NIHR Signal Chlorhexidine mouthwash is useful short-term for people with mild gum disease

Published on 11 July 2017

In people with mild gum disease chlorhexidine mouthwash, in addition to tooth brushing, reduces plaque build-up in the first weeks or months of use. However, when used for longer than four weeks chlorhexidine mouthwash can lead to tooth staining and a build-up of chalky deposits on the teeth, called tartar. There is insufficient evidence to assess its effectiveness in people with moderate to severe gum disease.

Plaque is a sticky bacteria-filled substance that forms on teeth and can cause gum disease, resulting in sore, bleeding gums, infections and even tooth loss. Chlorhexidine is an antiseptic which kills most bacteria. In the UK chlorhexidine mouthwashes are licensed for 30 days’ use and are not recommended for routine use.

This systematic review suggests that chlorhexidine mouthwash may be considered as an addition to usual care for people with mild gum disease. There is scope for further investigation of the role of chlorhexidine in moderate to severe gum disease.

Chlorhexidine mouthwash is useful short-term for people with mild gum disease

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Why was this study needed?

Dental plaque is a sticky substance containing bacteria that builds up where the teeth meet the gums. Some of the bacteria in plaque can be harmful to teeth and gums, leading to gum disease (gingivitis).

The symptoms of gum disease are sore and swollen gums that can bleed during tooth brushing or flossing, and bad breath. Untreated gum disease can lead to receding gums and gum abscesses, potentially causing loose teeth or even tooth loss. The easiest way to prevent gum disease is to maintain good oral hygiene through regular tooth brushing, flossing and regular dental check-ups.

Chlorhexidine is an antiseptic used in a variety of ways, including disinfecting skin before operations and cleaning wounds. This review explored whether chlorhexidine reduced gum disease, prevented plaque or slowed development of tartar (chalky deposits on the teeth).

What did this study do?

This Cochrane systematic review included 51 randomised controlled trials, including 5,345 people. The studies involved people brushing their teeth, either with or without using floss or other interdental brushes to clean between teeth, and professional tooth cleaning. To this dental hygiene regime was added chlorhexidine mouthwash, a placebo mouthwash or no mouth rinsing.

Fifty out of 51 studies were judged to be at high risk of bias; the other study had an unclear risk of bias. The main source of bias was around not concealing which treatment people received from them and those assessing their gum disease. There were high drop-out rates from studies, a risk of selective reporting and substantial differences between the studies. Despite these risks of bias, the authors feel that the consistency of results mean that we can have confidence in their findings.

What did it find?

  • Chlorhexidine mouthwash reduced mild gum disease (less than 1 on a gum disease scale of 0 to 3) by an average of ‑0.21 after four to six weeks (95% confidence interval [CI] ‑0.31 to ‑0.11) and by ‑0.20 after six months (95% CI ‑0.30 to ‑0.11). There was insufficient evidence to draw conclusions about the effectiveness of chlorhexidine in people with moderate to severe gum disease (scoring 1.1 to 3).
  • Using chlorhexidine moderately reduced gum bleeding at four to six weeks (standardised mean difference [SMD] ‑0.56, 95% CI ‑0.79 to ‑0.33) and six months (SMD ‑0.72, 95% CI ‑1.02 to ‑0.42).
  • Plaque was assessed using various tools including the Plaque Index and the Turesky modification of the Quigley Hein Index. All indicated that chlorhexidine use had a large effect in reducing plaque at four to six weeks (SMD ‑1.45, 95% CI ‑1.90 to ‑1.00) and at six months (SMD ‑1.59, 95% CI ‑1.89 to ‑1.29).
  • Levels of tartar were higher amongst people using chlorhexidine. Tooth staining was also significantly increased among people using chlorhexidine at four to six weeks, seven to 12 weeks and six months.
  • There was insufficient data to draw conclusions about whether the frequency or concentration of chlorhexidine affected any of the studied outcomes.

What does current guidance say on this issue?

NICE’s Clinical Knowledge Summary service recommends that tooth brushing and interdental cleaning are used to remove plaque. Mouthwashes are not recommended for routine gum disease treatment because they do not act on established plaque and do not stop gum disease from progressing. The British Society of Periodontology and the Scottish Dental Clinical Effectiveness Programme suggest that chlorhexidine mouthwashes may be helpful to control plaque in the short term when mechanical cleaning is painful. In the UK, chlorhexidine mouthwashes are only licensed for 30 days’ use.

What are the implications?

Combining tooth brushing and cleaning with chlorhexidine mouthwashes reduces plaque build-up, compared to tooth brushing and cleaning alone.

However, using chlorhexidine mouthwashes for longer than four weeks leads to tooth staining (requiring professional cleaning) and a build-up of tartar. This supports UK guidance and licensing, which already restricts chlorhexidine mouthwash use to 30 days at a time.

Healthcare professionals should discuss the likely benefits, limitations and risks of using chlorhexidine mouthwashes in addition to tooth brushing and cleaning in people with mild gum disease. They should also point out that they do not replace flossing and regular dental hygienist visits for tartar removal.

Citation and Funding

James P, Worthington HV, Parnell C et al. Chlorhexidine mouthrinse as an adjunctive treatment for gingival health. Cochrane Database Syst Rev. 2017;3:CD008676.

Cochrane UK and the Oral Health Cochrane Review Group are supported by NIHR infrastructure funding. The review was also funded by the Cochrane Oral Health Global Alliance and Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, UK.

Bibliography

BSP. The good practitioner’s guide to periodontology. London: British Society of Periodontology; 2016.

CKS. Scenario: gingivitis and periodontitis. London: National Institute for Health and Care Excellence; updated 2016.

NHS Choices. Gum disease. London: Department of Health; updated 2016.

SDCEP. Prevention and treatment of periodontal diseases in primary care dental clinical guidance. London: Scottish Dental Clinical Effectiveness Programme; 2016.

Why was this study needed?

Dental plaque is a sticky substance containing bacteria that builds up where the teeth meet the gums. Some of the bacteria in plaque can be harmful to teeth and gums, leading to gum disease (gingivitis).

The symptoms of gum disease are sore and swollen gums that can bleed during tooth brushing or flossing, and bad breath. Untreated gum disease can lead to receding gums and gum abscesses, potentially causing loose teeth or even tooth loss. The easiest way to prevent gum disease is to maintain good oral hygiene through regular tooth brushing, flossing and regular dental check-ups.

Chlorhexidine is an antiseptic used in a variety of ways, including disinfecting skin before operations and cleaning wounds. This review explored whether chlorhexidine reduced gum disease, prevented plaque or slowed development of tartar (chalky deposits on the teeth).

What did this study do?

This Cochrane systematic review included 51 randomised controlled trials, including 5,345 people. The studies involved people brushing their teeth, either with or without using floss or other interdental brushes to clean between teeth, and professional tooth cleaning. To this dental hygiene regime was added chlorhexidine mouthwash, a placebo mouthwash or no mouth rinsing.

Fifty out of 51 studies were judged to be at high risk of bias; the other study had an unclear risk of bias. The main source of bias was around not concealing which treatment people received from them and those assessing their gum disease. There were high drop-out rates from studies, a risk of selective reporting and substantial differences between the studies. Despite these risks of bias, the authors feel that the consistency of results mean that we can have confidence in their findings.

What did it find?

  • Chlorhexidine mouthwash reduced mild gum disease (less than 1 on a gum disease scale of 0 to 3) by an average of ‑0.21 after four to six weeks (95% confidence interval [CI] ‑0.31 to ‑0.11) and by ‑0.20 after six months (95% CI ‑0.30 to ‑0.11). There was insufficient evidence to draw conclusions about the effectiveness of chlorhexidine in people with moderate to severe gum disease (scoring 1.1 to 3).
  • Using chlorhexidine moderately reduced gum bleeding at four to six weeks (standardised mean difference [SMD] ‑0.56, 95% CI ‑0.79 to ‑0.33) and six months (SMD ‑0.72, 95% CI ‑1.02 to ‑0.42).
  • Plaque was assessed using various tools including the Plaque Index and the Turesky modification of the Quigley Hein Index. All indicated that chlorhexidine use had a large effect in reducing plaque at four to six weeks (SMD ‑1.45, 95% CI ‑1.90 to ‑1.00) and at six months (SMD ‑1.59, 95% CI ‑1.89 to ‑1.29).
  • Levels of tartar were higher amongst people using chlorhexidine. Tooth staining was also significantly increased among people using chlorhexidine at four to six weeks, seven to 12 weeks and six months.
  • There was insufficient data to draw conclusions about whether the frequency or concentration of chlorhexidine affected any of the studied outcomes.

What does current guidance say on this issue?

NICE’s Clinical Knowledge Summary service recommends that tooth brushing and interdental cleaning are used to remove plaque. Mouthwashes are not recommended for routine gum disease treatment because they do not act on established plaque and do not stop gum disease from progressing. The British Society of Periodontology and the Scottish Dental Clinical Effectiveness Programme suggest that chlorhexidine mouthwashes may be helpful to control plaque in the short term when mechanical cleaning is painful. In the UK, chlorhexidine mouthwashes are only licensed for 30 days’ use.

What are the implications?

Combining tooth brushing and cleaning with chlorhexidine mouthwashes reduces plaque build-up, compared to tooth brushing and cleaning alone.

However, using chlorhexidine mouthwashes for longer than four weeks leads to tooth staining (requiring professional cleaning) and a build-up of tartar. This supports UK guidance and licensing, which already restricts chlorhexidine mouthwash use to 30 days at a time.

Healthcare professionals should discuss the likely benefits, limitations and risks of using chlorhexidine mouthwashes in addition to tooth brushing and cleaning in people with mild gum disease. They should also point out that they do not replace flossing and regular dental hygienist visits for tartar removal.

Citation and Funding

James P, Worthington HV, Parnell C et al. Chlorhexidine mouthrinse as an adjunctive treatment for gingival health. Cochrane Database Syst Rev. 2017;3:CD008676.

Cochrane UK and the Oral Health Cochrane Review Group are supported by NIHR infrastructure funding. The review was also funded by the Cochrane Oral Health Global Alliance and Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, UK.

Bibliography

BSP. The good practitioner’s guide to periodontology. London: British Society of Periodontology; 2016.

CKS. Scenario: gingivitis and periodontitis. London: National Institute for Health and Care Excellence; updated 2016.

NHS Choices. Gum disease. London: Department of Health; updated 2016.

SDCEP. Prevention and treatment of periodontal diseases in primary care dental clinical guidance. London: Scottish Dental Clinical Effectiveness Programme; 2016.

Chlorhexidine mouthrinse as an adjunctive treatment for gingival health

Published on 1 April 2017

James, P.,Worthington, H. V.,Parnell, C.,Harding, M.,Lamont, T.,Cheung, A.,Whelton, H.,Riley, P.

Cochrane Database Syst Rev Volume 3 , 2017

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 Loe 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.

Expert commentary

Chlorhexidine mouthwash is readily available and widely used. This review clarifies its effectiveness in reducing plaque levels whilst reminding us that this can come with a cost, tooth staining being the main side effect.

This high quality review managed to combine data from relatively large numbers of studies, so the results are robust and can be acted on with confidence by clinicians and patients alike.

Dr Paul Ashley, Paediatric Dentistry, UCL Eastman Dental Institute

Categories

  •   Medicines, Oral and dental health, Primary care