10.59987/ads/2015.2.35-42



&nbsp;
VOLUME 6 - NUMBER 2 - 2015

Introduction. A good control of bacterial plaque is an essential factor for the success of periodontal therapy, therefore it is the main objective that the clinician together with the patient must get to have a healthy periodontium. The plaque control with mouthwashes is the most important home therapy as it helps to reduce the formation of plaque between the mechanical removal with a toothbrush. Aim. Authors analyzed the clinical data from a trial carried out with 3 different mouthwashes containing 0.2% Chlorhexidine (CHX). In addition, the ADS (Anti Discoloration System - Curaden Healthcare) was tested in comparison with the other mouthwashes without this system. Materials and methods. We tested antiplaque activity showed by 3 of the most commercialized mouthwashes, moreover, we tested the ability in reducing the dental staining related to the oral assumption of Chlorhexidine. Discussion and conclusion. Our results demonstrated the clinical efficacy of the 3 mouthwashes with CHX. Particularly performing was the anti discoloration system (Curaden Healthcare), with a clinical detection of dental stainings significantly less than the others tested. This study demonstrated the clinical efficacy of ADS system in the reduction of tooth staining, without a loss of antiplaque activity with respect to the competing mouthwashes containing CHX.




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Annali di stomatologia
dental staining
 A comparative, randomized, controlled study on clinical efficacy and dental staining reduction of a mouthwash containing Chlorhexidine 0.20% and Anti Discoloration System (ADS)
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Review article
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2022-08-12
2015-06-01
2023-12-04
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Ann Stomatol (Roma)
M. Tatullo
2015
10.59987/ads/2015.2.35-42
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dental staining
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 A comparative, randomized, controlled study on clinical efficacy and dental staining reduction of a mouthwash containing Chlorhexidine 0.20% and Anti Discoloration System (ADS)
https://www.annalidistomatologia.eu/ads/article/download/88/75
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                                                                                                   Review article



    A comparative, randomized, controlled study
    on clinical efficacy and dental staining reduction
    of a mouthwash containing Chlorhexidine 0.20%




                                                                                                    i
                                                                                                  al
    and Anti Discoloration System (ADS)




                                                                                               on
    Massimo Marrelli, MD1,2                                  Key words: dental plaque, oral hygiene, dental ed-
    Massimiliano Amantea, MD1                                ucation, Chlorhexidine, dental pigmentation, den-
    Marco Tatullo, DDS, PhD1,2                               tal staining.




                                                                                      zi
    1   Unit of Maxillofacial Surgery, Calabrodental, Cro-   Introduction
        tone, Italy
    2   Tecnologica Research Institute, Biomedical Sec-      The plaque control is the most important aim that the




                                                                         na
        tion, Crotone, Italy                                 clinician together with the patient must achieve to ob-
                                                             tain an effective prevention of periodontal disease.
                                                             Many studies conducted in animal models have es-
    Corresponding author:                                    tablished that the presence of pathogenic bacteria is
    Marco Tatullo                                            an indispensable condition that makes possible the




                                                               er
    Tecnologica Research Institute, Biomedical Section       onset and development of gingival and periodontal
    Dept. of Oral Hygiene and Periodontics, Calabroden-      diseases (1).
    tal Clinic                                               Additional studies have verified that the control of
    St. E. Fermi


                                                       t     bacterial plaque through proper procedures of oral
    88900 Crotone, Italy
    E-mail: marco.tatullo@tecnologicasrl.com
                                                    In       hygiene at home allows the complete resolution of
                                                             the inflammatory process (2).
                                                             Other studies have found that a good control of bac-
                                                             terial plaque is an essential factor for the success of
    Summary                                                  surgical and non-surgical periodontal therapy (3, 4).
                                                 ni
                                                             On the contrary, Becker et al. (5) have demonstrated
    Introduction. A good control of bacterial plaque is      that without an optimal control of plaque, periodontal
    an essential factor for the success of periodontal       therapy alone is poorly effective in restoring peri-
                                    io

    therapy, therefore it is the main objective that the     odontal health. This suggests that it is possible to
    clinician together with the patient must get to          achieve similar clinical outcomes through different
    have a healthy periodontium. The plaque control          surgical procedures, provided, however, that a regu-
    with mouthwashes is the most important home              lar and proper control of bacterial plaque is done.
                           iz



    therapy as it helps to reduce the formation of           The chemical control of plaque can be obtained with dif-
    plaque between the mechanical removal with a             ferent pharmacological categories, including antibiotics
    toothbrush.                                              (6) essential oils (7), and antibiotics biguanides (8).
           Ed




    Aim. Authors analyzed the clinical data from a tri-      Among the therapies commonly used to maintain
    al carried out with 3 different mouthwashes con-         control of plaque, the antiseptic Chlorhexidine (CHX)
    taining 0.2% Chlorhexidine (CHX). In addition, the       (9) is certainly the most studied and the most effec-
    ADS (Anti Discoloration System - Curaden Health-         tive for the inhibition of plaque and for the prevention
    care) was tested in comparison with the other            of gingivitis: it is recognized by more than twenty
    mouthwashes without this system.                         years as the gold standard for its anti-plaque and an-
IC




    Materials and methods. We tested antiplaque ac-          ti-bacterial activity in oral hygiene.
    tivity showed by 3 of the most commercialized            Some studies (10) have also verified that the con-
    mouthwashes, moreover, we tested the ability in          stant use of CHX did not give rise to the development
    reducing the dental staining related to the oral as-     of resistant microorganisms: these results have al-
C




    sumption of Chlorhexidine.                               lowed us to assert that Chlorhexidine is a safe drug,
    Discussion and conclusion. Our results demon-            even if used for long periods.
    strated the clinical efficacy of the 3 mouthwashes       However, even the CHX showed unfavorable charac-
    with CHX. Particularly performing was the anti           teristics, in fact, after administration of the CHX
                                                             mouthwash, a temporary alteration of taste occurs
©




    discoloration system (Curaden Healthcare), with a
    clinical detection of dental stainings significantly     (11); hypogeusia induced by Chlorhexidine concerns
    less than the others tested. This study demon-           specifically salty and bitter taste.
    strated the clinical efficacy of ADS system in the       Among the well known side effects occurring with a
    reduction of tooth staining, without a loss of an-       frequent use of CHX, the most unaesthetic one is un-
    tiplaque activity with respect to the competing          doubtedly the brownish pigments that accumulate on
    mouthwashes containing CHX.                              the surfaces of teeth, as well on prosthetic crowns

    Annali di Stomatologia 2015; VI (2): 35-42                                                                    35
    M. Marrelli et al.


    and tongue: these pigmentations restrict the use of        The patients selected and involved in this study gave
    CHX and patient compliance (12).                           their signed informed consent, according with the
    The biochemical pathways underlying the formation          guidelines approved by Calabrodental dental clinic
    of pigmentations due to Chlorhexidine are the Mail-        (Crotone, Italy). The study and the related procedures
    lard reaction with a reaction of protein denaturation:     were conducted in compliance with guidelines ap-




                                                                                                        i
    the triggering factor is represented by the interaction    proved by the Calabrodental Ethics Committee (Prot.




                                                                                                      al
    between food or drinks rich in chromogens after ad-        n°3 July-2011/HIAP). Calabrodental ethics committee
    ministration of Chlorhexidine.                             specifically approved this study. The study was con-
                                                               ducted in compliance with the “Ethical principles for




                                                                                                   on
                                                               medical research involving human subjects” of
    Aim of the work                                            Helsinki Declaration. The study was conducted in ac-
                                                               cordance with Italian laws and regulations.
    Authors analyzed data carried out from a randomized
    controlled clinical trial, using three products for oral




                                                                                         zi
    hygiene, commonly sold in the dental market, with the      Study Design
    same concentrations of CHX:
    • Curasept mouthwash (Curaden Healthcare)                  The 3 mouthwashes, Control 1 mouthwash 0,20%




                                                                           na
        0,20% CHX                                              CHX, Curasept mouthwash (Curaden Healthcare,
    • Control 1 mouthwash 0,20% CHX                            Saronno, Italy) 0,20% CHX, and Control 2 mouth-
    • Control 2 mouthwash 0,20% CHX.                           wash 0,20% CHX, were marked respectively with the
    In addition, we evaluated whether the ADS influences       letters C, D and E: operators and patients were not




                                                                 er
    the antiplaque activity of CHX in the formulation          informed about the correspondence between the
    0,20% compared to other formulations without ADS;          name of the mouthwash and the corresponding letter.
    finally, we evaluated the effectiveness of the ADS on      In addition, the blinded mouthwashes were included
    the reduction of the Lobene Staining Index compared        in a similar packaging, with no signs or references
    to products without ADS.


                                                         t     that could indicate the name of the mouthwash: on
                                                      In       the bottle was shown only the letter C, D or E, corre-
                                                               sponding to the group of the same name.
    Materials and methods                                      The patients were mainly female (Male/Female =
                                                               36/64%) and under 50 years old (<50yrs = 84%): they
    We compared 3 commercially available mouthwash-            were randomly allocated in 3 groups named “Group
                                         ni
    es: Control 1 mouthwash 0,20% CHX, Curasept                C”, “Group D” and “Group E”; each group was treated
    mouthwash (Curaden Healthcare, Saronno, Italy)             with the same protocol of oral hygiene but with a dif-
    0,20% CHX, and Control 2 mouthwash 0,20% CHX.              ferent mouthwash. The mean age of the patients in
                                io

    Our study was aimed to assess the effectiveness of         the 3 groups was homogeneous; moreover, it was as-
    CHX anti-plaque action by means of the clinical            sessed the percent of smokers in the three groups
    evaluation of periodontal indices and clinical out-        and the group E was the one with the higher percent-
    comes; moreover we evaluated the presence/ab-              age of smokers, while the group C showed the lowest
                         iz



    sence of the unaesthetic pigmentation of the tooth         percentage (Tab. 1).
    surfaces, usually following the administration of oral     Each patient has been identified with a different pro-
    CHX, by means of the recording of Staining-Index           gressive code, represented by the name of the dental
          Ed




    values.                                                    hygienist who has carried out the entire treatment of
    200 subjects were recruited at the Department of           the patient, together with the indication of the group
    “Oral Hygiene and Periodontics” of Calabrodental           where the patient has been allocated after the random-
    dental clinic (Crotone, Italy): this study was conduct-    ization (for example: Hygienist Name-number / C-1).
    ed among September 2011 and March 2012 and was             The recruitment was conducted according to the protocol.
    commissioned by Curaden Healthcare.                        Exclusion criteria in this study were: absence of sys-
IC




                                                                         Table 1. Prevalence of smokers in the 3 groups.
C
©




    36                                                                            Annali di Stomatologia 2015; VI (2): 35-42
    A comparative, randomized, controlled study on clinical efficacy and dental staining reduction of a mouthwash containing
    Chlorhexidine 0.20% and Anti Discoloration System (ADS)

    temic diseases, such as diabetes, coagulopathies,              Table 2. Baseline data of the 3 values investigated in each
    uncompensated heart diseases, vascular diseases,               of the 3 groups.
    metabolic bone diseases, gastro-esophageal dis-
    eases allergy, etc. Patients with erosions, abrasions                         Group C          Group D          Group E
    and abfractions of the enamel, patients affected by            P. Index       m.v. 1,88        m.v. 1,82        m.v. 2,0




                                                                                                            i
    the bruxism and patients with mouth breathing were             B. Index       Y                Y                Y




                                                                                                          al
    also excluded.                                                 S. Index       m.v. 0,68        m.v. 0,56        m.v. 0,59
    Inclusion criteria were:                                       Legend:
    1. Age ± 18 years old                                          m.v. : mean value




                                                                                                       on
    2. Non-smokers or slight smokers (<10 cigarettes/day)          Y: yes (according to mB.Index described in the Methods
    3. Non-drinkers or slight drinkers (<3 glasses of              section)
        wine/day)
    4. Good compliance with the dental hygienist                   recorded before the previously described first oral hy-




                                                                                              zi
    The following indices were analyzed and stored:                giene treatment (T 0 ) (Tab. 2). The analyzed data
    a. Plaque Index (PI, according to Silness and Löe,             showed a correct randomization. Follow-up evalua-
        1963) (13);                                                tions were performed after 7 days (T1) and after 14




                                                                                na
    b. Bleeding Index (mBI, modified Bleeding Index so             days (T2) from the first visit (T0). Photographic docu-
        to assess the presence/absence of bleeding after           mentation was archived at baseline, T0,T1 and T2.
        probing of the gingiva) (14);                              In order not to influence the formation of the pigmen-
    c. Staining Index (SI, according to Lobene, 1968) (15);        tations, the patients were advised to limit the chewing
    Plaque Index was assessed according to the follow-             and drinking of chromogenic foods such as tea, cof-




                                                                     er
    ing clinical criteria (13):                                    fee, red wine, spinach, during the 15 days of duration
    • Value 0: Absence of bacterial plaque                         of the study: every assumption of these substances
    • Value 1: Evident plaque by sliding the probe on              was to be reported in the appropriate schedule pro-
        the surface of the teeth                                   vided them in the T0 visit.
    • Value 2: Visible plaque

                                                          t
    • Value 3: Abundant plaque.
                                                       In
    Modified Bleeding Index was assessed according to              “Reverse” motivation
    the following clinical criteria (14):
    • No: Visible gingival inflammation with bleeding              During the study, patients were required not to use
        caused only by the passage of the probe on the             the daily mechanical oral hygiene, while they were
                                                 ni
        gingiva                                                    required only to rinse with 10 ml of solution of the
    • Yes: Evident gingival inflammation with sponta-              assigned mouthwash, twice a day, not before 30
        neous bleeding.                                            minutes from their meals, for a duration of about 60
                                    io


        The tooth is examined with a calibrate probe (di-          seconds.
        ameter 0.63mm) on the lingual, mesial, distal, and         The reverse motivation finds its rational application in
        buccal surfaces, and probed to test the degree of          our study, and was reported in literature in a study by
                           iz



        firmness. Bleeding can be more prevalent if a site         Ross et al. (16), in which subjects who had heard
        is continually probed, thus it’s important to insert       messages that dissuaded to perform the oral hy-
        the probe in four sites, removing the probe after          giene, showed a significantly more negative attitude
          Ed




        the insertion. Moderate force (< 25g) should be            toward this practice and remembered fewer episodes
        used during the probing.                                   in which they had washed their teeth.
    Staining (only area) Index was assessed according to
    the following clinical criteria (15):
    • Value 0: Absence of pigmentations                            Statistical analysis
    • Value 1: Pigmentation covering up to 1/3 of the
IC




        region                                                     The collected data were analyzed by means of the sta-
    • Value 2: Pigmentation covering 1/3 to 2/3 of the             tistical software SPSS/PC version 10.1 for Windows.
        region                                                     The statistical evaluations were carried out by means
    • Value 3: Pigmentation covering 2/3 of the region.            of Student’s t test for paired samples 2-tailed. The re-
C




    Staining (only intensity) Index was assessed accord-           sults were obtained by comparing, for each group of
    ing to the following clinical criteria (15):                   patients analyzed, the values detected at time T1 and
    • Value 0: No stain                                            the values measured at time T2 [T1 vs T2]. The test
    • Value 1: Light pigmentations                                 was considered significant with p-value <0.05.
    • Value 2: Moderate pigmentation
©




    • Value 3: Marked pigmentation.
    Patients were properly visited and they were subject-          Results
    ed to supragingival calculus removal employing ultra-
    sonic scaler tips; polishing and tooth stains removal          At the end of the study, data were analyzed from
    was also performed in the first visit (T 0). Baseline pa-      many points of interest, and results were investigated
    rameters of PI, mBI and SI index were properly                 per groups and per single value.

    Annali di Stomatologia 2015; VI (2): 35-42                                                                             37
    M. Marrelli et al.


    P. Index

    The P. Index distribution in the 3 groups appears sub-
    stantially homogeneous with the exception of Group
    E, in which we detected few patients with P. Index




                                                                                                        i
    values between 2 and 3.




                                                                                                      al
    P. Index values show that the Group C has an in-
    crease of 0.03 points/media from T1 to T2; Group D
    shows a clear reduction of P. Index values, a de-




                                                                                                   on
    crease of 0.26 points/media. Group E is the only one
    with very high values if compared with the other two
    groups, with a decreasing of points/media of just -        Table 4. Comparison of S.Index mean values between T1
    0.06; however, the Group E is also the one who start-      and T2 in the 3 groups.
    ed with mean values of P.Index equal to 2 before the




                                                                                         zi
    initial hygiene performed in T 0; therefore, it is sup-    static and anti-plaque action of CHX 0.20%; however,
    posed that the patients allocated in Group D are less      this specific result may also depend in substantial
    prone to plaque control. It should be noted that the       part by the clinical condition at baseline of the Group




                                                                           na
    Group D starts with a P. Index at baseline equal to        E, as previously stated (Tab. 3).
    1.82 and after 7 days it has a P. Index equal to 1.7,
    which constantly tends to stabilize itself at lower val-
    ues (1.44) in the following days (Tab. 3).                 S. Index




                                                                 er
    After the data evaluation, we can assert that P. Index
    variations detected in the 3 Groups C, D and E are         S. Index data in the 3 groups show that the Group C
    not statistically significant, with the exception of       presents an increase in the average value of the stain-
    Group D which shows a high significance. This data         ing index computed in 0.29 points/media, between the
    allows us to observe a better clinical outcome


                                                         t     control at 7 days and the control at 15 days. Group E,
    showed by mouthwash with ADS, in relation to the
    control of dental plaque.
                                                      In       instead, shows an increasing in the average value of
                                                               S.Index of 0.34 points/media, when you compare the
                                                               control values at 7 days and the control values at 15
                                                               days; however, the detected average value of S.Index
    mB. Index                                                  at 14 days is lower than the one observed in the
                                         ni
                                                               Group C. Finally, the Group D shows a variation of the
    The modified B. Index values of the Group C show           average value of S. Index assessed in 0.28 points/me-
    that the bleeding persists even after the first week of    dia between the control at 7 days and the control at 15
                                io

    treatment with the mouthwash C, however, starting
                                                               days, however, it’s important to emphasize that the
    from the second week the leakage of blood stops.
                                                               absolute values at T2 control reveal a pigmenting abili-
    The Group D shows an absence of bleeding at the
                                                               ty of Curasept mouthwash significantly lower than the
    first follow-up and this finding remains unaltered even
                         iz



                                                               other tested mouthwashes: this mouthwash has a for-
    during the final visit at T2. The Group E is the only
                                                               mulation containing the anti discoloration system
    one that does not seem to benefit from the bacterio-
                                                               (ADS) that has just the function of reducing the dental
          Ed




                                                               pigmentations (Tabs. 3, 4).
    Table 3. Comparison between T1 and T2 data of the 3 val-
    ues investigated in each of the 3 groups.

                               T1                      T2      Discussion
    Group C
                                                               Oral care is an essential part of the general health of
IC




    P.Index                    1,82                    1,85    the population. Dental bacterial plaque has been re-
    P.Index (≥2)               2,09                    2,07    lated to several systemic diseases such as pneumo-
    B.Index                    Y                       N       nia and endocarditis (17). The development of oral
    S.Index                    0,52                    0,81    diseases is often associated with the composition and
C




    Group D                                                    the quantity of dental plaque, with the diet, and with
    P.Index                    1,7                     1,44
                                                               the typology of the salivary flow (18).
    P.Index (≥2)               2,1                     2       CHX has been investigated for over 30 years as an
    B.Index                    N                       N       antimicrobial agent for the chemical control of plaque
                                                               formation. Different concentrations are available on
©




    S.Index                    0,21                    0,49
                                                               the market, mainly ranging from 0.02 to 0.3%; howev-
    Group E
                                                               er, recently, the Food and Drugs Administration
    P.Index                    2,1                     2,04    (FDA) introduced high concentration solution (3.5%)
    P.Index (≥2)               2,04                    2,04    to be diluted with water before use. As shown by in
    B.Index                    Y                       Y       vivo studies (19), the mechanism of action of the
    S.Index                    0,3                     0,64    Chlorhexidine seems to be dose-dependent: bacterio-

    38                                                                            Annali di Stomatologia 2015; VI (2): 35-42
    A comparative, randomized, controlled study on clinical efficacy and dental staining reduction of a mouthwash containing
    Chlorhexidine 0.20% and Anti Discoloration System (ADS)

    static at very low concentrations (0.02-0.06%), and            Although CHX is unanimously recognized as one of
    bactericidal at higher concentrations (0.12-0.20%).            the most effective cationic antiseptic compound cur-
    FDA suggested a use of CHX (at 0.12 and 0.2% con-              rently used in medical practice (34), different re-
    centrations) administered as oral rinses of 10-15 mL,          search groups have investigated the antiplaque ac-
    for about 30 seconds, for a limited period of time (re-        tion of other mouthwash products containing different




                                                                                                            i
    spectively, 1 month or 2 weeks) (20, 21).                      principles rather than CHX (36). All these works failed




                                                                                                          al
    CHX would appear to have dose-dependent effects                to find an alternative antiplaque solution as effective
    also in terms of its most common local adverse ef-             as CHX, such as Listerine (without CHX) which has
    fects: dysgeusia and tooth pigmentation (22). Be-              been demonstrated to have a significantly lower an-




                                                                                                       on
    cause of this, different concentrations have been sug-         timicrobial activity than CHX-based products (35).
    gested over time, trying to balance beneficial and ad-         Notwithstanding, some studies demonstrated that
    verse effects of CHX, in order to improve the patient          CHX elicits a low efficacy in the treatment of severe
    compliance.                                                    periodontal diseases (36), or in the presence of coro-




                                                                                              zi
    As recently reported in the literature (23, 24), the use       nal caries (37), if it is not associated to a mechanical
    of mouthwashes containing 0.2% of CHX showed a                 removal of bacterial plaque. It is likewise important to
    substantial reduction of gingival inflammation and             emphasize that in the presence of advanced peri-




                                                                                na
    plaque indexes (23, 24). Several studies demonstrat-           odontal disease the use of CHX could result not suffi-
    ed that subjects that performed their oral care with           cient to improve the periodontal condition, if not asso-
    mouthwashes containing 0.2% of CHX improved sig-               ciated with subgingival treatment (38).
    nificantly their P. Index (25), the B. Index (26, 27),         On the other hand, it has been demonstrated the possi-
    and the S. Index (28).                                         bility of interaction and mutual inactivation of chlorhexi-




                                                                     er
    Recently, it has been investigated the possibility of          dine and toothpaste that contains a common detergent
    reducing brown pigmentations associated with the               compound, sodium lauryl-sulfate (38). Therefore, we
    use of CHX-based products, particularly the mouth-             recommend the use of CHX after an interval of 30 min-
    washes (29), by interrupting the Maillard reaction. To         utes by the use of other products for oral hygiene.
    date, the efficacy of antiseptic solutions containing

                                                           t       Previous works evidenced also an antagonist action
    0.20% CHX has been consistently carried out by
                                                        In         of CHX with monofluorophosphate content in some
    some peer-reviewed publications (30-32), and ac-               mouthwashes (39).
    cording to these studies, it was highlighted that CHX          Gusolley (40) provided in the 2010 a ranking of the an-
    products with effective anti-staining additives, led to a      tiplaques and antigingivitis effects of the three mouth-
    reduction of CHX antimicrobial activity (33).                  washes containing CHX, essential oils (EOs) and ce-
                                                 ni
    In our work we have analyzed the antiplaque activity of        typyridinium chloride (CPC). Among these three, EOs
    3 of the most frequently used mouthwashes on the               was reported as the second best antiplaque and anti-in-
    market, moreover, we have assessed their ability to            flammatory mouthwash right after CHX (41).
                                    io


    avoid the typical pigmentations occurring after a lasting      Phenols and essential oils have been used for a long
    of oral CHX treatment with a duration of several days.         time to rinse the oral cavity. One of the main products
    We compared the three mouthwashes. Patients treat-             is Listerine, made of essential oils, thymol and euca-
                           iz



    ed with Curasept mouthwash, based on a formulation             lyptol combined with alcohol-based menthol. Al-
    with ADS, showed a fairly constant antiplaque activi-          though this product is not as effective as chlorhexi-
    ty, compared to baseline values stored in this re-             dine (34) it obtained significant reductions in the level
          Ed




    search. This finding is fully confirmed by the sub-            of plaque and gingivitis in various studies. EOs were
    analysis performed in patients with full-mouth P. In-          also demonstrated to represent a reliable alternative
    dex ≥2: in fact, even into this sub-group, we can ob-          to chlorhexidine mouthwash in long-term use (41).
    serve a noticeable reduction of the plaque index in            Antiplaque and antimicrobial mouth rinses used thus
    Curasept group; although the observed plaque con-              far in periodontal practice also contain ingredients
    trol in this group is not clinically satisfactory, we must     such as alcohol or sugar (42). These ingredients en-
IC




    consider the concomitant relative absence of me-               hance the cariogenic potential of the substrate and
    chanical oral hygiene required by the “reverse moti-           promote halitosis. A recent study evaluated the effects
    vation” described in the methods section, as required          of the use of an herbal mouth rinse on oral hygiene im-
    by the protocol.                                               provement (43). In this study emerged that the Indian
C




    We evaluated the effectiveness of the ADS on the               herb Triphala (44-46) exhibits similar antiplaque effica-
    reduction of the S. Index. In the Group C (Control 1)          cy to that of CHX and was more effective in inhibiting
    the average value of S. Index resulted increased be-           plaque formation with lesser or no side effects (47).
    tween the control at 7 days and at 15 days. In the             Together with EOs, CHX is still considered the gold
    group E (Control 2) we observed a similar trend,               standard against plaque formation (48). CHX is also
©




    with average S. Index values increased between the             available in gel at different concentrations ranging
    T 1 and the T 2 . Finally, the Group D (treated with           from 1 to 0.2 and 0.12% (49); studies proved the an-
    Curasept) showed some variations of the average S.             tibacterial activity of CHX gels at the high concentra-
    Index values, revealing that Curasept mouthwash                tions available (2%, 1%) while at the lower concentra-
    has a lower pigmenting ability, with respect to the            tions (0.2%) CHX gel action resulted inhibited by
    other tested mouthwashes.                                      dentin matrix and type I collagen (50). Furthermore,

    Annali di Stomatologia 2015; VI (2): 35-42                                                                             39
    M. Marrelli et al.


    some studies reveal that the gel cannot reach all sur-      cio, Curaden Healthcare, for their precious contribu-
    faces of the tooth.                                         tion to this clinical research;
    Alternatively, instead of rinse, there is a spray (18)      Dr. Marta Giovannardi, Curaden Healthcare, for her
    that allows for convey the compound directly on the         valuable contribute to the study design and to the crit-
    surfaces of the teeth making a dosage, normally low-        ical analysis of the outcomes;




                                                                                                               i
    er than that used in mouthwashes, effective. Spray          Dr. Roberto Cimmino, Curaden Healthcare, for his




                                                                                                             al
    formulations would appear to be particularly indicated      kind support in the organizations of the research ac-
    in patients with mental and physical impairments,           tivities;
    leading to a significant reduction in plaque and gingi-     Dr. Dora Marrelli, Dr. Sandro Sestito, Dr. Domenico




                                                                                                          on
    val bleeding indexes (51-53).                               Tarsitano, Department of Oral Hygiene and Periodon-
                                                                tics of Calabrodental Clinic, for their hard and profes-
                                                                sional work in the collection of the data.
    Conclusions                                                 A sincere thank you to the Department of Oral Hy-
                                                                giene and Periodontics of Calabrodental Clinic, to all




                                                                                               zi
    Our trial has clinically showed, once again, the efficacy   the administrative area and to all the operators of
    of chlorhexidine mouthwashes. All mouthwashes ana-          Marrelli Group that participated to the organization of
                                                                the research activities.




                                                                               na
    lyzed showed an action not only in reducing the ability
    of plaque formation in the absence of brushing, but also
    in the protection of the gingival tissues, which showed a
    less erythematous appearance, and with a lower index        List of Abbreviations
    of spontaneous bleeding. But, the major and significant




                                                                  er
    evidence we had it in assessing the optimal response        Anti Discoloration System (ADS)
    of the system ADS, by Curasept, to the formation of         Chlorhexidine (CHX)
    pigmentation on tooth enamel. This response has al-         Plaque Index (PI)
    lowed to combine aesthetics and antiplaque action,          modified Bleeding Index (mBI)
    without reducing the effectiveness of each of them in

                                                          t     Bleeding Index (BI)
    oral hygiene at home.
                                                       In       Staining Index (SI)
                                                                Time 0, 1, 2 (T0, T1, T2)
                                                                Essential oils (EOs)
    Consent Statement                                           Cetypyridinium chloride (CPC)
                                          ni
    Written informed consent was obtained from the pa-
    tient for publication of this case report and accompa-      References
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    42                                                                                              Annali di Stomatologia 2015; VI (2): 35-42
