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Abstract
Aims and Objectives: The objectives of this study were to assess the antiplaque and antigingivitis properties of
Listerine mouth rinse and to investigate its effect on serum level of C-reactive protein.
Materials and Methods: patients received Listerine or placebo (water) in a single-blind 4-week trial. Thirty
qualifying subjects aged 20-50 years completed a 2-week preparatory period during which scaling and polishing
were done twice. Subjects were then randomly grouped into: Listerine or water (control) group. Clinical periodontal
parameters including visible plaque index (VPI), sulcus bleeding index (SBI), calculus index (CI), extrinsic tooth stain
index (SI) and percentage of sites with bleeding on probing (BOP) were obtained from test group as well as matched
controls. The measurements were performed at baseline and 4 weeks thereafter. Moreover, serum C-reactive protein
levels (CRP) were assayed. Subjects then started rinsing twice daily with 20 ml of their respective mouthwash as
adjunct to their usual mechanical oral hygiene procedures. Subjects were re-examined after 4 weeks, and intergroup
differences for all clinical variables and CRP level were tested using appropriate statistical procedures.
Results: All thirty subjects were evaluated after 4 weeks. Rinsing compliance was high for both groups. There
were no statistically significant differences between the two groups at baseline for all clinical variables with the
exception of the percentage of sites with BOP which was slightly significantly higher for the Listerine group compared
with the water group (p=0.047). At the end of the experimental period, Listerine group showed statistically significant
reductions in the VPI (-24.1), SBI (-0.9) and percentage of sites with BOP (-28.7) compared with the water group
(p<0.05). However, there were no statistical significant differences in CI and SI between the two groups. Moreover,
Listerine mouth rinse did not show statistical significant reduction in the serum levels of CRP compared with the water
group (-0.4 and -0.7 respectively, p=0.743).
Conclusion: This 4-week controlled clinical trial demonstrated that Listerine mouth rinse possesses antiplaque
and antigingivitis activities. Insofar, Listerine did not result in any side effects such as calculus formation and teeth
staining. Furthermore, Listerine couldnt show any effect on the serum levels of CRP relative to baseline measures.
Dentistry
ISSN: 2161-1122 Dentistry, an open access journal
Citation: Al Habashneh R, Qubain TG, Alsalman W, Khader Y (2014) The Effect of Listerine Mouthwash on Dental Plaque, Gingival Inflammation and
C - reactive protein (CRP). Dentistry 4: 191. doi:10.4172/2161-1122.1000191
Page 2 of 5
Methods
Participants
One hundred subjects were randomly recruited from Elite dental
center in Amman, Jordan during the period of January 2012 to June
2012. The study was approved by Ethical Committee at Jordan University
of Science and Technology in Jordan. Subjects were interviewed and
examined for eligibility to be included in the study. Subjects were
included in this study if they were diagnosed with chronic gingivitis.
The American Academy of Periodontology (1999) definitions of
plaque-associated gingivitis and localized, was used in the study [22].
Plaque-associated gingivitis is defined as gingival inflammation, which
is confined to the gingivae with no clinical attachment loss or on stable,
but reduced periodontium and is only associated with dental plaque
and no other local contributing factors [22]. Participants have to be
with no history of systemic diseases that may affect the C- reactive
protein level (CRP), such as impaired glucose tolerance, diabetes
mellitus or other endocrine diseases, nephrotic syndrome, chronic
renal disease and cardiovascular disease. Only nonsmokers who have
at least 20 natural teeth and not subjected to periodontal treatment in
the 6 months prior to the study were included. Patients were excluded if
they pregnant have had any systemic alteration(s) that might interfere
with the periodontal disease course, according to the literature; wearing
fixed or removable orthodontic appliances; having used antiseptic
mouthwashes in the three months prior to the study; undergoing
treatment with antimicrobial or anti-inflammatory drugs within the
3 months prior to the study. Only 30 patients (13 male, 17 female)
accepted to participate, fit the inclusion criteria, and completed the
baseline test after signing the consent form. The power was calculated
for testing the difference in the mean changes of studied parameters
between the study and control groups at a level of significance of 0.05.
For a sample size of 15 in group 1 (Essential oil mouth rinse) and 15 in
Dentistry
ISSN: 2161-1122 Dentistry, an open access journal
Study procedures
Screening and selection of subjects was conducted by a single dental
experienced examiner (TQ). All subjects filled the study questionnaire
that included questions concerning the socio demographic information
of the subjects, dental history and medical history. Also they underwent
screening examination to assess the overall status of their dentition.
This was followed by a two week preparatory period during which
supragingival scaling and professional mechanical tooth cleaning was
done twice a week to remove all visible calculus, plaque, and extrinsic
tooth stain. The professional mechanical tooth cleaning was done using
abrasive paste with a brush or a rubber cup. In addition, subjects were
told to continue their usual mechanical home-care methods.
After completing the preparatory period, subjects were randomly
assigned, by tossing a coin, into two groups:
Group 1: Essential oil mouthrinse (Listerine antiseptic): 15 subjects
(7 males and 8 females) mean age of 28.07 ( 4.93) years;
Group 2: Water as a negative control: 15 subjects (6 males and 9
females) with mean age of 28.4 (6.12) years.
Approximately one week after the debridement visit, subjects
returned for baseline data collection (Week 0), which were collected in
the following order: Visible Plaque Index (VPI) [23], Sulcus bleeding
index (SBI) [24], Calculus Index (CI) [25], Tooth stain index (SI)
[26], - Le and Silness gingival index (GI) [27], and Probing depths in
millimeters (PD).
Prior to the beginning of this study, measurement reliability was
determined, based on examinations performed on 20 patients. Of the
replications, 98% were consistent for VPI, 94% were consistent for SBI
and 97% were consistent for CI, SI and percentage of sites with BOP, by
making two visits one week apart.
The two week preparatory period was followed by a four weeks
experimental period during which subjects were asked to rinse twice
with 20 ml of their respective mouthwash for 30 seconds (according
to the manufacturer instructions) as adjunct to their usual mechanical
home-care methods. Patients were instructed to perform regular oral
hygiene habits, i.e. twice-daily brushing by roll-on technique for a
minimum of 2 min, using a standard tooth brush (Colgate with soft
consistency bristles) and tooth paste (Colgate dental ) provided to
them during the preparatory and experimental periods. The type of
Listerine mouth rinse bottles that were provided to subjects were of
the Advanced Listerine with Tartar Protection- Arctic Mint one.
Subjects were also provided with toothbrushes and toothpastes to use
them during the preparatory and experimental periods. Compliance
of subjects was also assessed by measuring the residual volume of the
mouth rinse in the bottles.
At the end of the baseline visit, subjects received a randomlyassigned mouthwash. Subjects were instructed to brush as usual then
rinse their mouth with the assigned mouth wash daily. At Weeks 8,
measurements were retaken on the same teeth in the same order as
Week 0. Subjects were questioned about any changes in their medical
histories and whether they had experienced any side effects. If at the end
of the study a subject presented with any one or all of these-calculus,
stain, and BOP, an exit debridement was performed. All subjects were
Citation: Al Habashneh R, Qubain TG, Alsalman W, Khader Y (2014) The Effect of Listerine Mouthwash on Dental Plaque, Gingival Inflammation and
C - reactive protein (CRP). Dentistry 4: 191. doi:10.4172/2161-1122.1000191
Page 3 of 5
dismissed after finishing the trial and requested to return to their usual
oral health care professional for continuing care.
One examiner, who was blinded to the treatment assignments
and calibrated before the study began, collected the clinical data on all
subjects. All measurements were taken on six sites per tooth (mesialbuccal, buccal, distalbuccal, distal-lingual, lingual, and mesial-lingual)
on all teeth except third molars and teeth with crown and bridge
coverage. Scores were averaged per tooth then added together and
divided by number of teeth for the subjects full mouth score.
Water Group
D0
mean (SD)
mean (SD)
VPI
52.2 (11.6)
52.0 (15.3)
0.971
SBI
2.15 (0.4)
2.05 (0.41)
0.481
CI
0.0 (0.0)
0.0 (0.0)
SI
0.3 (0.8)
0.0 (0.0)
0.207
% BOP
68.3 (10.9)
61.5 (6.7)
0.047
C reactive protien
4.4 (8.04)
2.7 (3.3)
0.454
Clinical Parameters
p- value
Statistical analysis
Paired t-test was used to test the statistical significant difference of
change in dependant variables within each group between baseline and
at the end of the experimental period (28 days). Independent t-test was
used to test for the statistical significant difference of change in clinical
parameters between Listerine and water groups. A p-value of less than
0.05 was considered statistically significant.
Results
Baseline characteristics
This study included 15 subjects (7 males and 8 females) in Listerine
group and 15 subjects (7 males and 9 females) in water group. The mean
(SD) age was 28.07 (4.93) year for subjects in Listerine group and 28.4
(6.12) year in water group with no significant difference. At baseline,
there were no significant differences in the percentage of sites with
visible plaque, Sulcus Bleeding Index, Calculus Index, Stain Index, and
serum level of C-reactive protein (Table 1). However, percentage of sites
with bleeding on probing was significantly higher in the Listerine group.
Listerine Group
VPI (%)
SBI
D0
D 28
D28-D0
mean(SD)
mean(SD)
mean (SD)
52.2(11.6)
28.1(6.2)
-24.1(9.5)
2.2(0.4)
1.3(0.2)
-0.9(0.5)
Water Group
D0
D 28
D28-D0
mean(SD)
mean(SD)
mean(SD)
0.000
52.0(15.3)
52.5(14.4)
0.5(1.7)
0.309
0.000
2.0(0.4)
2.0(0.4)
0.0(0.1)
0.975
0.164
p-value
pvalue
CI
0.0(0.0)
0.3(0.5)
0.3(0.5)
0.041
0.0(0.0)
0.1(0.4)
0.1(0.4)
SI
0.3(0.8)
1.1(2.1)
0.9(2.0)
0.121
0.0(0.0)
0.0(0.0)
0.0(0.0)
--
68.3(10.9)
39.6(9.4)
-28.7(8.7)
0.000
61.5(6.7)
63.1(7.6)
1.5(1.8)
0.005
4.4(8.0)
4.0(9.1)
-0.4(2.7)
0.574
2.7(3.3)
2.0(3.3)
-0.7(1.1)
0.039
% BOP
CRP
SD= Standard Deviation, D0= Day 0, D28= Day 28, VPI=Visible Plaque Index, SBI= Sulcus Bleeding Index, CI= Calculus Index, SI= Stain Index, %BOP= Percentage of Sites
with Bleeding on Probing, CRP= Serum Level of C-Reactive Protein
Table 2: Mean values for all clinical parameters at the start and at the end of the experimental period and their mean difference.
Clinical Parameter
Listerine Group
(D28- D0)
Water Group
(D28- D0)
mean (SD)
mean (SD)
p- value
VPI
-24.1 (9.5)
0.5 (1.7)
0.000
SBI
-0.9 (0.5)
0.0 (0.1)
0.000
0.379
CI
0.3 (0.5)
0.1 (0.4)
SI
0.9 (2.03)
0.0 (0.0)
0.110
% BOP
-28.7 (8.7)
1.5 (1.8)
0.000
CRP
-0.4 (2.7)
-0.7 (1.1)
0.743
SD= Standard Deviation, D0= Day 0, D28= Day 28, VPI=Visible Plaque Index, SBI= Sulcus Bleeding Index, CI= Calculus Index, SI= Stain Index, %BOP= Percentage of Sites
with Bleeding on Probing, CRP= Serum Level of C-Reactive Protein
Table 3: Mean values for the difference in clinical parameters between day 0 and day 28.
Dentistry
ISSN: 2161-1122 Dentistry, an open access journal
Citation: Al Habashneh R, Qubain TG, Alsalman W, Khader Y (2014) The Effect of Listerine Mouthwash on Dental Plaque, Gingival Inflammation and
C - reactive protein (CRP). Dentistry 4: 191. doi:10.4172/2161-1122.1000191
Page 4 of 5
VPI with the use of Listerine mouth rinse (-24.1) compared with the
water group (0.5).
The stain index (SI) with Listerine group 0.9 ( 2.0) were little
higher than water group 0.0 (0.0). However, the difference was not
statistically significant (p=0.110).
Discussion
This randomized, placebo-controlled, single-blind study suggests
that Listerine is effective in the treatment of gingivitis, as evidenced
by the decreases in inflammatory signs. Subjects who participated in
this study presented with varying amounts of plaque, calculus and
gingivitis. These subjects were then involved in a two-week preparatory
period, during which scaling and polishing was performed twice. The
preparatory period was important in order to obtain realistic and
objective levels of plaque and gingival health, and it was followed by
a four-week experimental period during which subjects rinsed twice
daily with 20ml of their respective mouthwash (Listerine or water).
During both the experimental and the preparatory periods, all subjects
continued to practice their regular, self-performed and non-supervised
oral hygiene and they were provided with new toothbrushes and
identical dentifrice (toothpaste).
This study demonstrated that rinsing twice daily for 4 weeks with
Listerine mouth rinse as adjunct to mechanical home-care methods
resulted in significant reductions in plaque accumulation and gingivitis
levels. However, rinsing with Listerine did not significantly affect
calculus formation nor did it cause staining of the dentition. Moreover,
this is the first study conducted to investigate the effect of twice daily
rinsing with Listerine mouth rinse for a period of 4 weeks on the serum
level of C-reactive protein (CRP). Results showed that Listerine mouth
rinse slightly decreased the serum level of CRP but this decrease was
not statistically significant.
Visible Plaque Index (VPI) measures the percentage of sites
harboring visible plaque which gives an indication about the level of
plaque accumulation. This study showed a significant decrease in the
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ISSN: 2161-1122 Dentistry, an open access journal
Moreover, results of this study are in agreement with many longterm studies. For example Sharma et al. conducted a 6-month controlled
clinical trial comparing the antiplaque and antigingivitis effectiveness
of CHX and essential oil mouth rinses, during which subjects
continued their oral hygiene methods [29]. The study demonstrated
that essential oil and CHX mouth rinses possessed antiplaque property
[29]. Similarly, Gordon et al. performed a 9-month clinical trial (in
which subjects continued their oral hygiene methods) and showed that
Listerine significantly reduced the development of plaque at 1, 3, 6 and
9 months [31].
Sulcus Bleeding Index (SBI) is a measure of the level of gingivitis.
This study showed a significant reduction in the SBI in the Listerine
group (-0.9) compared with water group (0.0) which showed no change.
Although the guidelines of the American Dental Association on the
use of trials to measure gingivitis reduction insist on a period of at least
six months, studies of lesser duration have been conducted in spite of
the guidelines. Moreover, in most cases, the amount of plaque present
is assessed together with gingivitis [32].
Short-term studies have showed that Listerine could reduce plaque
compared with placebo but its ability to reduce gingivitis is not marked
[32]. For example, the two short-term studies conducted by Brecx et al.
showed that the gingival index scores were equal in Listerine, Meridol
and placebo groups, while in the CHX group the values were only half
those of other groups [27,28]. These two studies showed no effect of
Listerine mouth rinse on gingivitis, which may be due to the short
duration of the studies [33,34].
On the other hand, long-term studies have showed that Listerine
possessed an antigingivitis property. For example, in a 6-month
clinical trial conducted by Sharma et al. comparing the antiplaque
and antigingivitis effectiveness of CHX and Listerine mouth
rinses demonstrated that both mouth rinses possessed comparable
antigingivitis property [29]. This antigingivitis property was obvious
for CHX at both 3 and 6 months, while for Listerine it was obvious
only at 6 months [29]. Similarly, Gordon et al. showed that Listerine
mouthrinse significantly reduced the development of gingivitis at 9
months [25].
Calculus Index (CI) measures the amount of calculus accumulation
on the lingual surface of the lower anterior teeth. This study did not
show significant increase in calculus accumulation in the Listerine
group compared with water group. The 6-month controlled clinical trial
Citation: Al Habashneh R, Qubain TG, Alsalman W, Khader Y (2014) The Effect of Listerine Mouthwash on Dental Plaque, Gingival Inflammation and
C - reactive protein (CRP). Dentistry 4: 191. doi:10.4172/2161-1122.1000191
Page 5 of 5
Dentistry
ISSN: 2161-1122 Dentistry, an open access journal