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Chlorhexidine reduces plaque and inflammation, but causes staining Critical Summary Prepared by: Anthony Jackson DDS 

OVERVIEW

  • Systematic Review Conclusion:

    Chlorhexidine (CHX) mouthrinse together with oral hygiene (OH) versus placebo or control mouthrinse significantly reduces plaque and gingivitis but increases staining of teeth as well.

  • Critical Summary Assessment:

    The authors performed a systematic review (SR) and meta-analysis (MA) of randomized control trials (RCTs), which included 30 publications that primarily provided baseline data and end of trial assessments. The authors considered the risk for selection bias to be low and found consistent evidence showing a reduction of plaque in patients who use CHX rinses compared to those who use placebo and control rinses. The concentration of CHX in these studies ranged from 0.05 percent to 0.2 percent.

  • Evidence Quality Rating:

    Good

A Critical Summary of:

Effect of a chlorhexidine mouthrinse on plaque, gingival inflammation and staining in gingivitis patients: a systematic review

Van Strydonck, Danielle A. C., Slot, Dagmar E., Van der Velden, Ubele, Van der Weijden, Fridus. Journal of Clinical Periodontology. 2012;39(11):1042-55

  • Clinical Questions:

    In adults with gingivitis, does CHX mouthrinse as a monotherapy or as an adjunct to mechanical oral hygiene, improve plaque and other parameters of gingival inflammation as compared to a placebo rinse, a control rinse or regular OH in RCTs lasting at least four weeks?

  • Review Methods:

    The authors performed a comprehensive search of all oral CHX products in three electronic databases up to April 2011. Eligibility criteria were English language papers with (1) RCTs design; (2) Studies on humans in good health and > 18 years of age; (3) Gingivitis patients; (4) Intervention of CHX mouthrinse, either alone or as adjunct; (5) Comparison of either placebo rinse, control rinse or regular OH; (6) Minimum duration of > 4 weeks; (7) Outcome parameters of mean scores of plaque, gingivitis, bleeding and staining. Two reviewers independently screened the studies, and two reviewers then processed them for data extraction. One reviewer was common to both functions. Two reviewers also hand searched the reference lists of all of the selected manuscripts. Whenever possible, the two reviewers resolved any disagreements by discussion or, if the disagreement persisted, by the judgment of a third reviewer. The authors performed quality assessments (QA) but did not exclude any qualifying studies because of QA classifications. The potential risk of bias was low in 9 of 30 studies, moderate for 10 studies and high for 11 studies. For data analysis, primary parameters were plaque and parameters of gingival inflammation; stain was assessed as a secondary parameter evaluating adverse effects. The data were summarized in terms of weighted mean differences (WMDs). The authors also did a secondary analysis that included only the studies at low risk of bias..

  • Main Results:

    This review included 30 RCTs; and although there was significant variability amongst them with regard to RCT design, CHX concentration and regimen, evaluation period, and population, there were no statistically significant differences observed between the subgroups for plaque scores, papillary bleeding, gingival scores or bleeding on marginal probing (BOMP). However, the MA of 19 out of 20 studies showed statistically significant differences for more staining in the CHX group. The MA showed that CHX mouthrinses outperformed other mouthrinses for reduction of plaque, gingivitis and bleeding, but also showed an increase in staining. There were WMDs favoring CHX use of -0.39 and -0.67 for two plaque indices, and WMDs of -0.08 and -0.21 for two bleeding indices, also favoring CHX use. With respect to end scores of gingivitis, use of CHX demonstrated a WMD improvement of -0.32 [95 percent confidence interval (CI): -0.42 to -0.32], p<0.00001 compared to the control. Using BOMP, again a favorable measure of improvement was observed with a WMD -0.16 [95 percent CI: -0.26 to -0.07], p<0.0008 when compared to control. As a secondary parameter, the MA of the end stain scores had a significant WMD for the Lobene Stain Index, WMD -0.91 [95 percent CI: 0.12 to 1.70], p<0.00001 comparing CHX to control.

  • Conclusion:

    The data presented in this SR provide good evidence for the anti-plaque and anti-gingivitis effects of a CHX mouthrinse used as an adjunct to regular OH over placebo or control rinses in patients with gingivitis. Rinsing with CHX in addition to OH procedures results in approximately 33 percent less plaque and 26 percent less gingivitis as compared to controls, but also increases the staining of teeth. These percentages are gleaned from the MA of the studies at lowest risk of bias.

  • Source of funding:

    Self-funded by authors and supported by their institution Academic Centre for Dentistry Amsterdam (ACTA)

Commentary:

  • Importance and Context:

    The subjects in the SR approximated patients seen in most dental practices. CHX use has been established as the gold-standard for chemotherapeutic gingivitis treatment, and this review focused on patients with gingivitis. This focus is particularly relevant because long-term gingivitis increases the risk of attachment loss, and the prevention of gingival inflammation might reduce the prevalence of mild to moderate periodontitis (Lang et al. 2009). The well-known side effect of staining from CHX use is noted in this review. This staining can be an obstacle to patients’ long-term compliance in proper use.

  • Strengths and Weaknesses of the Systematic Review:

    The authors limited their search to papers written in English. Reviewers used a “safety net” approach; therefore the number of articles that they scrutinized in full text was relatively large. The authors performed bias and quality assessments. The authors of the study appropriately analyzed the studies with the lowest risk for bias separately. The authors were able to include a large number of articles (13) in the MA.

  • Strengths and Weaknesses of the Evidence:

    The data exhibited considerable heterogeneity. Clinical heterogeneity was also present with respect to the number of subjects (20 to almost 600), gender and age of the subjects, and the use of dentifrice. Different concentrations of CHX (0.05 percent to 0.2 percent) were used in the studies, although most used a concentration of 0.12 percent. The studies did not specify whether a particular concentration of CHX had better results. Not all studies had an oral prophylaxis administered at baseline. The MA for end scores of Plaque Index, Gingival Index and staining showed moderate to considerable inconsistency; the data concerning the Papillary Bleeding Index and BOMP were consistent in favor of the CHX use. The data are from RCTs, and approximately two-thirds of the studies included were at low to- moderate risk of bias, which is a strength.

  • Implications for Dental Practice:

    The benefits of decreased plaque and therefore inflammation potential as well as increased staining from CHX use must be disclosed to each patient. The improvement of plaque and gingival scores with the use of CHX has been established, but at which concentration and regimen is still unclear, so it is up to the practitioner to customize CHX use in a way that strikes a balance between the patient’s therapeutic needs and the potential for staining.

    Lang et al. Gingivitis as a risk factor in periodontal disease. J Clin Periodontol 2009 Jul;36 Suppl 10:3-8. doi: 10.1111/j.1600-051X.2009.01415.x.

  • Critical Summary Publication Date: 12/5/2013

These summaries are not intended to, and do not, express, imply, or summarize standards of care, but rather provide a concise reference for dentists to aid in understanding and applying evidence from the referenced systematic review in making clinically sound decisions as guided by their clinical judgment and by patient needs. American Dental Association ©

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