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Comparative antiplaque and antigingivitis efficacy of a multipurpose

essential oil-containing mouthrinse and a cetylpyridinium chloride-
containing mouthrinse: A 6-month randomized...

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Q u i n t e s s e n c e I n t e r n at i o n a l

Comparative antiplaque and antigingivitis

efficacy of a multipurpose essential oil–containing
mouthrinse and a cetylpyridinium chloride–
containing mouthrinse: A 6-month randomized
clinical trial
Sheila Cavalca Cortelli, DDS, MS, PhD1/
José Roberto Cortelli, DDS, MS, PhD1/Mei-Miau Wu, Dr, PhD2/
Krista Simmons3/Christine Ann Charles, RDH4

Objective: This 6-month, examiner-blind, single-center, randomized, parallel group clinical

trial compared the antiplaque and antigingivitis effects of an essential oil–containing
mouthrinse with zinc chloride and sodium fluoride (EO) to a 0.05% cetylpyridinium chloride-
containing mouthrinse (CPC) also with fluoride. Method and Materials: Four hundred and
eight gingivitis subjects were monitored for the primary outcomes of modified Gingival
Index (MGI) and Plaque Index (PI) at baseline and 3 and 6 months. Subjects were
randomly assigned to 6-month twice a day unsupervised use of EO, CPC, or negative
control rinse in conjunction with normal brushing and flossing. Results: EO was always
better than CPC at 3 and 6 months considering all parameters. All benefits allowed by EO
increased from 3 to 6 months. CPC was better than the negative control at 3 and 6 months
with respect to whole mouth plaque, and the proportion of more severe sites (baseline
scores > 3) in PI and MGI. At 6 months, CPC did not differ from negative control in relation
to whole mouth MGI reduction, proximal MGI reduction, and percentages of sites improved
over baseline in PI and MGI. Conclusion: This new EO mouthrinse provided superior
clinical benefits to CPC and demonstrated increasing plaque and gingivitis reductions
over 6 months. Our findings support the regular long-term use of the EO mouthrinse and
selection over a 0.05% CPC rinse for better efficacy. (Quintessence Int 2012;43:e82–e94)

Key words: cetylpyridinium chloride, clinical trials, essential oil, gingivitis, mouthrinse

Oral biofilms have been related to the
development and severity of both gingivitis
1Associate Professor, Department of Periodontology, University
of Taubaté, SP, Brazil.
Associate Director, Biostatistics, Biometrics, and Clinical Data
2
Systems, Johnson & Johnson Consumer & Personal Products
Worldwide (Division of Johnson & Johnson Consumer
Companies), Morris Plains, New Jersey, USA.
Senior Clinical Research Associate; Clinical Research; New
3
Claims; Oral Care Research, Development, and Engineering,
Johnson & Johnson Consumer & Personal Products Worldwide
(Division of Johnson & Johnson Consumer Companies); Morris
Plains, New Jersey, USA.
Director, Scientific and Professional Affairs; Johnson & Johnson
4
and periodontitis. Therefore, oral biofilm
control plays a key role in prevention,
treatment, and decrease of recurrence of
periodontal diseases. Although this relation-
ship has long been recognized, appropriate
self-performed biofilm control still remains
an area with opportunity for improvement.
In general, patients fail in reaching the
required level of mechanical plaque con-
trol,1 and only a small percentage of the
total mouth area can be cleaned after
the use of dental floss and a toothbrush.2
In addition, due to increasing cosmetic
requirements, patients have been looking

Consumer & Personal Products Worldwide (Division of
Johnson & Johnson Consumer Companies); Oral Care Research,
Development, and Engineering, Morris Plains, New Jersey, USA.
Correspondence: Dr Sheila Cavalca Cortelli, Rua Professor
Nelson Freire Campelo, 343 – Jardim Eulália, Taubaté, São
Paulo, Brazil. Email: revistasobrape@unitau.br, cavalcacortelli@
uol.com.br
for multipurpose oral products that could
offer more than one benefit. In this context,
effective mouthrinses can be used as an
adjunct to mechanical plaque control. They
can partially fulfill oral care needs and
also help professionals recommend more

e82 VOLUME 43  •  NUMBER 7  •  JULY/AUGUST 2012


effective preventive oral care programs that
will contribute to better oral health.3
Essential oils (EO) and cetylpyridinium
chloride (CPC)–containing mouthrinses are
indicated for long-term regular daily use,
aiming at preventing and controlling biofilm
and gingivitis. Since they present the same
pattern of clinical use, comparative studies
can better support the choice for EO or CPC.
CPC is a quaternary ammonium com-
pound that has demonstrated plaque- and
gingivitis-reducing benefits when com-
pared with placebos.4 EO is a natural con-
centrated compound extracted from plants;
such natural agents have been the focus of
oral product research.5 A fixed combination
of four EO compounds (eucalyptol 0.092%,
menthol 0.042%, methyl salicylate 0.060%,
thymol 0.064%) has been tested. Besides
being a natural product, when compar-
ing this fixed combination of EO to other
agents (especially chlorhexidine), studies
showed little or no adverse effects (such as
tooth staining) for the product.6,7 A review
of published results also showed that there
are microbial8 and clinical4,9,10 benefits from
the use of this EO fixed combination com-
pared with a placebo. More importantly, EO
were shown to be superior compared with
other antiseptics such as triclosan,11 amine
fluoride/stannous fluoride,8,12 or even be
comparable to chlorhexidine. 8,13
However,
a systematic review14 of CPC-containing
mouthrinses supported a small additional
benefit in reducing plaque accumulation
and gingival inflammation provided by this
agent when used in combination with either
supervised or unsupervised oral hygiene.
Although statistically significant, these
differences could be clinically irrelevant.
Therefore, the question to be evaluated
is what degree of clinical relevance these
discrete statistically significant results will
provide. Systematic reviews of EO demon-
strated more consistent and robust results
compared with CPC.4,15,16 It is important
to emphasize that all presented literature
focused on the fixed combination of four
EO.
As mentioned before, in an attempt to
meet professional and consumer needs,
new products have been formulated provid-
ing multiple benefits and consumer value.
Thus, with the purpose of making this fixed
VOLUME 43  •  NUMBER 7  •  JULY/AUGUST 2012
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Cor telli et al
EO (eucalyptol, menthol, methyl salicylate,
and thymol) a multipurpose product, zinc
chloride and fluoride (sodium fluoride and
acidulated phosphate topical solution) were
added. These two specific agents were
chosen because of their well-recognized
benefits—fluoride being an agent for car-
ies control,17 and zinc chloride having an
anticalculus property when incorporated in
mouthrinses.18,19 An additional effect against
volatile sulphur compound–producing bac-
teria has also been demonstrated by zinc
chloride alone20 or in an EO mouthrinse.21
Based on the data presented, it seemed
reasonable to test two hypotheses. The
first was to see if the previous greater anti-
plaque and antigingivitis effects demon-
strated by the fixed combination of the four
EO in comparison to CPC are also provided
by the same four EO when combined with
zinc chloride and sodium fluoride in a new
mouthrinse formulation. And second was to
test if this new formula showed the same
pattern of progressive cumulative clinical
benefits. To test this new formula, a large
group of Brazilians was selected. The study
population was chosen considering that
literature has shown higher prevalence and
severity of gingivitis in developing countries
than in populations in developed coun-
tries.22,23
Therefore, the present longitudinal study
aimed at comparing the antiplaque and
antigingivitis potential of an EO-containing
mouthrinse plus zinc and fluoride with a
CPC-containing mouthrinse over a 6-month
period.
Method and Materials
Study design
It has been demonstrated that 6-month
daily use of the EO-containing mouth-
rinse provides greater antiplaque and
anti­
gingivitis efficacy than both a 0.05%
CPC-containing mouthrinse and a nega-
tive control. Therefore, we investigated the
efficacy of this EO rinse with added zinc
chloride and sodium fluoride (Listerine Total
Care, Johnson & Johnson) compared with a
0.05% CPC rinse (Plax Overnight, Colgate-
Palmolive) on the control of plaque and
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Q u i n t e s s e n c e I n t e r n at i o n a l
Cor telli et al
gingivitis. A flavored 5% hydroalcohol rinse
served as the negative control.
The candidates for this this 6-month,
examiner-blind, single-center, randomized,
parallel group study were individuals of both
sexes in good general health (no reported
chronic disease or diagnosed condition or
comorbidity) and good oral health (except
gingivitis), 18 years of age or older, with
at least 20 natural teeth showing scorable
facial and lingual surfaces. Individuals
attended a screening appointment in the
Dental Clinic of University of Taubaté, São
Paulo, Brazil, between November 2008 and
March 2009. Inclusion criteria for this study
were mean modified Gingival Index (MGI)
≥ 1.75 and mean Plaque Index (PI) ≥ 1.95.
Exclusion criteria were a diagnosis of peri-
odontitis or any type of gingival overgrowth;
subjects wearing orthodontic devices,
extended prosthetic fixed devices, remov-
able partial dentures, or having overhang-
ing restorations; pregnancy or lactation; a
history of sensitivity or suspected allergies
following use of oral hygiene products or
red food dye; serious medical conditions
(mainly chronic diseases requiring specific
treatments such as cancer, diabetes, renal,
and cardiovascular disorders); the use of
local or systemic antibiotics, anti-inflam-
matories, or anticoagulant therapy during
the month preceding the baseline exam; a
need for antibiotic prophylaxis; regular use
of chemotherapeutic antiplaque or antig-
ingivitis products such as triclosan-, EO-,
CPC-, or chlorhexidine-containing mouth-
rinses within the 2 weeks prior to baseline;
alcohol abuse; and unwillingness to return
for follow-up.
The planned sample size of 360 sub-
jects (120 per group) to complete the
study was based on previous 6-month stud-
ies.24–27 Based on estimates of mean values
and standard deviations from those stud-
ies, this sample size provided at least 80%
power to detect a 10% difference in mean
PI and 90% power to detect a 5% difference
in mean SGI between the EO-containing
mouthrinse and the CPC-containing mouth-
rinse. We included 48 additional subjects
to account for the estimated dropout. Four
hundred and eight generally healthy sub-
jects who met the required criteria were
enrolled in this clinical trial.
e84 VOLUME 43  •  NUMBER 7  •  JULY/AUGUST 2012
Data and personal information relat-
ed to the medical and dental histories
were obtained by interview. According to
a Brazilian governmental institute, ethnic-
ity was evaluated through a self-reporting
color of skin (www.ibge.com.br) form.28
All subjects signed an informed consent
form, which was previously reviewed and
approved by the Committee on Research
Involving Human Subjects (protocol num-
ber 295/08) from the University of Taubaté.
The present study was performed accord-
ing to the World Medical Association
Declaration of Helsinki and the Brazilian
National Resolution 196/96.
Clinical procedures
A complete oral examination was car-
ried out at baseline and 3 and 6 months.
Measurements of MGI29 and PI,30 were
obtained by one blinded, trained, and cali-
brated examiner at four and six sites,31
per tooth, respectively. The examiner was
considered calibrated if Kappa values were
> .80 and < .95. Intra-examiner error was
recalculated 1 week prior to the evaluation
in the third and sixth month, and throughout
the study Kappa values remained between
> .82 and < .95.
At baseline, the prescreened subjects,
having refrained from oral hygiene for at
least 8 hours, but no more than 18 hours,
attended an appointment at the clinical
site for general oral examination and gin-
givitis and plaque assessments. Qualified
subjects were randomized to treatment;
received complete dental prophylaxis (con-
firmed by the use of disclosing solution) to
remove plaque, stain(s), and calculus; and
were instructed in their assigned treatment
and rinsed under supervision. The three
treatment groups were: twice a day rinsing
with 20 mL of EO mouthrinse (eucalyptol
0.092%, menthol 0.042%, methyl salicy-
late 0.060%, thymol 0.064%, zinc chloride,
sodium fluoride 0.0221%) for 30 seconds;
20 mL of CPC mouthrinse (0.05% cetyl-
pyridinium chloride) for 60 seconds (CPC)
(both used according to marketed labeled
directions); or 20 mL of a 5% hydroalco-
hol negative control rinse for 30 seconds.
Toothbrushes and fluoride toothpaste were
provided to all subjects as needed. The
first treatment rinse was performed at the

clinical site under supervision, while all
other rinses were unsupervised. Subjects
were instructed to brush and rinse each
morning and night. At the 3- and 6-month
visits, subjects had refrained from using
their assigned mouthrinses for at least 8
hours (to avoid potential examiner bias from
the odor of the mouthwash formulations),
but no more than 18 hours, prior to their
clinical examinations. For each examina-
tion visit after baseline, a visit window of
± 14 days was accepted. Qualified sub-
jects were assigned product sequentially,
in ascending numerical order, according
to a block randomization with a fixed block
size of six. The randomization scheme
was generated by a validated SAS-based
randomization application developed by
the sponsor. Neither the clinical examiner
nor the recorder had access to the treat-
ment code. One researcher allocated the
next available numbered bottle upon the
subject’s entry into the trial. The bottles of
mouthrinses were overwrapped with new
labels numbered with the randomization
code and rinsing directions, but no other
identifying information, to maintain blind-
ness. The negative control was packaged
identically to one of the test products.
Personnel dispensing study mouthrinses
or supervising their use were not involved
in examination of the subjects to minimize
potential bias. Besides dispenser person-
nel, other researchers that had any contact
with participants were blinded to treatment
assignment for the duration of the study and
completion of statistical analysis.
Subjects were allowed to use interdental
cleaning devices to remove impacted food
between the teeth and continued using
interdental cleaning device(s) regularly if it
was part of their regular oral care regimen.
Each month, the clinical test site dis-
pensed the assigned mouthrinse for sub-
jects’ daily home use. Compliance was
evaluated at each visit by reviewing the per-
sonal diary card, used to document each
brushing and rinsing time; and by weighing
residual volumes of returned mouthrinse
bottles. Any adverse events were recorded.
In addition, the oral examination was con-
ducted at baseline and at 3 and 6 months to
monitor the effect of the mouthrinse formula-
tions on soft and hard tissue.
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Subjects were not allowed to have rou-
tine dental care during the course of the
study, such as dental prophylaxis or whiten-
ing, but could have emergency dental care
if needed.
Statistical analysis
Demographic and baseline characteristics
were compared across treatment groups
using analysis of variance (ANOVA) or a chi-
square test (as appropriate for the type of
data being considered). When the expected
number of subjects within a category was
sufficiently small, the Fisher exact test was
used in place of the chi-square test.
To evaluate efficacy, the primary end-
points were mean MGI and mean PI at 6
months after baseline. These same mean
indices when measured at 3 months were
defined as secondary endpoints. Additional
endpoints were conducted post hoc: the
severity index (defined as the proportion of
sites with scores ≥ 3 for both plaque and gin-
givitis) and the percentage of sites showing
improvement in both plaque and gingivitis.
Comparisons for primary and secondary
endpoints were based on a one-way analy-
sis of covariance (ANCOVA) model with
mouthrinse treatment as a factor and the cor-
responding baseline value as a covariate.
EO-containing mouthrinse, CPC-containing
mouthrinse, and control mouthrinse were
tested following pairwise comparisons. To
compare the EO-containing mouthrinse with
the 0.05% CPC-containing mouthrinse, it
was required that the EO-containing mouth-
rinse was statistically significantly better than
the negative control with respect to both PI
and MGI. For evaluating the EO-containing
mouthrinse vs the CPC-containing mouth-
rinse, statistical comparisons for PI and MGI
were based on a stepwise procedure start-
ing with PI. Each comparison was tested at
the two-sided .05 level.
The primary analysis was based on data
from intent-to-treat (ITT) subjects, defined
as all randomized subjects who used at
least one dose of study mouthrinse and
had baseline and at least one postbaseline
PI or MGI assessment. Secondary analy-
sis was based on data from per protocol
subjects, defined as ITT subjects with no
major protocol violations. Analyses were
performed using the ANCOVA model. All
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Q u i n t e s s e n c e I n t e r n at i o n a l
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Table 1 Demographics and baseline whole mouth mean values for PI and MGI

Treatment mouthrinses
Variables Negative control CPC EO Total Overall
n 136 136 136 408 .225*
Sex
 Men 56 52 58 166 .752**
 Women 80 84 78 242
Race
 White 117 112 115 344 .343***
  Black 5 4 10 19
 Asian 1 1 1 3
 Other 13 19 10 42
Smoker
 Yes 8 10 14 32 .387**
  No 128 126 122 376
PI 3.01 ± 0.34 3.01 ± 0.33 2.94 ± 0.33 2.99 ± 0.33 .099*
MGI 2.20 ± 0.15 2.21 ± 0.15 2.19 ± 0.16 2.20 ± 0.15 0.336*

n, number of subjects; SD, standard deviation; §other, native, mestizo; *ANOVA model with term for treatment;
** chi-square test; *** Fisher exact test.

statistical analysis was performed using
SAS 9.1 (SAS).
The post hoc analysis of the severity index
utilized the ANCOVA model with the treatment
as a factor and the corresponding baseline
value as the covariate. The percentage of
sites improved from baseline was analyzed
using the ANOVA model, having the treat-
ment as a factor. The comparisons were
tested at the .05 level, two-sided.
Results
Table 1 shows demographics and baseline
characteristics for all randomized subjects
with no differences among groups.
Figure 1 shows the flow of participants
throughout the study conducted from March
2009 to September 2009. Successfully
treated subjects were those who completed
at least 3 months of experimental period as
clinical benefits could only be measured
after a 3-month regular daily use of the
tested products. A total of 392 participants
who had at least one posttreatment exami-
nation of either plaque or gingival index
were included in the ITT analysis. Since
there were no major protocol violations, the
ITT subjects were also the per protocol sub-
jects; thus, one set of results are reported
below.
Of 408 volunteers, 385 completed the
study. There were 16 dropouts from base-
line to 3 months and 7 dropouts between 3
and 6 months. These 23 subjects dropped
out of the study for different reasons, mainly
due to “lost to follow-up” or “no longer
willing to participate in the study.” Most
dropouts occurred during the first month
(n = 11).
Low percentages of volunteers showed
at least one adverse event that could be
related to mouthrinse use (7 subjects in
the negative control group [5.1%], 7 in the
CPC group [5.1%], and 5 subjects in the
EO group [3.7%]). They reported adverse
events such as sensitivity of teeth (negative
control [n = 1], CPC [n = 2], and EO [n = 0]),
mouth ulceration (negative control [n = 2],
CPC [n = 0], and EO [n = 0]), glossodynia
(negative control [n = 4], CPC [n = 3], and
EO [n = 1]), dyspepsia (negative control
[n = 0], CPC [n = 0], and EO [n = 1]),
dysgeusia (negative control [n = 0], CPC
[n = 2], and EO [n = 2]), and oral discomfort
(negative control [n = 0], CPC [n = 1], and
EO [n = 2]).

e86 VOLUME 43  •  NUMBER 7  •  JULY/AUGUST 2012


Fig 1    Flow diagram of the progress through the phases of this randomized clinical trial.
In regard to plaque, at 3 and 6 months,
the EO-containing mouthrinse was supe-
rior to both negative control and CPC.
The CPC-containing mouthrinse was more
effective than the negative control (Table 2).
However, at 6 months (4.2% of reduction),
the CPC group was somewhat less effective
than at 3 months (7.6% of reduction) when
VOLUME 43  •  NUMBER 7  •  JULY/AUGUST 2012
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Cor telli et al
compared to the negative control. In con-
trast, compared with CPC, EO reductions
increased over time with 13.6% at 3 months
and 23.6% at 6 months. When comparing
EO with the negative control, reductions
observed represented 20.2% at 3 months
and 26.7% at 6 months.
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Q u i n t e s s e n c e I n t e r n at i o n a l
Cor telli et al

Table 2 Comparative analysis among mouthrinses at baseline and at 3 and

6 months regarding whole mouth plaque index (PI) and modified
Gingival Index (MGI)

Time Clinical variables Negative control CPC EO

Baseline PI 3.01 ± 0.34 3.01 ± 0.33 2.93 ± 0.33
MGI 2.20 ± 0.15 2.22 ± 0.14 2.19 ± 0.15
3 mo PI 2.67 ± 0.02 2.47 ± 0.02* 2.13 ± 0.02†
MGI 2.03 ± 0.01 1.96 ± 0.01* 1.85 ± 0.01†
6 mo PI 2.61 ± 0.03 2.51 ± 0.03* 1.92 ± 0.03†
MGI 2.16 ± 0.02 2.13 ± 0.02 1.71 ± 0.02†

^n = 127, 131, and 127 at 6 mo for negative control CPC, and EO, respectively.
*indicates difference in comparison to negative control, †indicates difference in comparison to CPC (P < .05).
Pairwise comparisons were based on ANCOVA model with term for treatment group and parameter baseline value
as covariate.

Table 3 Comparisons among mouthrinse groups regarding proximal PI and

MGI at 3 and 6 months

Time Interproximal sites Negative control CPC EO

Baseline PI 3.21 ± 0.3 3.21 ± 0.36 3.14 ± 0.3
MGI 2.35 ± 0.17 2.36 ± 0.15 2.34 ± 0.17
3 mo PI 2.86 ± 0.02 2.64 ± 0.02* 2.28 ± 0.02†
MGI 2.16 ± 0.01 2.11 ± 0.01* 2.02 ± 0.01†
6 mo PI 2.77 ± 0.03 2.67 ± 0.03* 2.04 ± 0.03†
MGI 2.33 ± 0.02 2.29 ± 0.0 1.87 ± 0.02†

^n = 127, 131, and 127 at 6 months for negative control, CPC, and EO, respectively.
*indicates difference in comparison to negative control; †indicates difference in comparison to CPC (P < .05).
Pairwise comparisons were based on ANCOVA model with term for treatment group and parameter baseline value
as covariate.

When considering gingivitis, CPC pro-
vided a statistically significant difference
from negative control at 3 months (3.5%).
However, CPC at 6 months (1.7%) was
not statistically significantly different from
the negative control. EO demonstrated an
8.8% reduction at 3 months and 20.9%
at 6 months vs control. EO provided a
19.5% reduction vs CPC at 6 months.
Comparisons among groups at each time of
evaluation are shown in Table 2.
Interestingly, proximal results for both
plaque and gingivitis were similar to the
whole mouth. CPC was more effective than
the negative control, except for MGI at
6 months (Table 3). EO was superior to
both negative control and CPC at 3 and
6 months. Again, at 6 months, CPC pro-
vided no additional benefit in comparison to
negative control; while the EO rinse showed
progressive reductions in PI and MGI from
3 to 6 months.
We also looked at the severity index, the
proportion of sites with plaque and gingivitis
scores ≥ 3, reflecting moderate inflamma-
tion and moderate to severe plaque scores
(Table 4). CPC was effective vs negative
control at 3 and 6 months in reducing sites
with more severe plaque or gingivitis (Table
4). EO was superior to negative control and
to CPC at 3 and 6 months.
For plaque, nearly 70% of sites in the
CPC group were scored ≥ 3 at baseline.
After 6 months of treatment, over half (0.53

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Cor telli et al

Table 4 Comparisons among mouthrinse groups regarding plaque severity index

and gingivitis severity index at 3 and 6 months

Time Severity index Negative control CPC EO

Baseline PI 0.68 ± 0.16 0.70 ± 0.16 0.66 ± 0.16
MGI 0.26 ± 0.13 0.27 ± 0.12 0.25 ± 0.13
3 mo PI 0.58 ± 0.01 0.45 ± 0.01* 0.25 ± 0.01†
MGI 0.11 ± 0.01 0.08 ± 0.01* 0.05 ± 0.01†
6 mo PI 0.53 ± 0.02 0.47 ± 0.02* 0.19 ± 0.02†
MGI 0.23 ± 0.01 0.20 ± 0.01* 0.05 ± 0.01†

^n = 127, 131, and 127 at 6 months for negative control CPC, and EO, respectively.

*indicates difference in comparison to negative control; †indicates difference in comparison to CPC (P < .05).
Pairwise comparisons were based on ANCOVA model with term for treatment group and parameter baseline value
as covariate.

Table 5 Comparisons among mouthrinse groups regarding percentage of sites

improved from baseline in PI and MGI at 3 and 6 months

Time % sites Negative control CPC EO

3 mo PI 41.5 ± 1.34 50.9 ± 1.35* 62.2 ± 1.37†
MGI 24.8 ± 1.07 29.8 ± 1.08* 36.0 ± 1.09†
6 mo PI 45.2 ± 1.55 49.2 ± 1.52 69.8 ± 1.55†
MGI 20.3 ± 1.16 22.0 ± 1.14 46.9 ± 1.16†

^n = 127, 131, and 127 at 6 months for negative control CPC, and EO, respectively.
*indicates difference in comparison to negative control; †indicates difference in comparison to CPC (P < .05).
Pairwise comparisons were based on ANOVA model with term for treatment group.
% sites improved is the percent of sites, per subject, improved over baseline.

in proportion) of the sites in the nega-
tive control group remained 3 or higher.
Subjects treated with CPC rinse had statis-
tically significantly fewer sites ≥ 3 than the
negative control; however, the proportion of
such sites was nearly half after treatment
(0.45 at 3 months and 0.47 at 6 months).
For subjects treated with EO, the propor-
tion of plaque sites ≥ 3 reduced to 0.25 at
3 months and less than one-fifth (0.19) at
6 months, significantly smaller than nega-
tive control and CPC.
For gingivitis, about a quarter (0.25 in pro-
portion) of the sites were moderate or severe
(≥ 3) at the study entry. With treatment,
the proportion of moderate to severe sites
(≥ 3) in control and CPC groups reduced to
about 10% at 3 months but bounced back
to about 0.20 proportions after 6 months.
The CPC group was a little lower than the
negative control, and the comparison was
statistically significant at both time points.
The proportion of more severe sites in the
EO group reduced to 5% after 3 months and
maintained the same magnitude through
6 months. Compared with negative control
and CPC, EO was statistically significantly
superior at 3 and 6 months.
An additional ITT analysis was per-
formed on the percentage of sites show-
ing PI and MGI improvements from
baseline (Table 5). At the 6-month evalua-
tion, the percentage of sites that improved
regarding PI and MGI did not statistically

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Q u i n t e s s e n c e I n t e r n at i o n a l
Cor telli et al
differ between CPC and negative control.
In contrast, the EO group exhibited sig-
nificantly more improved sites than negative
control and CPC with respect to PI and MGI
at both time points.
Discussion
The search for a healthy mouth is not new.
To provide clean and white teeth, fresh
breath, and healthy gums, different proce-
dures, devices, products, and techniques
have been tested worldwide. Since bacte-
rial plaque was recognized as a biofilm
related to the occurrence of oral diseases,
dentistry has been looking for treatment
approaches and products presenting sci-
entific evidence of its properties against
biofilms and good clinical results.
Although oral biofilm control represents
a key point for prevention, treatment, and
decrease of recurrence of periodontal dis-
eases, the appropriate self-performed bio-
film control is not easily reached. Despite
the use of different strategies, patients still
fail to comply with the rules of the treatment
for many reasons.32,33 In addition, changes
in lifestyle such as diet habits, work over-
load, and lack of physical activity have
made people more susceptible to different
systemic conditions such as obesity, which
seems to make people more vulnerable to
gum disease.34 Therefore, patients and pro-
fessionals have been looking for multipur-
pose oral products that could help in having
a healthier mouth. This aim is reinforced by
the concept that an unhealthy mouth could
negatively impact the health of the body35
and that periodontal status could impact
quality of life.
36
The present research protocol was des-
ignated as single-blinded because although
the bottles of mouthrinses were overwrapped
with new labels and numbered with the ran-
domization code and rinsing directions, it
is impossible to assure that all participants
could not identify the commercially available
test mouthrinses by taste and/or shape of
the bottles. However, it is also relevant to
remember that negative control was pack-
aged identically to one of the test products.
e90 VOLUME 43  •  NUMBER 7  •  JULY/AUGUST 2012
This 6-month longitudinal study com-
pared two long-term regular daily use
mouthrinses having a hydroalcohol solution
as a negative control. A positive control rinse
was not selected. Although widely applied,
chlorhexidine was not selected as a posi-
tive control based on its different pattern of
clinical usage (ie, short-term prescription).
Therefore, considering the gingival status of
the study population and the specific aims
of the research, the inclusion of a negative
control can be considered enough to con-
firm the effects of CPC mouthrinse and to
first demonstrate the effects of the new EO
combination mouthrinse.
Antiplaque and antigingivitis properties
were significantly demonstrated by the new
multipurpose EO plus fluoride and zinc-
containing mouthrinse in comparison to the
CPC mouthrinse and to the negative control.
The low percentage of dropouts as well
as the analysis of the rinsed volume revealed
a good adherence to the protocol. However,
it should be kept in mind that in the present
study participants performed twice daily
unsupervised rinses and that personnel dia-
ries can offer limited information. Actually,
reaching an appropriate degree of par-
ticipant compliance with oral care regimens
seems to be difficult even when considering
the use of mouthrinses.37 However, compli-
ance could influence the expected clinical
outcomes from oral treatments.
In addition, the tested mouthrinses were
tolerated well by participants. Moreover,
good acceptance becomes more evi-
dent when the fact that the majority of the
study population consisted of nonusers
or nonregular users of mouthrinses. Good
acceptance of mouthrinses could be seen
as beneficial to patients, since literature
reviews37 have supported the conclusion
that they are safe to be used as part of a
daily oral care regimen.
The literature has also demonstrated
that gingivitis patients could benefit from
the regular use of an EO mouthrinse, mainly
studies that adopted similar periodontal
inclusion criteria.10,24,27,38 Our baseline PI
and MGI values were around 3 and 2.2,
respectively. Interestingly, this study popu-
lation with a similar pattern of gingival
disease also benefited from the use of the
EO, zinc, and fluoride mouthrinse, reach-

ing comparable ranges of clinical indi-
ces reductions observed in different study
designs.11,12,13,16,38 Because this new formula
was tested among mild to moderate gin-
givitis patients, the external validity of the
observed findings still needs to be inves-
tigated. Therefore, future studies should
be performed with patients under different
periodontal statuses.
In general, the group that rinsed with
the EO combination product showed lower
mean plaque values than participants who
rinsed with CPC or negative control at 3
and 6 months. A relatively similar pattern
was observed when gingivitis was consid-
ered. However, in the sixth month, CPC
was somewhat less effective in controlling
gingivitis than in the third month. Therefore,
CPC was better than brushing alone, pro-
vided some additional clinical benefits, and
was more effective in reducing plaque than
in reducing gingivitis. The present results
corroborate data previously reported, which
showed that CPC demonstrated antiplaque
and antigingivitis properties.39,40 In addition,
the findings of the present study confirm the
small clinical benefit in terms of plaque and
gingivitis control suggested by a systematic
review of CPC-containing mouthrinses.14
The superiority of EO over CPC was
previously observed using an experi-
mental gingivitis model.10 Although this
superiority had been reported by other
systematic reviews,4,15,16 data about the new
formula had not been available before the
present research. Moreover, the progres-
sive decrease in plaque and gingivitis fol-
lowing this EO rinse provided additional
evidence for its long-term regular use and
confirmed the results of a previous short-
term clinical trial.10
Interestingly, superiority of EO over CPC
and negative control was also observed in
proximal dental sites. These findings are
clinically relevant since proximal sites are
traditionally considered of limited access
and more susceptible to periodontal dis-
ease. Based on previously reported data
about clinical parameters for proximal
sites,27 one could assume that the use of
EO could be beneficial to those who com-
bine its use with brushing and flossing.
Additionally, it could be perhaps presumed
that regular use of products containing the
VOLUME 43  •  NUMBER 7  •  JULY/AUGUST 2012
Q u i n t e s s e n c e I n t e r n at i o n a l
Cor telli et al
fixed combination of EO could overcome
deficiencies of dental floss users or even
provide a benefit for nonregular dental floss
users. Data supporting this possibility has
been shown in different systematic reviews
and studies15,25,41 that compared the effects
of the use of flossing or EO mouthrinses
alone with the combination of both in proxi-
mal sites. Indices values showed that EO
resulted in more evident plaque reductions
compared with either control rinse or floss-
ing. EO were also compared with dental
floss in their abilities to reduce proximal
gingivitis and plaque.25 Considering proxi-
mal plaque reductions, EO were better than
negative control at 3 and at 6 months, while
dental floss was superior to control only
in the third month.25 Results from a short-
term study reinforced that in combination
with toothbrushing, long-term daily use of
mouthrinses may result in a higher proximal
plaque reduction than daily flossing.41
Based on the cited findings, it can
be speculated that the general population
could experience the same degree of dif-
ficulty as volunteers in clinical trials who
seem to, in the long-term, find rinsing sim-
pler than flossing.42 Professionals need to
determine for which patients proper flossing
could be considered an achievable target.43
Unfortunately, a social cognitive approach
applied to 39 patients revealed very little
intention to floss in spite of the observed
positive intention to brush.44 Therefore, in
the future, these proximal effects should
be evaluated in different populations.
Moreover, the overall reductions in plaque
and oral inflammatory levels could, after
a few months, impact more specific oral
sites such as the proximal ones. However,
it is most important to remember that for
patients who brush and floss on a daily
basis, the benefits provided by the EO rinse
would be even better.27
Different relevant findings are related
to severity of plaque accumulation and
gingival inflammation. For plaque, about
70% of the sites were moderate or severe
(≥ 3) at baseline, while for gingivitis this
proportion was around 25%. Again, in gen-
eral, CPC was more effective in reducing
sites with more severe plaque or gingivitis
than negative control at 3 and 6 months.
Similar results were reported by a group
e91
Q u i n t e s s e n c e I n t e r n at i o n a l
Cor telli et al
who found greater reductions provided
by CPC than those provided by control
in reducing plaque and gingivitis sever-
ity indices scores after 6 weeks of rinse
use.45 However, the EO mouthrinse was
still superior to negative control and CPC at
both time points. Actually, in the EO group,
19% presented moderate or severe plaque
scores at 6 months. For gingivitis, however,
the reduction from baseline to 3 months
in the severe sites was not sustained until
6 months considering CPC and control
groups. On the other hand, the propor-
tion of more severe sites in the EO group
were reduced to 5% after 3 months and
maintained the same magnitude through
6 months. Since after baseline examina-
tion, a complete dental prophylaxis was
performed, it could be speculated that
reductions observed in the third month
derived more from the prophylaxis than
from the CPC and control use. However, in
the EO group, the product seemed to have
contributed to maintaining the postbaseline
provided reductions. It is interesting to note
that in a short-term study conducted to test
the effectiveness of the combined use of
amine fluoride/stannous fluoride–containing
toothpaste and mouthrinse, the baseline
level of gingival inflammation influenced
gingivitis reductions.46
In populations with high levels of gingi-
vitis, the regular use of mouthrinses as part
of the daily oral care could represent an
easy tool in controlling biofilm and gingival
plaque–related diseases. Considering the
overall percentages of reduction of plaque
and gingivitis found,4,7,47 we could establish
a range of reduction for EO. For plaque, this
range was 20.0% to 69.7%, while for gingivi-
tis it was 11.1% to 36.3%. Therefore, based
on the fact that the results from the present
study, after a long-term use of EO plus zinc
and fluoride, were also within theses ranges
of reduction, it was inferred that the addition
of zinc and fluoride did not disturb the tra-
ditional clinical effects provided by formulas
containing the standard combination of the
4 EO. Similarly, EO seemed to contribute to
treating gingivitis (from baseline to the third
month) and to inhibit gingivitis development
(from the third to the sixth month).
Confirming the proposed null hypoth-
esis, the results from the present study
e92 VOLUME 43  •  NUMBER 7  •  JULY/AUGUST 2012
showed a greater antiplaque and anti-
gingivitis efficacy demonstrated by the EO
mouthrinse in comparison to CPC and the
negative control when used in combina-
tion with unsupervised brushing. Together,
these findings confirmed the superiority of
EO products over 0.05% CPC products.
The results provided by this new multi-
purpose EO were similar to the range of
previously reported results for an EO rinse.
Although more discrete, the results of the
present study also confirmed the antiplaque
and antigingivitis properties related to CPC
mouthrinse. Although the 0.05% CPC was
better than mechanical plaque control
alone, especially for a short period of time,
the regular long-term use was supported
only for EO, since the progressive clinical
benefits were not observed in the other two
groups. Therefore, these findings confirmed
our second tested hypothesis.
The findings of the present study sug-
gest that mouthrinses containing a fixed
combination of EO is the first choice for
regular daily use, because of the evident
clinical benefits observed over 6 months.
Acknowledgment
Financial support for this study was provided by
Johnson & Johnson Consumer & Personal Products
Worldwide (Division of Johnson & Johnson Consumer
Companies). This study was designed by Johnson &
Johnson Consumer & Personal Products Worldwide
(Division of Johnson & Johnson Consumer Companies)
and conducted by University of Taubaté staff.
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