journal of dentistry 43 (2015) 297308

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Review

Assessment of the effectiveness of mouthwashes

in reducing cariogenic biofilm in orthodontic
patients: A systematic review

Matheus Melo Pithon a,*, Letcia Iandeyara Dantas Andrade SantAnna a,

Felipe Carvalho Souza Baiao a, Rogerio Lacerda dos Santos b,
Raildo da Silva Coqueiro a, Lucianne Cople Maia c
a
Department of Healthy, Southwest Bahia State University UESB, Jequie, Bahia, Brazil
b
Department of Health and Technology Rural, Federal University of Campina Grande, Patos, Paraba, Brazil
c
Department of Pediatric Dentistry and Orthodontics, School of Dentistry, Federal University of Rio de Janeiro, Rio de
Janeiro, Rio de Janeiro, Brazil

article info abstract

Article history: Objectives: The use of fixed orthodontic appliances makes it difficult to clean the teeth and accessories
Received 12 January 2014 associated with it. For this reason, orthodontic patients have used oral antiseptics as coadjuvent means to
reduce cariogenic plaque. The aim of this systematic review was to evaluate the effectiveness of oral
Received in revised form
antiseptics on the reduction of cariogenic plaque on orthodontic patients.
3 December 2014 Data: This review has been registered at PROSPERO international prospective register of systematic
Accepted 12 December 2014 reviews under the number CRD42013006857.
Sources: A systematic review of the literature was conducted in the following electronic databases: Scopus,
PubMed, Web of Science, Medline, Embase and Cochrane, Grey literature and Clinical Trials, without
limitations on the year of publication or language. Clinical studies in patients with fixed orthodontic
Keywords: appliances, who were making use of oral mouthwashes in order to reduce cariogenic plaque, were included.
Cariogenic plaque Articles with patients using systemic drugs, syndromic patients, those using mouthwashes for other
Mouthwash purposes and/or using different cleaning techniques, and clinical cases were excluded. After selection by
Mouth rinses title and abstract, potentially eligible articles were read in full. The methodological quality and risk of biases of
articles included were evaluated according to the characteristics of the study, measurements and statistical
Fixed appliance
analyses of the study. The methodological quality was classified as high, moderate or low.
Study selection: The search identified 2716 articles, of which 15 met the inclusion criteria. Of these, 8
analyzed chlorhexidine-based mouthwashes, while in 1 article Cetylpyridinium was used; 1 analyzed the
mouthwash containing sanguinaria; 1 the use of NaF; 2 articles the use of AmF/SnF2; 2 the use of
Listerine1, 1 also analyzed the association between mouthwashes with octenidine and with PVP-I. Of
the articles analyzed, 11 were classified as having high and 4 as having moderate methodological quality.
Conclusion: There is evidence of effectiveness of the use of oral mouthwashes in the control of cariogenic
plaque in patients with fixed orthodontic appliances. The orthodontists may suggest the use of oral
antiseptics in the oral hygiene of their patients as coadjuvent means to reduce cariogenic plaque.
Clinical significance: Given current evidence, orthodontists may prescribe mouthwash as an auxiliary
method in the control of cariogenic biofilm in orthodontic patients.
# 2014 Elsevier Ltd. All rights reserved.

* Corresponding author at: Av. Otavio Santos, 395, sala 705, Centro Odontomedico Dr. Altamirando da Costa Lima, Bairro Recreio, CEP
45020-750 Vitoria da Conquista, Bahia, Brazil. Tel.: +55 7730842020; fax: +55 7734252062.
E-mail address: matheuspithon@gmail.com (M.M. Pithon).
http://dx.doi.org/10.1016/j.jdent.2014.12.010
0300-5712/# 2014 Elsevier Ltd. All rights reserved.
298 journal of dentistry 43 (2015) 297308
1. Introduction
Patients under treatment with fixed orthodontic appliances
are frequently incapable of effectively performing the me-
chanical oral hygiene methods, such as brushing and the use
of dental floss.1 This leads to changes in the oral cavity,
resulting in a reduction in pH and greater propensity for the
formation of bacterial colonies responsible for the onset and
progression of dental caries.2,3
As a result of the deficient oral hygiene, there is an
accumulation of bacteria around the brackets, capable of
causing gingival inflammation and demineralization of the
hydroxyapatite crystals of tooth enamel, leading to the
formation of caries lesions.47
Because of this difficulty, chemical agents, especially oral
mouthwashes with active principles (such as chlorhexidine,
sodium fluoride, AmF/SnF2 and Cetylpyridinium) have been
prescribed as coadjuvent means for the reduction of cariogen-
ic plaque in orthodontic patients.8 Mouth washes contain
antimicrobial agents capable of altering bacterial membrane
permeability, which contributes to its lysis, reduces cell
metabolism and its ability to adhere to the tooth surface.9,10
However, there are still many controversies with respect to
the real effects of these products on plaque reduction in
orthodontic patients. From this perspective, the aim of the
authors of the present study was to identify, by means of a
systematic review of the literature, the scientific evidence that
supports the use of oral mouthwashes to reduce plaque scores
in patients who use labial fixed orthodontic appliances.
2. Materials and methods
2.1. Focused question
The present systematic review was conducted in order to
answer the following focused question: Is there any scientific
evidence of reduction in plaque scores when patients
undergoing labial fixed appliance treatment use a mouth-
wash, in comparison with a control group that does not?
This systematic review was performed according to Preferred
Reporting Items for Systematic Review and Meta-Analysis
(PRISMA) statement for reporting systematic reviews that evalu-
ate health care interventions (MOHER, 2009). This review was
registered with PROSPERO international prospective register of
systematic reviews under the number CRD42013006857.
2.2. Search strategy
The methodology used in this systematic review was based on
the PRISMA guidelines (www.prisma-statement.org). In order
to identify relevant articles, without limitations on year of
publication and language, a search was conducted in the
following electronic databases: Scopus, PubMed, Web of
Science, Medline, Embase, Cochrane, Controlled Trials. Grey
literature (OpenGrey) was also consulted. The search strategy
was suited to each database. The following descriptors/MeSH
terms were used: mouthwashes, dental plaque, cariogenic,
orthodontic appliances, remineralization, oral hygiene, dental
prophylaxis and the key words: cariogenic plaque, mouth-
wash, mouth rinses and fixed appliance. The details of the
search strategy are presented in Table 1.
2.3. Eligibility criteria of the articles
In order for articles to be selected for this review, they had to
meet the following inclusion criteria: Be a controlled clinical
study, conducted in orthodontic patients with labial fixed
appliances; without age limit (P), with the use of oral
mouthwashes (I), comparing the effects obtained by the
different types of mouthwashes with a control group (C) on
the reduction in plaque score (O). The initial selection was
made by reading the titles and abstracts of the articles found.
Studies with patients making use of systemic drugs, those who
were syndromic, making use of oral mouthwashes for
purposes other than the removal of dental plaque and/or
making use of other techniques for its removal, but without
the use of oral mouthwashes, were excluded from the present
review. In addition, in vitro studies, case reports, reviews of the
literature and editorials were also excluded.
The articles of which the title and abstract did not present
sufficient information were downloaded and analyzed in full in
order to decide about their eligibility. Those that presented a
title within the theme, but the abstract was not available, were
also obtained and fully analyzed. Articles that appeared in a
database searched more than once, were considered only once.
Two researchers (L.I.D.A.S and F.C.S.B.) made the selections
independently and the results were compared, with the
purpose of avoiding discrepancies that could occur during
data collection. If disagreements were found between the two
evaluators as regards the inclusion or exclusion of any study, a
third evaluator would be consulted (M.M.P.) in a consensus
meeting in order to eliminate the discrepancies.
The lists of references of selected articles were evaluated
manually to verify whether there was any study that had not
previously been pointed out by the searched databases.
In cases in which additional data were necessary, the
corresponding authors of the studies were contacted by e-mail,
in order to clear up doubts as regards the eligibility criteria.
2.4. Quality assessment and risk of bias
For an evaluation of the methodological quality of the articles
included in the present systematic review, a scoring process was
used in this study, modified from the one used by Baratieri et al.11
and Lagrave`reet al.,12 in which items D, E, F and G were suited to
the requirements of the present review. With regard to item A
there was a change in the maximum score: this was increased
from 1 to 2 points due to its greater relevance, seeing that this
item gives a complete description of the population, mean age
and the participants condition. Items J and L were removed
because they did not fit into the context of the research.
The articles selected were then evaluated according to the
characteristics of the study, measurements of the study and
statistical analyses (Table 2). The criteria used for evaluating
the characteristics of the study, such as the description of the
selection criteria, comparison with control group, randomiza-
tion declared, description of the adequate use of mouthwash
and its composition, received the maximum score (1 point)
 journal of dentistry 43 (2015) 297308 299

Table 1 Database and method of search.

Database Search strategy
PubMed ((((((mouthwashes AND dental plaque AND orthodontic appliances[MeSH Terms])) OR (mouthwashes AND oral
hygiene AND remineralization AND biofilm[MeSH Terms])) OR (mouthwashes AND orthodontic appliances AND
Dental Prophylaxis[MeSH Terms])) OR (orthodontic appliances AND remineralization AND dental
prophylaxis[MeSH Terms])) OR (oral hygiene AND dental plaque AND mouthwashes)) OR (orthodontic appliances
AND mouthwashes AND oral hygiene AND biofilm)
Scopus (TITLE-ABS-KEY(mouthwashes AND orthodontic appliances AND dental plaque) OR TITLE-ABS-
KEY(orthodontic appliances AND cariogenic AND (dental prophylaxis OR oral hygiene)) OR TITLE-ABS-
KEY(orthodontic appliances AND cariogenic AND mouthwashes) OR TITLE-ABS-KEY(orthodontic appliances
AND mouthwahes AND biofilm) OR TITLE-ABS-KEY(orthodontic appliances AND (dental prophylaxis OR oral
hygiene)))
Web of Science Topic = (mouthwashes AND orthodontic appliances) OR Topic = (orthodontic appliances AND (cariogenic OR
dental plaque) AND (oral hygiene OR dental prophylaxis)) OR Topic = (mouthwashes AND orthodontic appliances
AND (oral hygiene OR cariogenic OR biofilm))
Embase Mouthwashes/exp OR mouthwashes AND (orthodontic/exp OR orthodontic) AND appliances OR (mouthwash/
exp OR mouthwash AND (dental AND plaque OR cariogenic)) OR (orthodontic/exp OR orthodontic AND appliance
AND (biofilm AND (prophylaxis/exp OR prophylaxis) OR oral/exp OR oral) AND (hygiene/exp OR hygiene)) OR
(appliance AND (dental AND plaque OR cariogenic) AND (mouthwashes/exp OR mouthwashes) AND
(orthodontic/exp OR orthodontic) AND appliances AND remineralization)
Medline Complete TX (mouthwashes AND orthodontic appliances) OR TX (orthodontic appliances AND (dental plaque OR cariogenic))
(EBSCO) OR TX (mouthwashes AND orthdontic appliances AND remineralization) OR TX (orthodontic appliances AND
biofilm AND (dental prophylaxis OR oral hygiene)))
Cochrane Mouthwashes AND orthodontic appliances or mouthwashes AND orthodontic appliances AND (dental plaque OR
cariogenic) or orthodontic appliances AND biofilm AND (dental prophylaxis or oral hygiene)
Controlled-Trials Mouthwashes AND orthodontic appliances
OpenGrey Mouthwashes AND orthodontic appliances

when suitably filled out, otherwise no point was awarded.
With regard to the description of the population, when the 3
items, age, sex and condition of the patient were mentioned,
the criterion was considered completely fulfilled, and the
Table 2 Protocol for qualitative score of methodology
(maximum score, 13 pointsb).
1. Characterization of study (9)
A. Adequate description of population (2)
Items analyzed: age sex and condition of the patient:
2 points when all items were satisfied;
1 point when two items were satisfied;
0 point when one or no item was satisfied.
B. Description of selection criteria (1)a
C. Sample size (2)
Item analyzed: number of participants:
2 points when there were 25 or more participants;
1 point when there were between 20 and 25 participants;
0 point when there were less than 20 participants.
D. Comparison with control group (1)a
E. Randomization declared (1)a
F. Description of adequate use of mouth wash (1)a
G. Description of mouth wash (1)a
2. Measurements of study (2)
H. Methodology appropriate for objective of article (1)a
I. Blinding of examiners and statistics (1)a
3. Statistical analysis (2)
J. Statistical Test Suited to Data (1)a
K. Presentation of p-value (1)a
a
Items B, D, E, F, G, H, I, J, K: 1 point when was satisfied; 0 point
when was not satisfied.
b
High quality: 1113 points, moderate quality from 6 to 10 points,
low quality below 6 points.
maximum score was awarded (2 points), when only 2 were
mentioned, half the score was awarded (partially fulfilled),
and when only one or none of them were fulfilled, no score
was awarded. As regards the amplitude of the sample, this
was scored according to the number of participants, both in
the control and group under treatment. Therefore, when
there was a number over 25 the maximum score was awarded
(1 point). Whereas for a number between 20 and 25 half the
maximum score was awarded. No point was given for values
lower than 20 participants, because it was considered that
samples smaller than 20 are less relevant. A number of 25
individuals was established, based on the sample calculation
made by Chen et al.14 According to these authors, 25
individual would be the minimum number required for
conducting this type of study.
Both the criteria for evaluation of the study measurements
and the statistical analysis criteria were scored with a
maximum score (1 point) if they were adequately fulfilled,
and no point was awarded if the criterion was not fulfilled.
The score ranged from 0 to 13, and the methodological
quality of the studies was classified as high when the score
ranged from 11 to 13, moderate from 6 to 10 and low when the
score was lower than 6.
3. Results
The search in the databases led to 2716 articles being found. By
the titles and abstracts, the articles not related to the topic of
this systematic review were excluded. Thus, 62 articles were
selected. Duplicated articles were removed, so that 15 articles
remained to be read in full, as they fulfilled the inclusion
criteria. The flow chart (Fig. 1) illustrates the search results.
300 journal of dentistry 43 (2015) 297308

3.1. Quality assessment
Table 3 illustrates the classification of the articles analyzed
and their scores. Of the 15 articles included, eleven were
qualified as high methodological quality,13,26 while four as
moderate methodological quality.3,2326 Only Ogaard et al.22
did not make comparisons between the test and control
groups (item D). Only the study of Dogan et al.23 did not
receive any score in item E, because it was not a randomized
study. Where the adequate description of the use of
mouthwash was concerned (item F) only the study of
Ousehal et al.3 received no score. With regard to description
of the mouthwash, only Hannah et al.15 and Tufekci et al.21
obtained no score. In five the statistical examiners were not
blinded, therefore they received no score.3,16,19,23,25 While 2
articles did not present statistical tests suited to the
data,24,26 all presented the significance of the statistical
analysis.
3.2. Sample size
As regards sample size, 3 articles received score 0,2325 i.e., they
had fewer than 20 participants in their sample, 1 study15 had a
sample size between 20 and 25 participants (score 1), while 11
articles2,13,14,1622,26 had a sample consisting of over 25
participants (score 2).

Fig. 1 Flow chart results of searches.

 journal of dentistry 43 (2015) 297308 301

Table 3 Protocol for qualitative scoring of methodology of articles analyzed.

Author A B C D E F G H I J K Total Quality
Pahwa, Kumar and 2 1 2 1 1 1 1 1 1 1 1 13 High
Gupta (2011)
Gehlen et al. (2000) 1 1 0 1 1 1 1 1 0 1 1 9 Moderate
Nelson-Filho et al. (2012) 1 1 2 1 1 1 1 1 1 1 1 12 High
Ogaard et al. (1988) 1 1 2 1 1 1 1 1 1 0 1 11 High
Ogaard et al. (2006) 1 1 2 0 1 1 1 1 1 1 1 11 High
Hannah, Johnson and 2 1 1 1 1 1 0 1 1 1 1 11 High
Kuftinec (1989)
Anderson et al. (1997) 2 1 2 1 1 1 1 1 1 1 1 13 High
Madlenaet al. (2012) 2 1 2 1 1 1 1 1 0 1 1 12 High
Tufekci et al. (2008) 2 1 2 1 1 1 0 1 1 1 1 12 High
Ousehalet al. (2011) 2 1 2 1 1 0 0 1 0 1 1 10 Moderate
Nelson-Filho et al. (2011a) 2 1 2 1 1 1 1 1 1 1 1 13 High
Dogan et al. (2009) 2 1 0 1 0 1 1 1 0 1 1 9 Moderate
Chen et al. (2012) 2 1 2 1 1 1 1 1 1 1 1 13 High
Gehlen et al. (2000) 1 1 0 1 1 1 1 1 1 0 1 9 Moderate
Nelson-Filho et al. (2011b) 2 1 2 1 1 1 1 1 0 1 1 12 High

3.3. Types of mouthwash
With regard to the type of mouthwash used as treatment to
reduce bacteriogenic plaque, 8 articles used chlorhexidine-
based mouthwashes,3,13,1719,2325 2 prescribed Amf/SnF2,16,22 1
made use of octenidine,23 1 of Cetylpyridinium,20 1 sodium
fluoride,26 2 used Listerine (essential oil),14,21 and Hannah et al.
used sanguinaria.
3.4. Quantity of mouthwash
For the quantity of mouthwash product used to perform each
mouthwash, the measurements of 10 ml,16,24,25 15 ml,13,15 and
20 ml14,19,21 were related. The prescriptions described by the
articles were 3 times a day,15 1 time at night,22,26 1 time a day,23
2 times at night and day,16,21,21 2 times a week.1719 Ousehal
et al.3 did not inform the prescription used in their study.
An abstract about the description of the studies included
and evaluated, explaining the characteristics of the partici-
pants sample, age and condition and the intervention of the
treatment used composition of the mouthwash, prescription
and total time is presented in Table 4.
On the subject of oral hygiene technique, only three
authors mentioned using the Bass technique or a modification
of it,13,15,16 while 7 authors mentioned having given their
patients oral hygiene instructions,14,18,19,21,2326 without giving
details about them, and only mentioned the frequency of
performing the hygiene protocol.14,1719,2125 As far as the type
of dentifrice was concerned, 3 used a fluoride-containing
product (Colgate Maxima Protecao Anticaries, Colgate- plaque, thus showing a higher plaque index than adults from the
Palmolive Industria e Comercio, Sao Paulo, Sao Paulo, 9th to the 18th month of treatment ( p < 0.05). This concern is
Brazil),1719 while 2 used a paste containing AmF/SnF2
(Meridol),16,22 1 Viadent,15 2 Silicea,24,25 1 Crest Regular Flavour
(Procter & Gamble, Cincinnati, Ohio, United States of Amer-
ica),13 and 5 did not mention the paste used.3,14,21,23,26
frices in comparison with the use of common dentifrice only
by children and adolescents has been verified in a previous
systematic review.27 However, a special group of patients
deserves investigation and the search for evidence as regards
the effectiveness of these auxiliary methods in cariogenic
plaque control, namely orthodontic patients. With a view to
filling this lack in the literature, the aim of the authors of this
systematic review was to seek evidence with respect to the
effectiveness of oral mouthwashes in the reduction of
cariogenic plaque in patients undergoing therapy with labial
fixed orthodontic appliances.
In the selected studies, the plaque index measurement was
performed in six teeth3,16,20,22 and the entire mouth.14,21,24,25
While some authors used other methods to calculate the plaque
index, Hanna et al.,15 for example, analyzed 12 teeth, units 1116
and 3136. Ogaard et al.,26,28 after conducting the study period,
extracted two premolars of the volunteer for analysis of the tooth
enamel structure. Dogan et al.23 used saliva samples to check the
mouthwash action against the bacteria. Analysis was performed
of bonding an adhesive to 3 premolars,17 and to 2 premolars.17,18
With regard to the statistical test suitable for the data, 13 articles
presented statistically significant results, with 8 of these having
been qualified as high quality studies1321 and 5 as having
moderate quality.3,2226 Due to the predominance of studies with
populations presenting the age group between 11 and 25 years,
the need for studies with populations of older age groups is
perceived, considering that Boyd et al., based on their results,
affirmed that adolescents are not as efficient in removing
cariogenic plaque as adults, so that they accumulate more
pertinent by virtue of the progressive increase in adult patients in
the dental offices during the last few years.27
5. Comparison with control group

4. Discussion Articles that had a control group using basic oral hygiene
without the use of mouthwash and an experimental group
The efficiency of the use of fluoridated substances (gel, using of some type of mouthwash revealed that the reduction
varnish, oral mouthwash) associated with fluoridated denti- in cariogenic plaque was higher in the test than in the control
302 journal of dentistry 43 (2015) 297308
Table 4 Description of studies included.
Participants
Author Total
Pahwa, Kumar TOTAL: 45 (25F/20M)
and Gupta CONTROL GROUP: Placebo.
(2011) TEST GROUP 1:
Cetylpyridinium.
TEST GROUP 2: Tooth
brushing.
Gehlen et al. TOTAL: 12 (8F/4M)
(2000) CONTROL GROUP (7):
Odol-med-3.
TEST GROUP (5):
Chlorhexidine.
Nelson-Filho TOTAL: 35
et al. (2012) CONTROL GROUP (18):
Placebo mouthwash
(58.8% F and 41.2% M).
TEST GROUP (17):
Use of chlorhexidine
(44.5% F & 55.5% M).
Orgaard TOTAL: 29
et al. (1988) I: Effect on development of
lesions:
CONTROL GROUP (5):
without use of F.
TEST GROUP (5): 0.2% NaF
solution.
TEST GROUP 2 (4): Fluoride
application.
II. Effect on established
lesions (10).
III. Effect of debanding on
established lesions (5).
Orgaard TOTAL: 97 (62F/35M)
et al. (2006) TEST GROUP 1 (50):
AmF/SnF2 (33 F and 17M).
TEST GROUP 2 (47):
NaF (29 F and 18M)
Hannah, Johnson TOTAL: 24 (12F/12M)
and Kuftinec CONTROL GROUP: Use of
(1989) toothpaste and oral
mouthwash with placebo.
TEST GROUP:
Use of toothpaste and oral
mouthwash with
sanguinaria.
Age Condition
(mean)
1125 years, Complete initial levelling and
mean 14.8 alignment. Patient under fixed
orthodontic treatment with
supports on anterior teeth and
bands on molars.
Mean 14.1 Not mentioned.
years
1422 Had good general health and had
years no antibiotics or oral anti-
microbial antiseptics within 3
months before the study.
1114 Premolars must be removed as
years part of orthodontic treatment.
1114 years
13.214.1 Be healthy. Without oral or
years systemic diseases, had no
periodontal pockets deeper than
5 mm, and had not been on an
antibiotic therapy regime for at
least 3 months before study began.
Individuals were prepared to use
only mouth washing tooth paste
and tooth brush provided by the
investigator and agreed to follow
the oral hygiene programme
prescribed by the investigator.
Intervention
Composition of mouthwash,
prescription and total time of
treatment
Prescription:
10 ml of mouthwash for 60 s used
30 min after breakfast and before
going to sleep.
Test mouthwash: Cetylpyridinium.
Treatment: 1 month.
Prescription: 10 ml of mouthwash
twice a day (morning and night).
Placebo mouthwash: CON, basic
source of fluoride: Odol-med-31.
Test mouthwash: 0.2%
Chlorhexidine.
Treatment:
Preliminary Phase: 2 weeks;
Test Phase A: 48 h;
Period of 5 days without use;
Test Phase B: 48 h;
Total: 23 days.
Prescription:
10 ml of test solution for 30 s, two
times per week (Tuesdays and
Fridays).
Test mouthwash:
0.12% Chlorhexidine.
Treatment: 30 days.
Prescription:
Perform mouthwash using solution
for 1 min every night after tooth
brushing.
Test mouthwash:
0.2% sodium fluoride (NaF) solution.
Treatment: 4 weeks.
Prescription:
Perform mouthwash every night
after tooth brushing.
Test mouthwash:
A solution containing AmF/SnF2
(250 ppm of F, pH 4.0), throughout
the entire treatment period.
Prescription:
15 ml of oral mouthwash for 30 s
after brushing, three times a day.
Test mouthwash:
Mouthwash containing sanguinaria.
Treatment: 8 months.
 journal of dentistry 43 (2015) 297308
Table 4 (Continued )
Participants
Author Total
Anderson TOTAL: 30
et al. (1997) CONTROL GROUP: Placebo
mouthwash
TEST GROUP:
Chlorhexidine
Madlena TOTAL: 40 (26F/14M)
et al. (2012) CONTROL GROUP (20):
Use of dentifrice only.
TEST GROUP (20): Brushing
with dentifrice based on
AmF/SnF2 and mouth
washing with AmF/SnF2.
Tufeckci TOTAL: 50
et al. (2008) CONTROL GROUP (25):
Brushing and use of dental
floss;
TEST GROUP (25):
Brushing and use of dental
floss and mouthwash.
Ousehal TOTAL: 84 (21M/65F)
et al. (2011) CONTROL GROUP (28):
Brushing with manual brush.
TEST GROUP 1 (28):
Brushing with electric brush.
TEST GROUP 2 (28):
Manual brushing and use of
mouthwash.
Nelson-Filho TOTAL: 33
et al. (2011a) CONTROL GROUP (17): Use of
placebo mouthwash.
TEST GROUP (16):
Use of antimicrobial
mouthwash.
Dogan TOTAL: 18 (5M/13F)
et al. (2009)
Age Condition
(mean)
1115 Under orthodontic treatment
years without systematic complications
or use of medications that could
interfere in oral tissues, present
band on at least one molar per
quadrant.
20.1  5.7 New orthodontic patients
years requiring therapy with fixed
appliance, without use of
antibiotics, immunosuppressants
or other drugs in the previous 6
months, healthy oral or gingival
flora, non-smokers.
16.6 years Under orthodontic treatment
without significant dental or
medical history in the first 6
months.
24% < 15 Use of multibracket orthodontic
years appliance in both arches, good
76% > 15 general health and free of
years periodontal diseases.
1133 Both sexes, using fixed orthodontic
years appliance for at least 16 months.
Present good general health and
had not used antibiotic or anti-
microbial mouthwashes within 3
months before the study.
1216 Under orthodontic treatment, with
years good oral health, without receiving
antibiotics or topical antiseptics in
the previous 30 days, or present
systemic disease that could alter
the plaque or saliva composition.
303
Intervention
Composition of mouthwash,
prescription and total time of
treatment
Prescription: 15 ml of mouthwash
for 30 s, twice a day, after breakfast
and before going to sleep.
Test mouthwash: 0.2%
chlorhexidine gluconate (Peridex,
Proctor and Gamble).
Treatment: 3 months.
Prescription:
Brushing with dentifrice and
mouthwash with 10 ml of
mouthwash for 30 s.
Test mouthwash:
AmF/SnF2-based mouthwash
(Meridol1).
Treatment: 4 weeks.
Prescription:
Mouthwash with 20 ml for 30 s 2
times a day, in addition to basic oral
health care.
Test mouthwash:
Listerine Cool Mint1.
Treatment: Evaluation in 3rd & 6th
month of treatment.
Prescription: Not mentioned.
Test mouthwash:
Kin1 with 0.12% chlorhexidine
without alcohol.
Treatment: 1 month.
Prescription:
10 ml of mouthwash for 30 s, twice a
week.
Test mouthwash: 0.12%
chlorhexidine gluconate (Periogard,
Colgate-Palmolive).
Treatment: 30 days.
Prescription:
15 ml of mouthwash for 30 s, once a
day, during the morning.
Test mouthwash:
Octenidine dihydrochloride;
0.2% Chlorhexidine gluconate;
7.5% complex
polyvinylpyrrolidone-iodine.
Treatment: 5 days for each
mouthwash with interval of two
weeks between each of them.
304 journal of dentistry 43 (2015) 297308

Table 4 (Continued )
Participants Intervention

Author Total Age Condition Composition of mouthwash,

Chen TOTAL: 90 (47F/43M)
et al. (2012) CONTROL GROUP (30):
Brushing and use of dental
floss.
TEST GROUP 1 (30): Use of
essential oil-based
mouthwash.
TEST GROUP 2 (30): Use of
two types of mouthwashes
(A & B).
(mean)
17.7  3.9 In use of fixed orthodontic
years appliance, over 13 years of age,
non-smokers, healthy, pre-
existent gingivitis and without
evidence of periodontitis.
prescription and total time of
treatment
Prescription:
20 ml of mouthwash for 30 s, twice a
day.
Test mouthwashes:
Test 1: Listerine1 Tartar Control;
Test 2:
Solution A: 5% umbuzeiro fruit
extract;
Solution B: 2% sodium
bicarbonate (perform mouthwash
with solution A and afterwards with
solution B).
Treatment: 6 months.

Gehlen TOTAL: 12 (8F/4M) 1113 Right-handed, without periodontal Prescription: 10 ml of mouthwash

et al. (2000) CONTROL GROUP (7): Placebo years pathologies, fixed orthodontic twice a day (morning and night).
mouthwash. appliance (archwire 016 in.) in Placebo mouthwash: CON, basic
TEST GROUP (5): use of maxillary arch in the last 6 source of fluoride: Odol-med-31.
chlorhexidine. months, and with elastic ligatures. Test mouthwash: 0.2%
Chlorhexidine
Treatment:
Preliminary Phase: 2 weeks;
Test Phases A: 48 h;
Period of 5 days without use;
Test Phase B: 48 h;
Total: 23 days.

Nelson-Filho TOTAL: 39 1113 Both genders, caries-free, with Prescription: 10 ml of mouthwash

et al. (2011b) CONTROL GROUP (20):
Placebo mouthwash.
TEST GROUP (19):
Chlorhexidine.
years complete dentition and
undergoing orthodontic treatment
with fixed appliance.
for 30 s, twice a week.
Active mouthwash: 0.12%
Chlorhexidine gluconate
(Periogard1).
Treatment: 30 days.

group.3,14,16,20,21,26 Ogaard et al. affirmed that with the use of
mouthwashes, carious lesion development was retarded
rather than inhibited, therefore the mouthwash acts only as
a bacteriostatic agent. Whereas Pahwa et al.20 affirmed that
the use of an oral mouthwash associated with mechanical
cleaning resulted in a more effective reduction in cariogenic
plaque than mechanical control alone. The results described
by these authors reinforce the important participation of
mouthwashes in bacterial control.
Articles in which the control group was composed of
subjects using placebo mouthwash, compared with those
using mouthwashes containing active substances, revealed
that the mouthwashes with active substances provided
greater antimicrobial activity, consequently greater reduction
in cariogenic plaque.13,1719,24,25 Moreover, articles that made
comparisons between two or more types of mouthwashes
revealed differences in the results, demonstrating that
different prescriptions and active principles have an influence
on the final result of reduction in cariogenic plaque.14,15,22,23
Some studies have demonstrated that the participation in
scientific studies could change the participants behaviour,
and could lead to false-positive results; that is, the participants
may feel motivated to perform a more satisfactory oral
hygiene with a view to obtaining good results.29 However, in
no study included in this systematic review was anything
mentioned about this problem.
6. Description of mouthwashes and
prescription
With regard to the effectiveness of the type of mouthwash, the
majority of the authors affirmed that those based on
chlorhexidine are effective in combatting the proliferation
of plaque.13,1719,24,25 Anderson et al. pointed out that the
effectiveness was greater after 90 days of use.
However, Nelson-Filho et al.17 found results that were not
statistically significant ( p = 0.66) as regards the plaque index,
in spite of having verified greater effectiveness of the
mouthwash with active principle than the placebo. The
results found by Nelson-Filho et al.17 could have been different
if the evaluation had been made for period of 3 months, a
period in which the mouthwashes demonstrated greater
effectiveness in bacterial plaque reduction. With regard to
these articles, Table 5 explains the methods of measurement,
results followed by p-value and conclusion of the authors.
Among the results presented by the studies with high
methodological quality, the study of Tufekci et al.21 is
 journal of dentistry 43 (2015) 297308 305

Table 5 Methods of measurement, results and authors conclusions.

Author Method of Result Authors conclusions
measurement
Pahwa, Kumar Plaque index (Pl) Mean alteration plaque index The 0.07% Cetylpyridinium mouthwash
and Gupta (2011) scores at end of one month: was verified to be effective in reducing
Control Group: 0.02286 plaque index scores.
Group with CHX: 0.214

Gehlen et al. PI Preliminary Phase: Washing with a 0.2% chlorhexidine solution

(2000) PI = 1.3 ( p = 0.042 for control and significantly reduced the clinical plaque
0.021 for test group) indices, plaque re-growth and microbial
Phase T0 vitality in orthodontic patients.
Control: PI = 0.9
Chlorhexidine: PI = 1.0
( p = 0.032)
Phase T1:
Control: PI = 1.02
Chlorhexidine: PI = 0.44
( p < 0.001)
Phase T2:
Control: PI = 2.27
Chlorhexidine: PI = 1.0
( p < 0.001)

Nelson-Filho PI The experimental group had less The levels of A. actinomycetemcomitans were
et al. (2012) dental plaque accumulation in significantly lower in individuals who
comparison with the control group performed washing two times per week
( p = 0.0006) with a 0.12% chlorhexidine solution for 30
days.

Ogaard et al. Microdensitometric The difference between the values The use of the neutral mouthwash 0.2%
(1988) technique with the use of the mouthwash NaF solution significantly retarded the
and the control group was development of lesion.
statistically significant at the level
p = 0.05 (t-test).

Ogaard et al. Visible plaque index Statistically significant in VPI was There was significantly less visible plaque
(2006) (VPI) found before bonding and on on maxillary anterior teeth after using the 2
debonding for maxillary anterior products AmF/SnF2.
teeth in the NaF Group. On
bonding: p = 0.2, on debonding p
between 0.2 and 0.25.

Hannah, Johnson PI In the active group there were 57%
and Kuftinec reductions in plaque. Differences
(1989) between the active and placebo
groups were statistically
significant in favour of the active
group for plaque ( p < 0.01)
The results were both statistically and
clinically significant. The result suggested
that the use of the sanguinaria mouthwash
could greatly improve the oral hygiene and
health of tissues in orthodontic subjects
during a period of 6 months.

Anderson PI After 3 months, there was a
et al. (1997) difference ( p > 0.05) between the
plaque index values on the distal,
mesial and tongue surfaces. A
higher value was observed in the
placebo group.
The results indicated that the use of
chlorhexidine mouthwashes could be
beneficial to orthodontic patients in
maintaining better oral hygiene.

Madlena PI Beginning: PI = 1.27  0.52 The use of the AmF/SnF2based

et al. (2012) 4 weeks: PI = 1.32  0.42 mouthwash brought beneficial clinical
( p = 0.00) effects as regards plaque accumulation
during orthodontic therapy.

Tufekci PI After 3 months Daily use of Listerine in the oral hygiene

et al. (2008) Control: PI = 1.6 regime was efficient in control of cariogenic
Listerine: PI < 1 biofilm.
After 6 months
Control: PI > 2
Listerine: PI = 1
( p < 0.001)
306 journal of dentistry 43 (2015) 297308

Table 5 (Continued )
Author Method of Result Authors conclusions
measurement
Ousehal PI Reduction of 0.39 in PI ( p = 0 < 0.05) Use of CHX- based oral mouthwash was
et al. (2011) efficient, however precautions must be
taken as regards prolonged use.

Nelson-Filho PI Control: PI = 1.8 (0.92.1) Use of 0.12% Chlorhexidinegluconate-based

et al. (2011a) Test: PI = 1.4 (1.02.0) mouthwashes was efficient in the reduction
( p = 0.66) of pathogenic microorganisms in patients
with fixed orthodontic appliances.

Dogan PI, Mitis Salivarius agar OCT: PI = 0.07 (01.05) The use of OCT, for 5 days of use, was
et al. (2009) and Rogosa agar CHX: PI = 0.02 (00.75) shown to be the most effective mouthwash
PVP-I: PI = 0.02 (00.085) with significant reduction in cariogenic
( p < 0.01) bacteria.

Chen et al. PI EOM The use of both the mouthwash containing

(2012) T1: PI = 1.61  0.45 essential oil (EOM) and that based on the
T2: PI = 1.70  0.45 umbuzeiro fruit extract presented no
T3: PI = 1.69  0.50 significant alterations in the
FMM microbiological profile of the orthodontic
T1: PI = 1.66  0.47 patient.
T2: PI = 1.91  0.50
T3: PI = 1.66  0.40
NC
T1: PI = 1.78  0.39
T2: PI = 1.87  0.48
T3: PI = 1.83  0.50
( p > 0.05)

Gehlen et al. (2000)
PI and Vital Preliminary Phase: The return of cariogenic plaque was
fluorescence PI = 1.3 ( p = 0.042 for control and significantly reduced by the use of the 0.2%
0.021 for test group) chlorhexidine mouthwash.
Phase T0
Control: PI = 0.9
Chlorhexidine: PI = 1.0
( p = 0.032)
Phase T1:
Control: PI = 1.02
Chlorhexidine: PI = 0.44
( p < 0.001)
Phase T2:
Control: PI = 2.27
Chlorhexidine: PI = 1.0
( p < 0.001)

Nelson-Filho et al. (2011b)
PI and checkerboard The use of the mouthwash with
DNADNA chlorhexidine was shown to be
hybridization more efficient than that of the
control in the reduction of S.
mutans.
S. mutans, S. sobrinus, L. casei and L. cidophilus
were detected in metal bracket samples,
with higher level of S. mutans and S.
sobrinus, with the use of CHX significantly
reducing the indices of S. mutans.

outstanding. This study confirms the efficacy of Listerine in
the control of cariogenic plaque, by maintaining the plaque
index (PI) around 1, whereas in the group cleaning with
brushing and using dental floss, the plaque index showed an
increase from 1.6 to PI > 2 ( p < 0.001). In their study, Nelson-
Filho affirmed that the use of 0.12% chlorhexidine gluconate
for 30 s twice a day significantly reduced the level of
Streptococcus mutans ( p = 0.03).
The use of mouthwash with cetylpyridinium chloride twice
a day for a month was shown to be effective in reducing the
plaque when associated with basic oral hygiene in patients
undergoing orthodontic treatment with fixed appliances, and
also improved the periodontal health of these patients.9 When
referring to the use of mouthwashes with essential oil
(Listerine1), Tufekci et al.21 affirmed that this was more
efficient for plaque reduction than the method used in the
control group (brush and floss); while Chen et al.14 affirmed
that the results obtained did not differ from those obtained in
the control group. As far as the oral mouthwash composed of
NaF is concerned, according to Ogaard et al.,26 its efficiency
can be affirmed. According to the above-mentioned authors,
the use of the mouthwash with NaF retards caries develop-
ment, however, the process is not completely inhibited.
Moreover, some authors16,22 have found the use of AmF/
SnF2 to be efficient in cariogenic plaque reduction.
Therefore, it may be inferred that this systematic review is
of importance to clinical practice, because it points out the
effectiveness of mouthwashes in reducing cariogenic plaque
 journal of dentistry 43 (2015) 297308
in orthodontic patients after their use for the period of 3
months. This allows orthodontists to indicate the use of these
substances to patients as coadjuvent means of performing
daily oral hygiene, with the goal of reducing cariogenic plaque,
since this type of chemical control has also been shown to be
effective when associated with other clinical practices.
7. Conclusion
By conducting this systematic review, it could be inferred that:
 There is some evidence showing that the use of oral
mouthwashes reduces cariogenic plaque in patients with
fixed orthodontic appliances.
 The prescription most indicated for this situation is the use
of the mouthwash twice a day, once before going to sleep
and once in the morning, with quantities of mouthwash
varying between 10 and 20 ml.
 According to the data set out, it was observed that the use of
mouthwashes based on chlorhexidine, octenidine, essential
oil (Listerine1), Cetylpyridinium, NaF, and AmF/SnF2 were
shown to be effective in the reduction of cariogenic plaque.
 Further controlled and randomized clinical studies, with a
longer period of study duration, larger sample size, and
better definition of the control and test groups as regards
gender of the participants are necessary to increase the
strength of the evidence of the effects on the reduction of
cariogenic plaque.
Acknowledgement
The authors would like to thank National Council of Research
(CNPq) for the financial support: Process numbers 302800/
2012-3, 150919/2014-0 and 446013/2014-5.
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