. The data were coded for analysis. Results: The study revealed poor oral hygiene practices among schoolchildren, with only 369 (23.9%) brushing their teeth twice daily, while 343 (22.2%) never brushed, particularly in western areas 216 (23.2%). Dental flossing was rare (1,503 (97.4%) never used floss), 18.9% lacked a toothbrush, and 292 (14.9%) shared one with family members. Infrequent brushing was significantly linked to gum bleeding, highlighting a greater risk of dental issues and the urgent need for community-focused oral health interventions. Conclusion: This study underscores the need for community-based oral health education programs, early interventions, and increased awareness to improve oral hygiene and prevent dental diseases in the population
... These findings are relevant, as regular flossing has been found to prevent and decrease the prevalence and severity of plaque, gingivitis, and gingival inflammation associated with periodontal disease, as compared to brushing alone (26,27). As such, it is important to explore the barriers to the use of dental floss and implement targeted solutions, as will be explored in the upcoming themes. ...
Introduction
Globally, oral health diseases surpass all other non-communicable diseases in prevalence; however, they are not well studied in underserved regions, where accessibility to dental services and oral health education is disparately worse. In Ecuador, further research is needed to understand such disparities better. We aimed to assess the effect of oral health disease on individuals' quality of life and how social disparities and cultural beliefs shape this.
Methods
Individuals 18 or older receiving care at mobile or worksite clinics from May to October 2023 were included. A mixed-methods approach was employed, involving semi-structured interviews, Oral Health-Related Quality of Life (OHRQoL) measures, and extra-oral photographs (EOP).
Results
The sample (n = 528) included mostly females (56.25%) with a mean age of 34.4 ± 9.44. Most participants (88.26%) reported brushing at least twice daily, and less than 5% reported flossing at least once per day. The median OHRQoL score was 4 (min-max), significantly higher among individuals ≥40 years old, holding high school degrees, or not brushing or flossing regularly (p < 0.05). Identified barriers to good oral health included affordability, time, and forgetfulness. Participants not receiving care with a consistent provider reported fear as an additional barrier. Participants receiving worksite dental services reported these barriers to be alleviated. Dental providers were the primary source of oral hygiene education. Most participants reported oral health concerns, most commonly pain, decay, dysphagia, and halitosis - consistent with EOP analysis.
Discussion
Findings underscore a need for multi-level interventions to advance oral health equity.
... Hence, there were low recommendations for using herbal preparations to substitute conventional oral hygiene products [36]. A recent meta-analysis showed that flossing, in addition to toothbrushing, reduced gingivitis compared to toothbrushing alone [37,38]. However, there was not enough evidence to support the effectiveness of flossing in preventing dental caries [39]. ...
Background
The COVID-19 pandemic has impacted overseas students, including their oral health. Due to movement restrictions, limited living allowances, dental treatment costs, and health insurance fees, overseas students might be more concerned about their oral health. The objective of the present study was to determine the association of knowledge and attitude toward oral healthcare behavior of overseas university students staying in Thailand between January 2020 to July 2022 and explore the experiences of their oral health problems.
Methods
A cross-sectional study was conducted using an online survey in English operated through the Google platform by convenience sampling among overseas Chulalongkorn University students. A newly developed self-administered questionnaire on knowledge and attitude toward oral health-related behavior and experiences in oral health problems was completed voluntarily. Descriptive statistics, Chi-square test, t-test, ANOVA, and Pearson correlations were employed using IBM SPSS version 29.
Results
Of 311 overseas students, 55.6% were male. The average age of students was 27.5 ± 4.5 years. 68.81% of students were from ASEAN countries, and 73.31% studied in non-health science programs. The study fields, health and non-health sciences, were associated with knowledge score (p < 0.001) and attitude score (p = 0.004), whereas the type of health insurance had an association with behavior score (p = 0.014) and the student’s perspective about dental visits (p = 0.014). Three hundred fifty-nine cases of oral health problems were experienced by 47.3% of overseas students. These problems consisted primarily of tooth hypersensitivity (21.2%), gingivitis (15.3%), caries (14%), cracked or broken tooth (10%), severe toothache (9%), fallen out filling (8%), and wisdom tooth pain (7.8%). There was an association between oral healthcare behavior and oral health problems (p < 0.001), and a negative correlation was found between behavior score and the number of oral health problems (p < 0.001, r=-0.204).
Conclusion
The oral healthcare habits of overseas university students correlated positively with knowledge and attitude. A negative correlation was observed between behavior and the number of oral health problems. Furthermore, studying in health science programs impacted students’ knowledge and attitude toward oral health, while dental treatment coverage insurance affected decisions for dental visits.
... If left untreated, it can progress to more serious stages of infection/inflammation called periodontitis [55]. Gingivitis and periodontitis may last for months or years and spread slowly the body when the bacteria enter the blood stream, leading to the release of a variety of inflammatory mediators [56,57]. Dental plaque, a unique biofilm, contains a wide variety of bacteria, viruses, and fungi [58]. ...
One of the primary causes of disability and mortality in the adult population worldwide is stroke. A person’s general health is significantly impacted by their oral and dental health. People who have poor oral health are more susceptible to conditions such as stroke. Stroke risk has long been linked to oral and dental conditions. The risk of stroke and its cost impact on the healthcare systems appear to be significantly reduced as a result of the decline in the incidence and prevalence of oral and dental illnesses. Hypothetically, better management of oral hygiene and dental health lead to reduced stroke risk. To the authors’ best knowledge, for the first time, the potential link between dental health and stroke were cross-examined. The most typical stroke symptoms, oral and dental illnesses linked to stroke, and the role of oral healthcare professionals in stroke prevention are revealed. The potential mediating processes and subsequent long-term cognitive and functional neurological outcomes are based on the available literature. It must be noted that periodontal diseases and tooth loss are two common oral health measures. Lack of knowledge on the effects of poor oral health on systemic health together with limited access to primary medical or dental care are considered to be partially responsible for the elevated risk of stroke. Concrete evidence confirming the associations between oral inflammatory conditions and stroke in large cohort prospective studies, stratifying association between oral disease severity and stroke risk and disease effects on stroke survival will be desirable. In terms of clinical pathology, a predictive model of stroke as a function of oral health status, and biomarkers of systemic inflammation could be useful for both cardiologists and dentists.
For centuries, diverse mouthrinses have been applied for medicinal purposes in the oral cavity. In view of the growing resistance of oral microorganisms against conventional antimicrobial agents e.g. chlorhexidine, the implementation of alternative treatments inspired by nature has lately gained increasing interest. The aim of the present study was to compare in vitro biofilm models with in situ biofilms in order to evaluate the antimicrobial potential of different natural mouthrinses. For the in vitro study a six-species supragingival biofilm model containing A. oris, V. dispar, C. albicans, F. nucleatum, S. mutans and S. oralis was used. Biofilms were grown anaerobically on hydroxyapatite discs and treated with natural mouthrinses Ratanhia, Trybol and Tebodont. 0.9% NaCl and 10% ethanol served as negative controls, while 0.2% CHX served as positive control. After 64h hours, biofilms were harvested and quantified by cultural analysis CFU. For the in situ study, individual test splints were manufactured for the participants. After 2h and 72h the biofilm-covered samples were removed and treated with the mouthrinses and controls mentioned above. The biofilms were quantified by CFU and stained for vitality under the confocal laser scanning microscope. In the in vitro study, 0.2% CHX yielded the highest antimicrobial effect. Among all mouthrinses, Tebodont (4.708 ± 1.294 log10 CFU, median 5.279, p<0.0001) compared with 0.9% NaCl showed the highest antimicrobial potential. After 72h there was no significant reduction in CFU after 0.2% CHX treatment. Only Trybol showed a statistically significant reduction of aerobic growth of microorganisms in situ (5.331 ± 0.7350 log10 CFU, median 5.579, p<0.0209). After treatment with the positive control 0.2% CHX, a significant percentage of non-vital bacteria (42.006 ± 12.173 log10 CFU, median 42.150) was detected. To sum up, a less pronounced effect of all mouthrinses was shown for the in situ biofilms compared to the in vitro biofilms.
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