10.59987/ads/2010.3-4.29-32
Aims. To determine whether the oral health benefits of recommending twice daily brushing and rinsing with an essential oil mouthrinse (EOM) are perceived and measurable by dentists and also perceived by their patients at a 3-month recall visit.
Methods. This is a monadic, open label, uncontrolled study involving 766 generally healthy Italian subjects aged 19-66 years, with mild to moderate levels of gingivitis, no pockets of more than 4 mm, and at least 20 scorable teeth. Eight dentists scored subjects for plaque and gingivitis at baseline and at 90 days using simplified 4-point plaque and gingivitis indices. All subjects brushed twice daily, immediately followed by rinsing for 30 sec with 20 ml of an essential oil mouthrinse (Listerine®).
Results. 735 subjects completed the study (95.9%). Average score reductions were 51.9% and 45.7% for plaque and gingivitis, respectively. About 62% and 70% were judged by the dentists as improved for plaque control and gingival health. 85% of subjects judged the EOM as efficacious.
Conclusion. The oral health benefits of brushing and rinsing twice daily with an essential oil mouthrinse are perceived by patients and professionals alike and measurable by dentists at a 3-month recall visit.
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A. Polimeni 
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Annali di stomatologia
essential oils
Perceived and measurable performance of daily brushing and rinsing with an essential oil mouthrinse
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Research Article
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Ann Stomatol (Roma)
A. Polimeni 
2010
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essential oils
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Perceived and measurable performance of daily brushing and rinsing with an essential oil mouthrinse
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1
    Perceived and measurable performance
    of daily brushing and rinsing with
    an essential oil mouthrinse




                                                                                                            i
                                                                                                          al
                                                                                                        on
    Andrea Pilloni, MD, DDS, MS1                                          were judged by the dentists as improved for plaque
    Giuseppe Pizzo, DDS2                                                  control and gingival health. 85% of subjects judged
    Alberto Barlattani, MD, DDS3                                          the EOM as efficacious.
    Roberto Di Lenarda, DDS4                                              Conclusion. The oral health benefits of brushing
    Mario Giannoni, MD, DDS5                                              and rinsing twice daily with an essential oil mouthrinse




                                                                                                      zi
    Luigi Guida, MD, DDS6                                                 are perceived by patients and professionals alike and
    Luca Levrini, MD, DDS7                                                measurable by dentists at a 3-month recall visit.
    Alessandra Majorana, MD, DDS8




                                                                              na
    Antonella Polimeni, MD, DDS1                                          Key words: oral hygiene, gingivitis, mouthrinses, es-
                                                                          sential oils.
    1
      “Sapienza” University of Rome, Rome, Italy
    2
      University of Palermo, Palermo, Italy
    3
      “Tor Vergata” University of Rome, Rome, Italy




                                                                            er
    4
      University of Trieste, Trieste, Italy                               Introduction
    5
      University of L’Aquila, L’Aquila, Italy
    6
      Second University of Naples, Naples, Italy                          Over the last few decades it has become apparent that re-
    7
      University of Insubria, Varese, Italy                               gular toothbrushing alone is not sufficient for plaque and
    8
      University of Brescia, Brescia, Italy

    Corresponding author:
                                                                 nt       gingivitis control and that flossing on a regular basis should
                                                                          be part of an optimal standard regimen for plaque control
                                                                          (1). However it has also been widely recognised that the
                                                       iI
    Prof. Giuseppe Pizzo                                                  full potential of mechanical means of plaque control is sel-
    Section of Oral Sciences                                              dom achieved. This is primarily through lack of sufficient
    University of Palermo, Palermo                                        motivation, manual dexterity or time for the individual to
    Via del Vespro 129 - 90127 Palermo, Italy                             maintain an acceptable standard of mechanical oral hy-
                                        on

    Tel. 39-091-6552231 - Fax: 39-091-6552203                             giene routine (2,3).
    E-mail: giuseppepizzo@unipa.it                                        In the Western world the shortcomings of mechanical oral
                                                                          hygiene are demonstrated by a high prevalence of pe-
                                                                          riodontal diseases (e.g. 40–45% moderate and 5–10% se-
                               i


                                                                          vere cases in UK adults) and by the presence of visible
                            iz



    Summary                                                               plaque and dental calculus in the large majority of the adult
    Perceived and measurable performance of daily bru-                    population (about 70% in UK adults) (4).
    shing and rinsing with an essential oil mouthrinse.                   New evidence based approaches to improving oral hygiene
           Ed




                                                                          outcomes are therefore needed. It has been proposed that
    Aims. To determine whether the oral health benefits                   this can be achieved by encouraging all individuals to adopt
    of recommending twice daily brushing and rinsing with                 daily rinsing with an antimicrobial rinse as an adjunct to
    an essential oil mouthrinse (EOM) are perceived and                   mechanical plaque control practices (3,5). However, only
    measurable by dentists and also perceived by their pa-                a few commercially available mouthrinses have been ex-
    tients at a 3-month recall visit.                                     tensively tested and have shown convincing evidence of
    Methods. This is a monadic, open label, uncontrolled                  their efficacy. Among these, chlorhexidine- and essential
IC




    study involving 766 generally healthy Italian subjects                oil-containing mouthrinses have been clinically proven to
    aged 19-66 years, with mild to moderate levels of gin-                provide long-term anti-plaque and anti-gingivitis efficacy
    givitis, no pockets of more than 4 mm, and at least 20                (6-14).
    scorable teeth. Eight dentists scored subjects for pla-               Chlorhexidine-containing mouthrinses are known to pro-
C




    que and gingivitis at baseline and at 90 days using sim-              duce a high rate of tooth staining and taste disturbances
    plified 4-point plaque and gingivitis indices. All                    among users, hence the tendency among professionals
    subjects brushed twice daily, immediately followed by                 to recommend these for short term treatment needs only
    rinsing for 30 sec with 20 ml of an essential oil mouth-              (10). On the other hand, a mouthrinse containing essen-
©




    rinse (Listerine®).                                                   tial oils, such menthol, thymol, methyl salicilate, eucalyp-
    Results. 735 subjects completed the study (95.9%).                    tol has the potential to meet long-term preventive objec-
    Average score reductions were 51.9% and 45.7% for                     tives, provided the patients’ motivation is also maintained
    plaque and gingivitis, respectively. About 62% and 70%                in the long term.


    Source of support: Johnson & Johnson (Santa Palomba-Pomezia, Italy) kindly provided mouthrinses and single-use equipment used to as-
    sess plaque and gingivitis indexes.


    Annali di Stomatologia 2010; I (3-4): 29-32                                                                                        29
    A. Pilloni et al.


    Here it is proposed that the long term patient motivation        Table 1 - Study population.
    to daily rinsing can be influenced by whether the patient
    can perceive the efficacy of the essential oil mouthrinse                                             Number of subjects
    (EOM). Moreover, the clinician’s motivation to recommend
    a significant modification of the patients’ oral hygiene rou-    Subjects enrolled at baseline        766




                                                                                                      i
    tine may depend on not only perceived but also measu-            Subjects not returned to 2nd




                                                                                                    al
    rable treatment performance by the dental professional.
                                                                     visit (after 90 days)                31
    This study evaluated perceived treatment performance by
                                                                     Subjects examined at baseline
    patients and professionals, as well as measurable perfor-
    mance by the dentists, shortly after the recommendation          and after 90 days                    735




                                                                                                  on
    of daily EOM use was given.                                      - male                               380 (51.7%)
                                                                     - female                             355 (48.3%)
                                                                     - mean age (±SD), years              30.5 (10.3)
    Materials and methods                                            - age range, years                   18-66




                                                                                                zi
    The study design was approved by the “Sapienza” Uni-
    versity Ethic Committee and was found to conform to the
    requirements of the “Declaration of Helsinki” as adopted




                                                                         na
    by the 18th World Medical Assembly in 1964 and subse-
    quently revised (15). Subjects were recruited at 8 university-
    based dental clinics across Italy. In order to be accepted
    onto the study all volunteers had to be at least 18 years




                                                                       er
    old, give written informed consent, be generally healthy,
    present mild to moderate levels of gingivitis with no pe-
    riodontal pockets of more that 4 mm probing depth, and
    a minimum of 20 scorable teeth. Enrolled subjects recei-
    ved scaling and polishing and were asked to refrain from
    taking non-essential medication and to avoid using any type
    of oral antiseptics for at least 30 days prior to the study
    start. A dentist in each clinic performed plaque and gin-
                                                               nt
                                                     iI
    gival health assessments at baseline and at 90 days. Each
    sextant was scored using a simplified 4-point plaque and
                                                                     Figure 1 - Plaque index at baseline and after 90 days of a
    gingival health index (16,17) as follows:
                                                                     twice/day use of an EOM as adjunct to brushing.
                                       on

    - Plaque Index
    0 = absence of plaque
    1 = mild, separate spots or a discontinuous band of pla-
         que at the gingival margin
    2 = moderate, homogeneous band of at the gingival
                              i


         margin covering less than a third of tooth surface
                           iz



    3 = heavy, plaque covering more than a third of tooth sur-
         face
    - Gingival Index
           Ed




    0 = absence of inflammation
    1 = mild, slight change of superficial texture, slight oede-
         ma
    2 = moderate, reddening, oedema, translucent gingiva
    3 = severe, marked reddening, oedema.
    At baseline all subjects were shown and instructed to bru-
    sh twice daily using a modified Bass technique and to rin-
IC




    se with 20 ml of an EOM (Listerine® Difesa denti e gen-
    give; Johnson & Johnson, Santa Palomba-Pomezia,
                                                                     Figure 2 - Gingival index at baseline and after 90 days of a
    Italy) immediately after brushing. At the final 90-day visit
                                                                     twice/day use of an EOM as adjunct to brushing.
    all subjects were asked to fill out a questionnaire. A pai-
C




    red sample t-test was used to detect significant differen-
    ces in plaque and gingivitis levels at baseline and at the
    90-day visit. The significance level was set at P<0.05.          to baseline, the 90-day average plaque scores had de-
                                                                     creased from 1.56 to 0.81, representing a 51.9% reduc-
©




                                                                     tion. Gingival inflammation scores had decreased from to
    Results                                                          1.95 to 1.06, representing a 45.7% reduction. Both chan-
                                                                     ges reached high statistical significance (P<0.001) (Figs.
    A total of 766 subjects were accepted onto the study and         1 and 2). The dentists judged 62.5 % of subjects as im-
    735 subjects (95.9%) were exited from the study having           proved for plaque control (21.1% greatly improved and
    completed it. The age range of participating subjects was        51.4% fairly improved). With respect to gingivitis levels,
    19-66 years and each of the eight study centres enrolled         69.8% of subjects were judged as improved (12.7% grea-
    between 50 and 118 subjects (Table 1). When compared             tly improved and 57.1% fairly improved). 84.9% of parti-

    30                                                                                   Annali di Stomatologia 2010; I (3-4): 29-32
    Perceived and measurable performance of daily brushing and rinsing with an essential oil mouthrinse


                                                                      would only have been useful to confirm the product’s ef-
                                                                      ficacy, which was clearly outside the scope of the study
                                                                      as it has already been largely demonstrated in multiple long
                                                                      term randomised clinical trials (6-9,11,12).
                                                                      Open label, uncontrolled, monadic studies offer the ad-




                                                                                                         i
                                                                      vantage that a large number of observations can be taken




                                                                                                       al
                                                                      within the context of every day general practice (18). For
                                                                      this purpose all assessments in this study were performed
                                                                      by a representative group of practicing dentists, who were
                                                                      also the actual caregivers to participating subjects.




                                                                                                     on
                                                                      There was a three-month period between baseline and fi-
                                                                      nal examination, rather than the more commonly adopted
                                                                      six-month review period. This short time interval was se-
    Figure 3 - Compliance of patients enrolled and which complet-     lected to ensure that patients were re-examined while they
    ed the study in terms of respect of the protocol suggested.




                                                                                                   zi
                                                                      were still likely to be practicing the newly recommended
    (Yes: compliance present; No: compliance absent; Not record-      habit of rinsing twice daily with EOM in addition to brushing.
    ed: data not recorded).
                                                                      In fact only 5.7% of participating subjects were found to
                                                                      be non-compliant at the end of the 3-month period. Both




                                                                          na
                                                                      the clinicians’ and the patients’ motivation will be reinfor-
    cipating subjects judged the product as efficacious (11.0%        ced further if the final positive results can be clearly attri-
    very efficacious, 48.2 % efficacious and 25.7% fairly ef-         buted to the recommendations given at the first visit.
    ficacious). One interesting data comes from the level of          Highly significant and substantial reductions in plaque and




                                                                        er
    compliance all patients showed in terms of fulfilling all of      gingivitis levels were measured by the dentists in this study.
    the requirements for proper completion of the study (Fig.         Being an open label study the clinician judgement would
    3).                                                               have been undoubtedly conditioned by expectations of im-
                                                                      proved oral conditions at recall. Further studies will need

    Discussion

    Daily rinsing with proven antibacterial agents may repre-
                                                                nt    to establish whether the large effect size measured by the
                                                                      professionals in this study was due more to the underlying
                                                                      product efficacy or to product performance expectations.
                                                                      In conclusion, the results of this study indicated that shor-
                                                      iI
    sent a universally applicable method of supplementing the         tly after a professional recommendation to brush and rin-
    benefits of mechanical plaque control. In fact rinsing does       se twice daily with an EOM, the oral health benefits will
    not pose any manual dexterity challenges and can deli-            be perceived by patients and dentists, and will measura-
                                        on

    ver anti-plaque benefits to hard to reach areas of the mouth      ble by the professionals themselves.
    more reliably than regular brushing alone or brushing and
    flossing (1,3,5,10).
    However sufficient motivation will be required for individuals    Acknowledgements
    to modify their long established oral hygiene habits and
                               i


    add rinsing with an antimicrobial rinse to their daily routi-     Mouthrinses and single-use equipment used to assess pla-
                            iz



    ne. It can be hypothesised that for a newly recommended           que and gingivitis indexes were kindly provided by John-
    regimen to be accepted by patients and to be sufficiently         son & Johnson S.p.A (Santa Palomba-Pomezia, Italy).
    motivating to the patients its benefits should be perceived
           Ed




    by them reasonably soon after receiving the professional
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