The focus of this study is on two types of mouthwashes - one containing a chlorhexidine (CHX) at 0.2% (CHX), and the other one containing CHX at a lower concentration of 0.12% with cetylpyridinium chloride (CPC). Both mouthwashes are used to help in the treatment of gum disease. CHX has been known for a long time for its effectiveness against plaque and mouth inflammation. It could inhibit and even kill them. However higher concentrations of CHX comes with unwanted side effect including altered taste, teeth staining and irritation in the mouth. Interestingly, these side effects seem to occur less frequently when a lower concentration CHX solution is used. CPC also combats bacteria by adhering quickly to the surfaces inside your mouth, although it has less substantivity than CHX, it has been shown to reduce plaque and gum inflammation effectively, and it typically causes fewer side effects than CHX. We hypothesize that this new formulation of CHX 0.12%+CPC mouthwash is non-inferior to CHX 0.2% in terms of its anti-plaque and anti-inflammatory properties while presenting with less side effects after 21 days of use. Microbiological samples and fluids from periodontal pockets will be collected before and after treatment for analysis of microbiological effects.
* Aim: To compare the effects of 2 formulations of antiseptics on clinical efficacy (reduction of gingival inflammation and plaque) and oral microbiome when used as an adjuvant in periodontal treatment. * Hypothesis: HA: The study mouthwash (CLX 0.12% + CPC 0.05%) when used as an adjunct to step 1 periodontal therapy, is non-inferior to control mouthwash (CHX 0.2%) in terms of inflammation and plaque control. * Primary outcome: Changes in full mouth Bleeding on Probing (BoP) at 2 months after 21 days daily use of test mouthwash as an adjunct to step 1 periodontal therapy compared to active control. * Secondary outcome: Changes in BoP at 21 days after baseline. Changes in Löe and Silness Gingival Index at 21 days and 2 months after baseline. Changes in modified O'Leary plaque index and Turesky modification of Quigley-Hein plaque index at 21 days, 2 months after baseline. Changes in Tongue Coating Index and Lobene Stain Index at 14, 21 days and 2 months after baseline. Pocket probing depth (PPD) and clinical attachment level (CAL) changes 2 months after baseline. Subgingival microbiological changes at 21 days and 2 months after baseline. Gingival cervical fluid volume and inflammatory biomarker profile changes at 21 days and 2 months. Taste alteration and mucosal irritation at 14 days, 21 days and 2 months after baseline. Changes in patient-reported outcome measures at 21 days and 2 months after baseline
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
QUADRUPLE
Enrollment
60
Test group: administration of experimental antiseptic (CHX 0.12%+CPC 0.05%) for 3 weeks
Active comparator: administration of control antiseptic (CHX 0.2%) for 3 weeks
% Bleeding on probing (BoP)
% BoP will be assessed at 6 surfaces (mesiobuccal, mid buccal, disto-buccal, mesio-oral, mid-oral, disto-oral.) in a dichotomous manner (Mühlemann \& Son, 1971). Bleeding will be positive after 15 seconds of probing the gingival sulcus to the most apical stop. The percentage of the full mouth BoP will be reported.
Time frame: 2 months
% Bleeding on probing (BoP)
% BoP will be assessed at 6 surfaces (mesiobuccal, mid buccal, disto-buccal, mesio-oral, mid-oral, disto-oral.) in a dichotomous manner (Mühlemann \& Son, 1971). Bleeding will be positive after 15 seconds of probing the gingival sulcus to the most apical stop. The percentage of the full mouth BoP will be reported.
Time frame: 21 days
Macpherson modification of the Lobene Stain Index (MLSI)
Tooth staining assessment by the Macpherson modification of the Lobene Stain Index (MLSI) (L. M. Macpherson, K. W. Stephen, A. Joiner, F. Schäfer, \& E. Huntington, 2000) on index tooth (11, 12, 21, 22, 31, 32, 41, 42). If an incisor is missing, the nearest canine will serve as substitute where appropriate.
Time frame: 21 days and 2 months
Full mouth plaque score
Full Mouth Plaque Score (FMPS) (O'Leary et al., 1972) will be measured as an indicator of oral hygiene on the mesial, distal, buccal and oral surfaces of each tooth. The FMPS will be assessed with the following formula: Number of surfaces with plaque/Total number of surfaces x 100%
Time frame: 21 days and 2 months
Clinical attachment level
CAL measures the distance from the cemento-enamel junction of the tooth to the base of the periodontal pocket. CAL will be measured at baseline and 2 months by recording the distance from the cervical line to the bottom of the probable pocket at 6 sites (Mesio-buccal, mid-buccal, disto-buccal, mesio-oral, mid-oral and disto-oral) for each of the study teeth.
Time frame: 2 months
Pocket probing depth (PPD)
PPD measures the distance from the free gingival margin to the base of the periodontal pocket. It will be measured at 6 sites (Mesio-buccal, mid-buccal, disto-buccal, mesio-oral, mid-oral and disto-oral) in the entire dentition.
Time frame: 2 months
Patient-reported outcome measures for mouthwash (PROMs-MW)
A mouthwash-specific questionnaire consisting of 6 questions was constructed to assess the compliance and potential side effects associated with mouthwash use, including burning sensation, altered taste and unpleasant taste assessed on a visual analogue scale., taking reference from Navabi and coworkers (Navabi, Afshari, Kamyabi, \& Mohammadi, 2024). A higher score indicates a poorer patient-perceived experience.
Time frame: 14 days, 21 days, 2 months
Oral health impact profile for chronic periodontitis (OHIP-CP)
Oral health impact profile for chronic periodontitis (OHIP-CP). The OHIP-CP is a condition-specific OHRQoL instrument for patients with chronic periodontitis consisting of 18 questions (He, Wang, Wei, \& Ji, 2017). Fifteen questions from the OHIP-CP Cantonese version was adopted from the translated and validated Chinese version of OHIP (Wong, Lo, \& McMillan, 2002). The remaining 3 questions were translated through forward translation, backward translation, expert committee process to reach a consensus. A higher score indicated poor oral health-related quality of life.
Time frame: 21 days and 2 months
Löe and Silness Gingival Index
Löe and Silness Gingival Index (1963) (Loe \& Silness, 1963) will be performed on 4 gingival surfaces of index Ramfjord teeth (16, 21, 24, 36, 41, 44). Each of the four gingival areas (buccal, oral, mesial, distal) of the tooth is given a score from 0 to 3. The scores of the 4 areas will be added and divided by 4 to give the GI for the tooth The scores for individual teeth may be grouped to have the GI for the group of teeth Finally, by adding the indices for the teeth and dividing by the total number of teeth examined, the Gl for the individual is obtained. The index for the subject is thus an average score for the areas examined. Missing teeth from the Ramfjord index teeth (16, 21, 24, 36, 41, 44) will not be substituted.
Time frame: 21 days and 2 months
Turesky modification of Quigley-Hein plaque index (TQHPI)
Turesky modification of Quigley-Hein plaque index (TQHPI)(Turesky et al.,1970) on Ramfjord teeth (16, 21, 24, 36, 41, 44) will be performed. Each tooth will be divided into 6 surfaces (mesiobuccal, mid buccal, disto-buccal, mesio-oral, mid-oral, disto-oral.) Each surface will be given a score. The score of all sites will be summed and divided by the number of sites to have the individual tooth index The subject mean plaque score will be calculated by summing all the plaque indices of teeth and dividing by the number of teeth. Missing teeth from the Ramfjord index teeth (16, 21, 24, 36, 41, 44) will not be substituted.
Time frame: 21 days and 2 months
Shannon or Simpson Diversity Index
This measure will assess the change in diversity of the microbial community in the sample (alpha diversity). A diversity index provides a mathematical measure that reflects the number of different species (richness) and the evenness of the species' abundances. It ranges from zero to infinity. A higher value means higer diversity.
Time frame: 2 months
Bray-Curtis Dissimilarity
It is a distance metrics that measures the beta-diversity. It quantifies the dissimilarity between microbial communitie/ the variation or differences in microbial communities between different samples. It ranges from 0 (identical communities) to 1 (completely different communities).
Time frame: 2 months
Biomarker concentrations from gingival cervicular fluid
The concentrations of a panel of biomarkers (IL-1β, TNF-α, IL-6, MMP-8,TIMP-1, TIMP-2) found within the gingival cervicular fluid (GCF) will be assessed with multiplex immunoassays. Unit: ng/mL or as appropriate based on assay's standard.
Time frame: 2 months
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