| Abstract|| |
Objectives: The objective of this triple blind randomized controlled clinical trial was to compare the efficacy of a mouth rinse containing amine fluoride (AmF) and chlorhexidine in controlling the supragingival plaque accumulation and gingival inflammation during a 4-week period in patients with chronic gingivitis.
Subjects and Methods: A total of 30 patients were participated in this study. Fifteen patients were prescribed an AmF-containing mouth rinse and 15 were prescribed a chlorhexidine mouth rinse. Plaque index, gingival index, bleeding index, tooth stain, and tongue stain (TS) were recorded at baseline, 15 days and 1-month. Patients' perception of odor, taste and any discomfort were recorded.
Results: The comparisons between the groups were done using Mann-Whitney U-test. The comparison within the group at different time visits were done using Wilcoxon signed rank test. Both the mouth rinses resulted in a significant decrease in plaque index, gingival index, bleeding index. However, AmF mouth rinse resulted in a statistically significant decrease in bleeding index and gingival index compared to chlorhexidine group. There was no significant difference in tooth stain and TS in both the groups.
Conclusions: The 4 weeks use of AmF containing mouth rinse is effective in reducing the gingival inflammation and plaque.
Keywords: Amine fluoride, chlorhexidine, mouthwash, oral hygiene, plaque control
|How to cite this article:|
Priya B M, Galgali SR. Comparison of amine fluoride and chlorhexidine mouth rinses in the control of plaque and gingivitis - A randomized controlled clinical trial. Indian J Dent Res 2015;26:57-62
Most forms of plaque-associated periodontal diseases start as inflammatory lesions of the gingiva. If left untreated, they may progress over time and eventually, involve and compromise the entire periodontal attachment apparatus.  Proper plaque control is a key factor in the prevention of periodontal diseases and has been demonstrated extensively by Loe (1965) and Axelsson et al. (1991). The most reliable and widely accepted method of plaque control involves personal and professional mechanical oral hygiene measures. Personal oral hygiene measures involve the use of a toothbrush and a range of interproximal devices. 
|How to cite this URL:|
Priya B M, Galgali SR. Comparison of amine fluoride and chlorhexidine mouth rinses in the control of plaque and gingivitis - A randomized controlled clinical trial. Indian J Dent Res [serial online] 2015 [cited 2019 Nov 14];26:57-62. Available from: http://www.ijdr.in/text.asp?2015/26/1/57/156809
Acceptable plaque control over prolonged periods of time by use of these devices is difficult to achieve.  A high degree of motivation and skill required by these devices may be beyond the ability of most of the patients.  Furthermore, mechanical tooth cleaning is a time-consuming procedure. The widespread presence of gingivitis suggests inefficiency of mechanical plaque control in the prevention of gingivitis. Long-standing gingivitis increases the risk of attachment loss. Prevention of gingivitis may reduce the prevalence of mild to moderate periodontitis. Therefore, there is a need for chemotherapeutic agents that would augment mechanical plaque control. Mouth rinses are a common adjunct to mechanical hygiene measures to facilitate the control of supragingival plaque and gingivitis. ,
Chlorhexidine, by virtue of its substantivity, remains the gold standard of chemical antiplaque agents and the positive control by which to compare other agents.  The typical regimen of use is 18-20 mg dose rinsed for 60s twice per day, usually derived from 0.12% or 0.2% chlorhexidine formulations, respectively. Chlorhexidine digluconate has proved to be the most effective agent in numerous studies , and is still examined intensely, either combined with other ingredients or as a positive control. ,,,
Fluorides are available as a mouth rinse or toothpaste preparations and are usually formulated with sodium, stannous or amine groups as a cation. Amine fluorides (AmF) were developed by the end of 1950`s by GABA international group in collaboration with Institute of Dentistry of Zurich.  AmF is an organic fluoride with a special molecular structure. It consists of a hydrophilic and fluoride binding amine groups attached to a hydrophobic hydrocarbon chain. The hydrophilic part is aligned toward the tooth surface providing the fluoride to the tooth surface while the hydrophobic part is towards the oral cavity. For this reason, they act like surfactants, reducing the surface tension of saliva, and forming a homogeneous film on teeth and all oral surfaces. This continuous film prevents rapid rinsing off by the saliva. The AmFs are thus available for longer periods of time.
Amine residues of AmF possess their own anti-bacterial property due to the positively charged amine part. They also inhibit the metabolic activity of bacteria and reduce acid production.  AmF has shown stronger antivital and antiadhesive effect on the initial biofilms and demonstrated a maximum antibacterial effect under the experimental conditions. 
The primary effect of AmF is anti-cariogenic while there is some evidence of antiplaque and antigingivitis response with stannous fluoride or AmF/stannous fluoride formulations. ,,
There are only limited studies on AmF alone as an antiplaque and anti-gingivitis agent, there have been no studies evaluating mouth rinse containing only AmF as an active ingredient on plaque and gingivitis.
The objective of the present randomized, triple-blind, controlled trial was to evaluate the efficacy of a mouth rinse containing AmF and chlorhexidine in controlling the supragingival plaque accumulation and gingival inﬂammation during a 4-week period in patients affected by gingivitis.
| Subjects and methods|| |
The study was initially approved by the institutional review committee. Patients seeking periodontal treatment at V.S Dental College and Hospital were screened for suitability. To be eligible for the study the following inclusion and exclusion criteria were applied. Patients with gingivitis with at least 20 natural teeth participated in the study. Gingivitis was defined by Gingival Index score of ≥ 1 at more than 60% of sites, plaque index of 1 or more and probing depths not more than 3 mm and no clinical attachment loss. In general, subjects were adults in good medical health with oral cavity free from major hard or soft tissue lesions.
Pregnancy or lactation, physical or mental handicap that could interfere with adequate oral hygiene performance, systemic and/or topical steroidal and nonsteroidal anti-inflammatory drugs and/or requiring antibiotics/antimicrobials during the last 6 weeks prior to the study; fixed or removable orthodontic device; oral soft tissue pathology, requiring prophylactic antibiotic coverage prior to invasive dental procedures were the exclusion criteria for the study.
A total of 39 subjects meeting the eligibility criteria were enrolled in the study. Eligible patients received verbal and written information sheets providing a detailed explanation on the nature of the study consistent with proposed claims for the product and the alternatives. However only 30 patients expressed their willingness to participate in the study and signed an informed consent [Figure 1]. The subjects were aged between 18 and 32 years (mean 29 years). Ethical approval for the study was obtained from the ethics committee of VS Dental College and Hospital.
|Figure 1: Changes in plaque index between the groups at different visits|
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At the baseline visit (Week 0), patients were given written and verbal oral hygiene instructions. All the study subjects were provided with a soft toothbrush for use during the study. The modified Bass technique was demonstrated on study models, and the subjects were made to repeat the maneuver on the models before the beginning of the study. No oral prophylaxis were carried out at baseline or during the study. The patients were assigned treatment mouth rinses according to a randomization list (15 each). Fifteen patients were prescribed an AmF containing mouth rinse and 15 were prescribed a chlorhexidine mouth rinse. The random allocation sequence was concealed from the main investigator. Both the mouth rinses were of the same color and in identical bottles. Subjects were thus unaware of the product used. Both the mouth rinses were prescribed 10 ml twice daily and a rinsing time of 60 s was recommended. The subjects were instructed to use the prescribed rinses either before or after brushing. In order to check on the compliance, subjects were requested to bring along the bottles on both the visits. Clinical measurements were taken at baseline (prior to the study), at 15 days and at the end of the study (4 weeks). Patients' perception of odor, taste and any discomfort were recorded. A single examiner, blinded to the mouth rinse used, performed all the measurements. The decoding of mouthrinses was made only after completion of all data acquisition and termination of the study.
At each visit, scoring of the supragingival plaque was done using Turesky modification of the Quigley-Hein plaque index.  Scoring of gingival inflammation (gingivitis) was done using Gingival Index of Löe and Silness  and scoring of gingival bleeding was done by Bleeding Index of Ainamo and Bay.  Assessment of gingivitis was done prior to the scoring of plaque to avoid masking the gingival inflammation with plaque-disclosing agents.
The presence of stain on teeth was assessed by means of a gingival modification of the stain index (Grundemann et al. 2000).  Each examined tooth was divided into 4 zones and the intensity of each zone was subjectively scored, where 0 = stain, 1 = light stain (yellow), 2 = medium stain (brown), and 3 = heavy stain (black). The presence of tongue stain (TS) was assessed according to the method reported by Claydon et al. (2001).  Stain on the dorsal anterior two-thirds of the tongue were scored as follows: (a) Stain area (TSa): As a % where 0 = no stain; 1 = 1-25% coverage; 2 = 26-50% coverage; 3 = 51-75% coverage; 4 = 76-100% coverage and (b) stain intensity (TSi): Subjectively scored as 0 = no stain; 1 = light stain (yellow); 2 = medium stain (brown); and 3 = dark stain (black). For intensity scores where mixed colors were observed, the higher score was applied. Teeth and TS were assessed at baseline, 15 days and at the end of 4 weeks.
The statistical analyses were done using statistical software SPSS version 17.0 (IBM corporation). The demographic data were analyzed using the Chi-square test. The comparisons between the groups were done using Mann-Whitney U-test. The comparison within the group at different time visits were done using Wilcoxon signed rank test. The level of significance was P < 0.05.
| Results|| |
All the 30 subjects completed the study. The mean age of the subjects in the chlorhexidine group was 22.07 ± 4.7 and AmF group was 23.3 ± 5.3. Both the groups were homogeneous with respect to gender and disease severity as there was no significant difference in plaque index, bleeding index, gingival index and stain index at baseline as shown in [Figure 1][Figure 2] [Figure 3] respectively. The mean plaque index, gingival index, bleeding index, tooth and TS indices at baseline and first visit are shown in [Table 1]. The indices at first and second visits are shown in [Table 2].
|Figure 2: Changes in bleeding index between the groups at different visits|
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|Figure 3: Changes in gingival index between the groups at different visits|
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The mean plaque scores at baseline for chlorhexidine were 1.69 ± 0.332 and AmF group were 1.61 ± 0.365. The mean plaque scores at day 15 for Chlorhexidine group were 1. 34 ± 0.369 while that for AmF group were 1.05 ± 0.304. The mean plaque scores at the end of the fourth week were 0.93 ± 0.368 and 0.69 ± 0.248 for chlorhexidine and AmF, respectively. Statistical analysis showed a significant decrease in plaque scores in both the groups at recall visits and significant difference between the groups at both 2 and 4 weeks.
|Table 1: Comparison of clinical parameters at baseline and at first visit (15 days) |
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|Table 2: Comparison of clinical parameters at first and at second visit |
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Mean scores for gingival inflammation at baseline were 1.78 ± 0.164 for Chlorhexidine group and 1.70 ± 0.298 for AmF group.The scores decreased to 1.28 ± 0.232 and 1.15 ± 0.219 at the end of 2 weeks, and to 0.96 ± 0.222 and 0.76 ± 0.172 at the end of 4 weeks for Chlorhexidine and AmF group respectively. There was a statistically significant decrease in the gingival index in both groups at both the recall visits. However between the groups, statistically significant decrease was observed only at the second visit.
Mean bleeding scores decreased significantly from 82.54 ± 13.264 to 46.00 ± 14.487 at first visit and to 32.19 ± 6.271 at the second visit for the chlorhexidine group while for AmF group there was a decrease from 80.03 ± 16.203 at baseline to 33.77 ± 11.332 at first visit and 23.95 ± 7.141 at the second visit. Statistical analysis showed a significant decrease in mean bleeding scores in both the groups at the recall visits and significant difference between the groups at both 2 and 4 weeks.
There were no significant difference within and between the groups for the teeth stain and TS index at both the visits.
| Discussion|| |
Inability of the adult population to remove plaque by mechanical means alone has led to the development of chemical plaque control agents as supplementary to home care procedures. The results of the present study indicate that the 4-week use of an AmF containing mouth rinse significantly reduced the growth of plaque and progression of gingivitis.
The present study is a short term triple-blind, parallel controlled clinical trial. Blinding or masking is almost necessary to establish efficacy or effectiveness. Triple masking provides a safeguard against bias since neither the statistician, examiner or patient knows the identity of the experimental group.  Crossover study designs are ideal to investigate the anti-plaque or the antigingivitis effect of chemical plaque control agents. This design provides considerable power to detect small differences with a relatively small sample size. However, without an adequate washout period the carry over effect may persist and hence a parallel design.
Although plaque accumulation models recommend thorough oral prophylaxis prior to the commencement of the study, the magnitude and the duration of its effect have not been accurately established. No supragingival scaling was carried out at baseline, and both the test and control groups were balanced with respect to disease status at the start of the study.
Compliance with the use of prescribed products and or instructions can influence the outcome of the study and is a difficult factor to monitor accurately. Compliance was assessed by asking all the study participants to bring along the bottles and toothbrush at every visit. All the patients complied with the use of mouth rinses and the brushing instructions.
Mouth rinses aim at improving the efficiency of self-performed mechanical plaque control. Mouth rinses are easy to use. Simple action of rinsing distributes the mouth rinse throughout the oral cavity accessing not only areas treated by toothbrush, but also soft tissue reservoirs. Use of chlorhexidine is one of the most undisputed ways to restrain plaque growth. Hence, chlorhexidine served as a positive control.
The plaque inhibitory effect was evaluated using Plaque Index of Turesky modification of the Quigley-Hein plaque index. The Turesky et al. index is a reliable index to assess plaque because it helps in detecting small amounts of plaque at the cervical margins of the teeth which play a role in the initiation of gingivitis. A signiﬁcant reduction in supragingival plaque deposits was recorded after both the test and the control mouth rinse. Although a signiﬁcant reduction in plaque scores was recorded after both the test and the control mouth rinse, AmF mouth rinse resulted in a significant decrease in the plaque scores at both recall visits. The use of the mouth rinses as an adjunct to manual toothbrushing may have limited the extent of plaque accumulation. ,,,
Amine fluoride, an organic fluoride forms a homogenous layer on the tooth surface and is not washed off by the saliva. In vitro studies on biofilms have shown a decrease in the thickness of biofilms and biofilms viability. ,,, Plaque samples from patients with chronic periodontitis exposed to AmF gel inhibited the growth of all cultivable bacteria. Gram-positive strains were found to be more sensitive than Gram-negative organisms.  An electrostatic interaction between cationic AmF and negatively charged bacterial surface is important for the reduction of biofilm formation by AmF.  Penetration of the mouth rinse through the biofilm layer is of utmost importance. An in vitro study demonstrated the penetration of the AmF up to outer third or half of the plaque biofilm layer. 
Gingival index is the most widely used index for investigating the oral hygiene products, and the anti-gingivitis effect was assessed by Gingival Index of Loe and Silness. The index measures color changes in gingival tissues preceding bleeding on probing. In the present study, a signiﬁcant decrease in GI was observed for both the mouth rinses. The difference in posttreatment GI between mouth rinses did not reach the statistical signiﬁcance at 15 days. However, there was a significant decrease in GI in the AmF group at the end of 4 weeks. AmF s inhibit the metabolic activity of bacteria, reduce bacterial enzymes.  The results of our present study are consistent with the observations of an earlier study. 
Bleeding on probing is an objective and a more reliable measure of gingival status compared to Gingival Index. BOP was evaluated using a Williams's periodontal probe. There was a significant decrease in bleeding scores between the groups at the first visit (P = 0. 016) and at the second visit (P = 0. 002). The reduction in the BOP is consistent with the anti-plaque, and an anti-gingivitis effect of AmF observed in our study.
Numerous studies have found the propensity of chlorhexidine to produce tooth staining in vivo and in vitro. ,, However, there was no significant difference in the teeth stain and TS between the groups. This may probably be due to the short duration of the study.
At each recall visit patients were asked about the efficacy of the mouth rinses used. In both the groups, the patients tolerated the mouth rinses well. One patient in the chlorhexidine group reported an alteration in taste at the first recall visit itself.
The study evaluated the anti-plaque and anti-gingivitis effect of the two mouth rinses in a small sample of subjects over a period of 4 weeks as an adjunct to routine home care procedures, as per the guidelines of ADA.  However, an appropriate model to study the short-term efficacy of the mouth rinse would be an experimental gingivitis model. Long-term efficacy can be evaluated in controlled clinical trials of 6 months or longer involving a larger sample size. However, such studies are expensive. Home use studies do exhibit Hawthorne effect across all participants whereby oral hygiene practices are improved irrespective of the test agent reducing the possible range of improvement that may be produced by the adjunctive use of a mouth rinse. 
| Conclusion|| |
Within the limitations of the present study, it can be concluded that the antibacterial effect and the minimal tooth staining of AmF make it a possible alternative to chlorhexidine in the treatment of gingivitis.
| Acknowledgment|| |
We would like to thank Dr. Kamala and Group pharmaceuticals for providing the required materials for the study.
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B Meena Priya
Department of Periodontics, Chettinad Dental College and Research Institute, Kelambakkam, Kanchipuram District, Karnataka
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]