Effect of Different Mouthwashes and Text Messages on Plaque Accumulation for Dental Students

Aims: Study and compare the effectiveness of different mouthwashes on dental plaque and assess the efficiency of text messages on the response of participants. Materials and Methods: The study was approved by Research Ethics Committee board (University of Mosul, College of Dentistry, REC reference No. POP/R.10/1/21). The Participants were (88) dental students, aged between 18 to 25 years (44 males and 44 females). Students with mild to moderate gingivitis were randomly divided into four groups, 22Participants for each. In Group A, participants were advised kin gingival mouthwash, Group B participants used Wisdom daily gum health mouthwash, Group C participants were given LACALUT aktiv, and KIN B5Gums was given to Group D. The subjects were advised to use 10ml of mouthwash for 30seconds, twice a day, not immediately after tooth brushing (at least5 minutes after tooth brushing), for 14days. Half of the students in all groups (44students) were motivated on regular intervals by personal text messages, to use mouthwash on regular basis. The parameter was recorded for Plaque index (TQHPI) at day 0 and14. Results: The reduction in dental plaque is highly significant on day 14(T1) compared to baseline values (T0). There are highly significant differences among the four types of mouthwashes used on the reduction of dental plaque. Mouthwash in Group C and D were significantly more effective than Group A and B. Mouthwash in Group A was significantly more effective than mouthwash in Group B. Group C mouthwash did not differ significantly from Group D nor Group A mouthwash in plaque build-up reduction. Conclusions: The four mouthwashes used has good efficacy in reducing dental plaque and there were differences in efficiency between them. KIN B5Gums and LACALUT aktiv mouthwashes were the most effective. Wisdom daily gum mouthwash was the least effective.


INTRODUCTION
The mouth is the mirror of the body and therefore the health of the mouth has been closely related to systemic health.
Periodontal disease is one of the most frequent oral diseases in the world (1) .Gingivitis, the mildest sort of periodontal disease, is caused by the dental plaque that accumulates on teeth nearby the gingiva (2) . A direct relationship has been verified between dental plaque levels and the severity of gingivitis (3) .
Although mechanical plaque control may effectively prevent gingivitis if carefully applied, the wide distribution of gingivitis presented in the general population shows that additional measures can prove beneficial. Chemotherapeutic agents have been suggested to be useful adjuncts to the daily oral home care within the control of dental plaque and gingivitis (1) . A number of chemical agents are advocated like fluorides, Chlorhexidine, quaternary ammonium compounds (Cetylpyridinium chloride), essential oils, triclosan and sanguinarine, which are either available like a toothpaste/dentifrice or as mouthwash (mouthwash). Among these, chlorhexidine gluconate is considered as the gold standard in dentistry for the prevention of bacterial plaque (3) . Mouthwashes containing chlorhexidine are usually available over the counter (4) . Chlorhexidine mouthwash is very effective but has certain side effects as brown discoloration in the teeth, bitter taste and oral mucosal erosion (5) .Text messages are relatively inexpensive, easily modified, sent directly to individuals, and a part of many individuals' daily life. Many studies utilize text messages as a reminder to help improve health care services (6) .
Despite of the popularity of the antimicrobial agents usually found in markets, there is little information about their efficacy on the control of bacterial plaque.
Therefore, this study is to gather information about the efficacy of the commonly available antimicrobial agents used to prevent dental plaque accumulation. Furthermore, to help the clinicians to select of the most effective plaque-preventing mouthwash when different products are existing.

Study design
This study was a parallel, singleblinded, randomized comparative clinical study. The study was conducted during the periods 2019-2020 at Dental College of Mosul University.

Subjects and materials used
The participants, dental students were selected from the age group 18 to 25 years (7)

Inclusion and exclusion criteria
To be eligible for the study the subsequent inclusion and exclusion criteria were applied :

Inclusion criteria:
Students with no systemic disease, who gave an informed consent, agreement to delay any elective dental treatment as oral prophylaxis, and agreement to fulfill the study visits was included within the study.
The ages of the students are between 18 to 25 years having mild to moderate gingivitis was defined by gingival index score between 0.1-2.0 (by Loe and Silness will record), plaque index of 1 or more (by Turesky-Gilmore-Glickman modification of Quigley Hein plaque index) was included in this study.

Exclusion criteria:
Uncooperative students, students with severe mal-alignment of teeth, orthodontic appliances, removable partial dentures; students already using mouthwash, tobacco consumers, or having smoke or hookah.
Students with any medical or pharmacological history that may compromise the conduct of the study were excluded.

Sample size and randomization
The sample size was defined in 22 students for each group (11males and 11 females) to possess a two-sided five percent (5%) significance level and a power of eighty percent (80%), so given an anticipated dropout rate of 10% (7) .

Plaque index
Plaque was scored using Turesky-

Gilmore-Glickman modification of
Quigley-Hein plaque (TQHPI) (8) , With the TQHPI, facial and lingual non restored surfaces of all the teeth except third molars were scored after using disclosing agents, and The Scoring was as follows: Plaque covering at least one-third but less than two-thirds of the crown of the tooth 5 Plaque covering two-thirds or more of the crown of the tooth

Periodontal clinical examination
The clinical examination was done in sequence to examine at least 5 to 6 students daily until reaching the required sample size. The Turesky-Gilmore-Glickman modification of Quigley-Hein plaque index was recorded at 0 then 14 days and all records were maintained on a record chart. Before the baseline examination, the students were refrained from conducting oral hygiene for at least eight hours, but no more than 18 hours (9) and also from eating, drinking in these period. These text messages were made every day to half of the students in each group (11 students).

Final examination (T1)
Compliance was checked with the help of a reminder sheet to be filled by the students daily after using the mouthwash to note down the time at which they rinse on.
These compliance sheets were checked by the investigator during subsequent examinations (T1). At the end of the study, the participants were asked to return their

DISCUSSION
The primary outcome observed in this study is the reduction in the dental plaque after use of the mouthwashes. The reduction in the dental plaque is highly signifi- Gram-negative, fungi and yeast (10) . A study carried out by Van Strydonck et al. (11) , showed that Chlorhexidine mouth-  (12) concluded that CPC containing mouthwashes, when used as adjuncts to oral hygiene (tooth brushing), provide significant additional benefit in reducing dental plaque accumulation. The Statistical test was analyzed post treatment scores for plaque; Turesky-

Gilmore-Glickman modification of
Quigley-Hein plaque index (TQHPI), and the result revealed no significant differences on plaque reduction between two groups as showed in Table (4). This may be due to confirmed oral hygiene instructions given to all participants to utilize the mouthwashes twice daily and also may be due to that the participants are dental students who are educated and awareness of adherence to treatments. And also repeated daily messages may be tolerated by participants so that no significant differences present between the two study groups.

Conclusions
In this study, all four mouthrinses used had good clinical efficacy in reducing dental plaque when utilized alongside tooth brushing with toothpaste. Mouthwashes lacalut Activ and KIN B5 appeared to provide similar plaque inhibitory action. lacalut Activ mouthwash did not differ significantly from KIN B5 mouthwash nor kin gingival mouthwash in plaque build-up reduction. Wisdom daily gum mouthwash was the least effective in reducing dental plaque among the four mouthwashes used in this study. This study showed no difference between text message and without text message groups regarding plaque reductions.