THE ANTI-PLAQUE EFFICACY OF LISTERINE USED IN COMBINATION WITH TOOTHBRUSHING AND FLOSSING IN ORTHODONTIC PATIENTSSpecific AimsTo determine whether Listerine® (Pfizer, Morris Plains, NJ) mouthrinse when added tothe standard oral hygiene regimen (brushing + flossing) would have an added benefit inreducing plaque and gingivitis development in orthodontic patients over a six-monthperiod.Background and SignificanceDuring orthodontic treatment, the development of white spot lesions is almost inevitablewhen oral hygiene is poor (Tufekci et al., 2004; O’Reilly and Featherstone, 1987;Lundstrom and Karasse, 1987). Decalcification is more commonly seen on the buccalsurfaces of orthodontically treated teeth than untreated teeth. This is due to prolongedplaque retention around the brackets. These incipient lesions can appear in as little as 2to 3 weeks after plaque accumulation in bucco-gingival areas of the teeth. Previousstudies have shown that there are increased levels of bacteria in the oral cavity after thebonding of orthodontic attachments (Beyth et al., 2003; Mitchell, 1992; Gorelick et al.,1982, von der Fehr et al., 1970). The presence of these microorganisms, namely S.mutans and lactobacilli increases the risk for decalcification as these are the mainpathogens in dental caries (Mitchell, 1992; Schwaninger and Schwaninger, 1979).Furthermore, the development of gingivitis and gingival overgrowth are also well-recognized problems during orthodontic treatment with fixed appliances. Therefore,adherence to oral hygiene recommendations is essential to minimize dental caries andgingival inflammation. Tooth brushing and flossing are the most common ways forfacilitating plaque control. However, patient cooperation has long been recognized as animportant factor in maintaining optimal oral hygiene. Many orthodontic patientsespecially children and adolescents fail to floss because they find this procedure time-consuming and tedious in the presence of the orthodontic archwires. Recently, it hasbeen reported that Listerine® antiseptic mouthrinse is as effective as flossing at reducinginterproximal plaque and gingivitis in subjects who brush twice a day (Charles et al.,
2002; Bauroth et al., 2002). The use of Listerine® in addition to the standard oralhygiene regimen may be beneficial for orthodontic patients in maintaining proper oralhealth.Materials and Methods50 orthodontic patients who agreed to participate in the study will be randomly assignedeither to the brush + floss (N= 25) or brush + floss + rinse with Listerine® (N = 25)groups. Subjects chosen will be in orthodontic treatment for about 6 months at thebeginning of this study, and in good health and without a medical history or medicationthat would otherwise affect the outcome of the research. They will be expected to betreatment at least 6 more months in order to ensure the completion of the study.Prior to the start of the study, ethical approval will be obtained from the InstitutionalBoard Review and volunteers will be asked to sign a consent form to participate.Subjects will be informed that they will be given $25 at the completion of the study inorder to encourage compliance in the study. At the beginning of the study, all of thevolunteers will be given instructions on how to brush and floss and will receive initialprophylaxis. At this time (T1), buccal measurements for the Ramfjord teeth will also berecorded for the gingival index, plaque index and bleeding index. Gingivitis will bescored according to the modified gingival index (MGI) (Lobene et al., 1986) on thebuccal marginal gingiva. (0: absence of inflammation, 1: mild inflammation, 2: mildinflammation, 3: moderate inflammation and 4: severe inflammation. Bleeding index(BI) will be assessed as described by Saxton and van der Ouderaa (0: absence of bleedingafter 30 s, 1: bleeding observed after 30s, 2: immediate bleeding). Plaque area will bescored according to the Turesky modification on the Quigley-Hein plaque index (PI) (0:no plaque, 1: discontinuous band of plaque at the gingival margin, 2: up to 1 mmcontinuous band of plaque at the gingival margin, 3: band of plaque wider than 1 mm butless than 1/3 of the surface, 4: plaque covering 1/3 or more of the surface, but less than2/3s of the surface and 5: plaque covering 2/3s or more of the surface.
Individuals in both groups will be asked to brush twice and floss once daily. Subjects inthe rinse group in addition to their main oral hygiene regimen will rinse for 30 secondstwice daily with 20 ml of Listerine®.All subjects will be monitored monthly for compliance with their assigned regimen. Allclinical measurements will be performed by one and the same blinded examiner under thesame conditions at 3 (T2) and 6 months (T3). Mean MGI, BI and PI will be statisticallycompared between the groups using Wilcoxon non-parametric test at T1, T2 T3.References 1) Bauroth K, Charles CH, Mankodi SM, Simmons K, Zhao Q and Kumar LD. The efficacy of an essential oil antiseptic mouthrinse vs. dental floss in controlling interproximal gingivitis: a comparative study. JADA 2003;134:359-65. 2) Beyth N, Redlich M, Harari D, Friedman M and Steinberg D. Effect of sustained- release chlorhexidine varnish on Streptococcus mutans and Actinomyces viscosus in orthodontic patients. Am J Orthod Dentofacial Orthop 2003;123:345-348. 3) Charles CH, Naresh SC, Galustians HJ, Mcguire JA and Vincent JW. Comparative efficacy of an antiseptic mouthrinse and an antiplaque/antigingivitis dentifrice. A six-month clinical trial. JADA 2001;132:670-675. 4) Gorelick L, Geiger AM and Gwinnett AJ. Incidence of white spot formation after bonding and banding. Am J Orthod Dentofacial Orthop 1982; 81:93-8. 5) Lundstrom F and Karasse B. Caries incidence in orthodontic patients with high levels of Streptococcus mutans. Eur J Orthod 1987; 9:117-21. 6) Mitchell L. Decalcification during orthodontic treatment with fixed appliances – an overview. Br J Orthod 1992;19:199-205. 7) O’Reilly MM and Featherstone JDB. Demineralization and remineralization around orthodontic appliances: an in vivo study. Am J Orthod Dentofacial Orthop 1982;92:33-40. 8) Quigley G and Hein J. Comparative cleansing efficiency of manual and power brushing. JADA 1962;65:26-9.
9) Saxton CA and van der Ouderaa FJ. The effect of a dentifrice containing zinc citrate and triclosan on developing gingivitis. J Periodontal Res 1989; 24:75-80. 10) Schwaninger B and Schwaninger NV. Developing an effective oral hygiene program for the orthodontic patient: review, rationale and recommendations. Am J Orthod 1979;75:447-52. 11) Tufekci E, Merrill TE, Pintado MR, Beyer JP and Brantley WA. Enamel loss associated with orthodontic adhesive removal on teeth with white spot lesions: An in vitro study. Am J Orthod Dentofacial Orthop 2004;125:733-9. 12) Turesky S, Gilmore ND and Glickman I. Reduced plaque formation by the chloromethyl analogue of Victamine C. J Periodontol 1970; 41:41-3. 13) Von der Fehr FR, Loe H and Theilade E. Experimental caries in man. Caries Res 1970;4:131-48.Institutional Board ReviewThe application for the IRB is underway.Budget Item Quantity Cost Total Compensation for participating in the study 50 $25/subject $1250 Dental Floss 120 $40/ box of 144 $40 Poster Printing for Clinic Day and IADR 1 $115 $115 Fees for printing and binding 5 $17.50 $87.50 Grand Total: $ 1492.50Listerine® will be provided by Pfizer.