Effects on gingivitis of daily rinsingwith 1.5% H2O2

R. L BoydDepartment of Growth and Development,School of Dentistry, University of California,San Francisco, San Francisco, CA 94143-0640,USA

Bovd RL: Effects of gingivitis of daily rinsing with 1.5% H2O2. J Clin Periodontol1989:16: 557-562. '

Abstract. The purpose of this study was to compare 2 groups of adolescentsundergoing orthodontic treatment with fixed appliances to determine whetheronce daily use of a mouthrinse containing 1.5% H2O2 along with toothbrushingwould be better than toothbrushing alone in maintaining their periodontal health.The 2 groups of subjects were selected non-randomly but were matched for ageand sex. The control group (A'̂ =34) used toothbrushing and a mint-flavored0.05% NaF mouthrinse once daily, while the treatment group (A'=25) used tooth-brushing and a once daily rinse with a preparation containing 0.05% NaF and1.5% H.Oj (Orthofiur®). 2 calibrated clinical examiners made single-blind clin-ical assessments of the plaque index, gingival index, and bleeding tendency in 6standard sites per subject. They also noted any generalized mucosal irritationsor staining ofthe teeth or tongue. Assessments were made before appliances wereplaced (baseline) and 1, 3, 6, 9, 12 and 18 months after apphances were placed.Results indicated that although there were no significant differences at baseline,the Orthoflur group had significantly fewer study sites with gingival indes orbleeding tendency scores greater than 1 than the control group from the 1-monththrough the 18-month examinations (P<0.01), and significantly fewer sites withplaque index greater than 1 and bleeding tendency scores of 2 or more from the3-month through the 18-month examinations (P<0.02 and 0.01, respectively).No generalized mucosal irritations or clinically significant staining of the tongueor teeth were noted in either group during the study.

Key words; hydrogen peroxide; gingivitis; or-thodontic treatment.

Accepted for publication 7 November 1988

During the last 2 decades, many studieshave documented the antibacterial ef-fects of H2O; (for review, see Miyasakiet al. (1986)). These effects appear tobe related to the availability of oxygen,which is bactericidal to obligate an-aerobes, organisms sensitive to oxygen.The topical application of HjOi rinseshas been reported to reduce plaque for-mation and gingivitis (Wennstrom &Lindhe 1979) and arrest acute ulcerativegingivitis (Wade & Mirza 1964). Unfor-tunately, no long-term studies havetested the effectiveness of H2O2 rinses.Some studies have shown that a pastemade of H2O2 and NaHCO, can be ef-fective for antimicrobial treatment ofperiodontal disease (Keyes et al. 1978a,b, Roshng et al. 1983), but other studieshave not found this method to be effec-tive (West & King 1983, Greenwelt etal. 1983 and 1985, Cerra & Killoy 1982).

The purpose of this study was to de-termine whether toothbrushing in com-bination with once daily use of a mouth-rinse containing 1.5% H2O2 would bemore beneficial than toothbrushing

alone for maintenance of periodontalhealth in a long-term study of adoles-cents undergoing fixed orthodontictreatment. Adolescent orthodontic pa-tients were chosen for study since theyoften show ineffective plaque controland gingivitis because of the difficultyof removing plaque while fixed ap-pliances are in place (for review, seeBoyd (1983)).

Material and MethodsStudy populaKon

60 adolescent patients were selected forthis study from among those scheduledto have fixed orthodontic treatment atthe Orthodontic Clinic of the School ofDentistry, Utiiversity of California, SanFraneisco. Informed consent to partici-pate in the study was obtained fromboth patients and their parents. Patientswith a history of rheumatic fever, con-genital heart disease, blood dyscrasiasor diabetes mellitus were not included.Patients were also excluded if they werediagnosed as having juvenile perio-

dontitis according to the criteria ofKornman & Robertson (1985). In ad-dition, none of the patients had usedantibiotics during the 6 months prior toorthodontic treatment. The study pop-ulation was divided into a control group(A^=34) and a treatment group (A'=26). The first 26 patients in the controlgroup and the treatment group werepaired for age and sex. The mean ageof the control group was 13.5 with arange of 10.3 to 17.2 years, white thetreatment group had a mean age of 13.2with a range of 10.1 to 17.4 years. Therewere 23 female and 11 male patients inthe control group, and 17 female and 9male patients in the treatment group.

Preventive treatment

All study patients received instructionsin toothbrushing in the horizontal scrubmethod (Zachrisson 1976) with anADA-approved sodium fluoride denti-frice (Crest Toothpaste, Proctor andGamble Co., Cincinnati, OH). The in-structions were provided by the same

558 Boyd

plaque control therapist. The therapistalso reinforced these instructions, usingthe Plaklite® disclosing system (Bristol-Meyers. Stamford, CT), at subsequentbanding/bonding visits (2-3 sessions)and at each monthly orthodontic treat-ment visit for the 18-month study per-iod. In addition, the control group wasinstructed to use 0.05% NaF mint-fla-vored mouthrinse (Flurigard'^, Colgate-Hoyt, Norwood MA) once a day. whilethe treatment group was instructed touse daily a rinse of similar color, mintflavoring and a 0.05% NaF but alsocontaining 1.5% H2O2 (Orthoflur^^, Col-gate Hoyt, Norwood, MA). All studypatients were instructed to keep 1/2ounce of the rinse in their mouth forone minute, then to expectorate but notto rinse with water after using the rinse.These instructions were also reinforcedat each monthly visit.

When baseline clinical assessmentswere completed, all subjects received aprophylaxis consisting of coronal toothpolishing. Patients were also requestedto maintain their usual frequency ofcheck-ups with their general dentist dur-ing orthodontic treatment.

Clinteai examinations

All study sites were evaluated beforeappliances were placed, and again at I,3, 6, 9, 12, and 18 months after ap-pliances were placed. The assessments

used were the plaque index (Silness &Loe 1964), gingival index (Loe & Silness1963) and bleeding tendency (Armitageet al. 1982). Any generalized mucosalirritation, or clinically significant stain-ing of the teeth or tongue were noted ateach of these examinations. Localyzedmucosal irritation associated withrough edges of fixed orthodontic ap-pliances were not included in this cate-gory. In each patient, the study siteswere six proximal-buccal line angles onthe following teeth: right maxillary firstmolar, mesiobuccal line angle; rightmaxillary cuspid, distobucca! line angle;left maxillary central incisor, distobuc-cal line angle; right mandibular centralincisor, distobuccal line angle; left man-dibu/ar canine, distobuccal Jine angle;left mandibular first molar, mesiobuccalline angle. If a study tooth was missing,the corresponding tooth on the contral-ateral side was examined. The clinicalexaminers had no knowledge of thegroup to which a subject belonged, andpatients were cautioned by the plaquecontrol therapist not to reveal theirgroup identity to the examiner.

Orttiodontic treatment

After the baseline ciinicai assessment,all study patients were treated with anedgewise appliance on both upper landlower dental arches. All theeth had di-rect bonded appliances placed except

PLAQUE INDEX > 1

* p < 0.02

BASEUNE 1 MONTH 3 MONTH 6M0^n•H 9 MONTH 12 MONTH 18 MONTH

COMTTOL ORTVOaUR

Fig. I, Mean % of sites with a plaque index greater than 1 for the control group and thegroup using a 1.5% HiOj rinse (Orthonur» )̂ over the 18-morith study period. Bars showstandard deviation. Asterisks mark significant differences between groups at the designatedexamination.

first molars, of which 78% were bandedand the remaining 12% were direct-bonded. Extractions were carried out inat least one arch in 42 (70%) of thestudy patients.

Compliance

To assess compliance with the use ofthe rinses, at the monthly orthodontictreatment visit the plaque control thera-pist asked patients how many days permonth they had not used the rinse asrecommended. If a patient reportedmissing an average of 10 or more daysper month for 9 or more months of the18-month study, the patient was classi-fied as non-comphant.

Statistical analysis

A two-way analysis of variance was per-formed for all tested variables for intra-group differences from baseline andintergroup differences at each obser-vation. Statistical significance was set ata P value of less than 0.05.

Two chnical examiners independentlyperformed all assessments. These exam-iners were carefully calibrated beforethe study and at 6-month intervals forthe duration ofthe study for both inter-examiner and intraexaminer reproduci-bility (minimum of 85% reproducibili-ty). The Kappa statistic was used toquantify agreement beyond chance(Hunt 1986),

Results

Complete data were obtained for 32control subjects and 24 Orthoflur sub-jects. 4 subjects withdrew from the studywhen they moved away from the area.No significant differences were foundbetween the 2 groups for baseline chn-ical indices.

The percentage of sites with a plaqueindex greater than 1 (Fig. 1) indicateda gradual increase in plaque accumu-lation from baseline to 9 months forboth groups. The Orthoflur groupshowed significantly less of an increaseafter 3 months than the control group(i'<0.01). Intragroup increases frombaseline were significant for the controlgroup {P<Q.Q\) but not for the Ortho-flur group.

The % of sites with a gingival indexgreater than 1 (Fig. 2) showed a patternsimilar to that for the plaque index, butthe %s for the Orthoflur group weresignificantly tower (P<0.01) at the 1-

GINGIVAL INDEX > 1

BASELINE 1 MONTH 3 MONTH 6 MONTH 9 MONTH 12 MONTH 18 MONTH

Fig. 2. Mean % of sitesOrthoflur group.

CONTROL

vith a gingival index gre

0 ORTHOFLURHer than I for the control group and the

through 18-month clitiical examinationsthan those ofthe control group. Signifi-cant intragroup differences (i'<0.01)between baseline and all subsequentexaminations were found for the controlgroup but not Orthoflur group.

The % of sites with a bleeding tend-ency score greater than 1 (Fig. 3) andgreater than 2 (Fig. 4) showed patternssimilar to those for the gingival index;again, there were significant differences(?<0.01) between the Orthoflur groupand the control group for sites withscores greater than 1 after 1 month, andfor sites with scores greater than 2 after

3 months. Significant intragroup differ-ences (/*< 0.01) from baseline werefound for the control group but not forthe Orthoflur group.

When mean values of the clinical in-dices were subjected to an analysis ofvariance, the P values obtained weresimilar to those of the percentage ofsites analysis.

No patients in either group developedclinically significant tongue or toothstaining or generalized mucosal irri-tation during the 18-month studyperiod.

Compliance data indicated that only4 of the control subjects and 2 of theOrthoflur subjects missed once dailyrinsing on 10 or more days per monthfor 9 or more months of the 18-monthstudy period. When the data were re-analyzed without these non-compliant

patients, the values obtained showed al-most identical patterns and statisticalsignificance to the analysis of all pa-tients.

The mean intra-examiner agreementof both clinical examiners was 87.2%,and the interexaminer agreement was86.5%. The kappa statistic for the clin-ical indices for both clinical examinershad a mean value of 0,73, with a rangeof 0.68 to 0.82.

Effects on gingivitis of H2O2 559

Discussion

The results of this study show that oncedaily use of a mouthrinse containing1.5% H2O2, in combination with tooth-brushing. is more effective in main-taining periodontal health in orthodon-tic patients over a long term than istoothbrushing without such a rinse.This study is in agreement with previousclinical trials that have found HiO:rinses to have beneficial effects on perio-dontal status (Wade & Mirza 1964. Ber-genholtz ei al. 1969, Johansen et al.1970, Wennstrom & Lindhe 1979, Go-mes et al. 1984). However, these pre-vious studies covered a much shorterterm than the present 18-month longi-tudinal investigation. Thus the length ofthis study addresses the concern thatthe antimicrobial effect of H2O2 may betransitory, or that plaque microorg-anisms might become resistant to theantimicrobial effect of H;0;.

Significant intragroup increases frombaseline in gingival inflammation andbleeding were seen for the control groupbut not for the Orthoflur group. Pre-vious studies have established that gin-gival inflammation generally increasesafter fixed appliances are placed (Zach-risson & Alnaes 1973, Zachrisson 1976,Boyd 1983). We hypothesize that in thisstudy the lack of increase in these scoresin the Orthoflur group occurred becausethe 1.5% H2O: tnnse was preventing gin-giva! inflammation that would have de-veloped if this rinse had not been used.

BLEEDING TENDENCY >1

BASEUNE 1 MONTH 3 MONTH 6 MONTH 9 MONTH 12 MONTH 18 MONTH

I CONTROL ORTHOFLUR

Fig. 3. Mean % of sites with a bleeding tendency score greater than 1 for the control group

and the Orthofiur group.

Boyd

BLEEDING TENDENCY > 2

BASELINE 1 MONTH 3 MONTH 6 MONTH 9 MONTH 12 MONTH 18 MONTH

_ 0 ORTHOFLUR

Fig. 4. Mean % of sites with a bleeding tendency score greater than 2 for the control groupand the Orthoflur group.

HjO; rinses have been used for manyyears as antiplaque-antigingivitis agents(for review see Gold 1985). Recently,several reports have described the anti-microbial activity of H1O2 as bacteri-cidal for known periodontal pathogenicbacteria such as Actinobacillus actino-mycetemcomitans, Haemophilus aphr-ophilus, Eikenella corrodens and Capno-cytophaga gingivalis (Miyasaki et al.1984, 1985, 1986). In addition,Wennstrom & Lindhe (1979) reportedthat an H:02 rinse prevented coloniz-ation of filaments, fusiforms, motile andcurved rods and spirochetes in develop-ing plaque. The results of the presentstudy offer additional clinical evidenceof this antimicrobial activity. H:0; inother types of preparations, such as ingels (Shipman et al. 1971), in tooth-pastes (Rundegren et al. 1973), andmixed with NaHCOi in a paste (Keyeset al. 1978a, b, Rosling et al. 1983),has also shown effects on plaque andgingivitis. Because all subjects in thisstudy used a rinse that contained 0.05%NaF, it is necessary to rule out any anti-microbial effects ofthe NaF componentof the rinses used. Both Tinanoff et al.(1976) and Andres et al. (1974) haveshown that 0.05% NaF rinses do notexhibit antimicrobial activity. However,NaF is effective in controlling decalcifi-cation in orthodontic patients (Zachris-son 1976, O'Reilly & Featherstone1987). Thus another possible benefit ofthe H:0: rinse used in this study is that0.05% NaF can be incorporated into

it in a stable formulation. Efforts toincorporate fluoride in a stable and ef-fective preparation in other antiplaque-antigingivitis agents, such as chlorhex-idine rinses and Listerine rinse, have notbeen successful.

6 standard interproximal sites wereused as study sites in this clinical trialbecause previous studies have demon-strated that they are representative ofthe status of the entire mouth with ap-proximately a 90% confidence level(Shick & Ash 1961, Jamison 1963,Ramljord 1974, Gettinger et al. 1983).Distobuccal sites of canines were usedinstead of premolars because in manyof the subjects the premolars had beenextracted for orthodontic purposes. Pre-vious studies (Schei et al. 1959) haveestablished that distal proximal surfacesshow recordings of periodontal destruc-tion similar to those of the mesial sur-faces. Buccal surfaces were not includedbecause these surfaces show less perio-dontal inflammation than proximalsites (Anenid et al. 1979, Clerehugh etal. 1988) and are more likely to showtoothbrush abrasion (Zachrisson 1976).Lingual surfaces were not used as studysites because they are susceptible to in-creased examiner error (Glavind & Loe1967). The intra- and interexaminer per-centage agreement for the clinical indi-ces and the Kappa statistics for bothclinical examiners correspond well withthose reported by others (Hunt 1986,Fleiss & Chilton 1983).

In this study, both groups showed ex-

cellent compliance with use of thmouthrinses. This was most likely because the patients (as they reported subjectively to the plaque control therapistliked the taste of these rinses and fountthem convenient to use. When dat.were reanalyzed without the non-compliant subjects, the statistical result:,were similar to those values obtainedfrom analysis of all subjects. The eom-pliance attained for use of the rinse inthis study was also higher than that re-ported for other types of adjunctivechemical preparation when used dailyby adolescent orthodontic patients,such as brush-on SnFz gels (Boyd etal. 1988) or oral irrigators containingantimicrobial agents (Boyd et al. 1982).

Although none of the patients usingthe H20j rinse in this study developedgeneralized mucosal irritation, recentreports have documented several ad-verse effects of topically applied H^Oz,such as pathologic changes of preneo-plastic lesions in hamsters (Weitzman etal. 1984 and 1986) and inhibition ofcollegen synthesis and glucose metab-olism in bone in vitro (Ramp et al.1987). In these studies, however, theconcentration of H3O: necessary to in-duce these cellular changes was 30%,far in excess of the 1.5% H2O2 used inthe Orthoflur rinse. Generalized muco-sal irritation from H2O2 also appears tobe related to the duration of contactwith H2O:; Martin et al. (1983) foundthat even a 1% H2O; solution wouldcause epithelial damage if it remainedin continuous contact for more than 8h with keratinized oral epithelium ofthedog. Rees & Orth (1986) reported twocases of generalized mucosal irritationsresulting from use of a 3% H2O2 rinse3 to 5 times daily. In the present study,the 1.5% H2O2 rinse was used only oncedaily for a 1 minute duration, whichis in line with current pharmacologicrecommendations for topical oral rinsescontaining H2O2 (Gilman et al. 1980),and patients were cautioned not to ex-ceed this frequency.

The results of this study do not indi-cate conclusively that the 1.5% H2O:rinse used once daily is the optimaltherapeutic level of H2O2 or the optimalfrequency of application. Additionalstudies testing rinses having differentconcentrations of H2O2 and used withdifferent frequencies will be necessary todetermine the optimal therapeutic dose.Also, currently used clinical indices maynot be sensitive enough to detect ben-eficial effects of mild preparations such

Effects on gingivitis of H2O2 561

as 1.5% H:0: in patients with less severegingivitis than shown by the patients inthis study. <

Acknowledgments

The author thanks Ms. April Price andMs. Patricia Renfrow for their technicalassistance and Ms. Evangeline Leashfor editing the manuscript. Funding forthis study was provided by the Colgate-Hoyt Corp. of Norwood, MA, USA.

Zusammenfassung

Die Wirkwig tciglicher Mimdspiilung mit 1.5%H;0^ auf die ZalmfleischenzUndungIm Rahmcn dieser Studie wurde beabsichtigt,2 erwaehsene Probandengruppen mit festenkieferorthopadischen Apparaten miteinanderzu vergleichen um klarzustellen, ob Zahne-putzen mit zusatzlichem, einmal taglichenSpiilen mil einer 1.5% H,0 , enthaltendenMundspullosung, zur Beibehaltung der paro-dontalen Gesundheit glinstigcr isl als dasZahneputzen als alleinige oralhygienischeMassnahme. Die beiden Probandengruppenwurden nicht nach den Kriterien zufalligerSelektion zusammengestellt, sie waren aberhinsichtlich Alter und Geschlechtszusam-mensetzung vergleichbar. Die Kontrollgrup-pe (A'= 34) putzte die Zahne und spiilte cin-mal taglich den Mund mit einer 0.05% NaFenthaltenden Mundspullosung mit Pfeffer-minzgeschmack. Die Versuchsgruppe (N =25) putzte die Zahne und spiiite einmal tag-lieh den Mund mit einer Losung, die 0.05%NaF und 1.5% H,0: (Orthonur") enthielt. 2kalibrierte (vorher trainierte Untersuchendemil kontrollierten, geringfugigen Abwei-chungen zwischen ihren Untersuchungsresul-laten) nahmen an 6 Standardstellen pro Pro-band, ''einzel-blinde" klinische Plaqueindex-, Gingivalindex- und Zahnfleischblulungsten-denz-Bestimmungen vor. Sie registriertenweiterhin alle generalisierten Schleimhautirri-lationen sowie Verfarbungen der Zahne oderder Zunge. Diese Registrierungen wurden vordem Anbringen der festen Apparatur durch-geflihrt (Fingangsuntersuchung) und I, 3, 6.9. 12 und 18 Monate danach. Die Resultatezeigten, dass - obwohl bei der Fingangsunter-suchung keine signifikanten Unterschiedevorlagen - bei der Orthoflurgruppe von derNachuntersuehung nach I Monat. durchge-hend bis zur abschliessenden 18-Monatsun-terstichung, signifikant weniger Untersu-chungsstellen mit den Gingival-Index oderden Zahnfleischblulungstendenz-Index Sco-res (Beurteilungseinheiten) von 1 und dar-iiber registriert worden waren als bci derKontrollgruppe (f<().01) und signifikantweniger Stellen mit einem Plaqueindex liberder Score I, mit der Blutungstendcnz der Sco-re 2 oder mehr - und das durchgehend vonder 3-Monate- bis zur Unlersuchung nach 18Monaten (P<0.02 und 0.01 in o.a. Reihen-Tolge). Bei keiner der beiden Probandengrup-

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Resume

Effets d'un rin^age quotidien avec !.S% Hfi^sur la gingiviteLe but de cette etude a ete de comparer deuxgroupes d'adolesccnts suivant un traitementorthodontique fixe en determinant si un dn-9age quotidien avec 1.5% H,02 en plus dubrossage serait plus efficace a maintenir unparodonte sain qu'un brossage seui. Les deuxgroupes de patients n'ont pas ete repartis auhasard mais suivant Page et le sex.e. Le grou-pe controle (« = 34) associait Ie brossage aurinijage quotidien avec une solution de 0.05%NaF mentholee. Le groupe test (N = 25) com-bioait le brossage au rin^age quotidien avecune solution de 0.05% NaF et de 1.5% H;0 :(Orthoflur®). Deux examinateurs ont effec-tues les mesures cliniques en simple aveugle:indice de plaque, indice gingival et tendanceau saignement au niveau de six sites standar-dises par sujet. Us ont egalement note touteirritation des muqueuses ou toute coiorationdes dents ou de la langue. Les mesures ont6te prises avant le traitement orthodontique(initial) et 1, 3, 6, 9, 12 et 18 mois apres lapose des appareils. Aucune difference n'a etenotee lors de Texamen initial, Le groupe testavait significativement moins de sites avecdes scores > 1 de GI et de tendance au saigne-menl que le groupe controie du premier moisau dernier (P<O.0i). Us avaient egalementmoins de sites avec Pil > 1 et tendance ausaigmements2 entre le 3eme et le I Sememois d'examen (respectivement P<0.Q2 et/" < 0.01). Aucune irritation mucosale genera-lisee ni aucune coloration cliniquement signi-ficative de ia langue ou de dents n'a ete notee.

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Address:

R. L. BoydDepartment of Growth and DevelopmentSchool of DentistryUniversity of California. San FranciscoSan Francisco. CA 94143-0640USA