A. Paul Burtner, DMD; Debra W. Low, DMD, MEd; Donald R. McNeal, DMD, MPH; Thomas M. Hassell DDS, Dr Med Dent, PhD; Robert G. Smith, RPh

Effects of chlorhexidine spray on plaque and gingival health in institutionalized persons with mental retardation In this study, eight institutionalized males received a 0.12%chlorhexidine gluconate spray twice daily. A second group of eight males received a placebo spray in the same manner. The results indicated that pumpadministered chlorhexidine spray can effectively reduce plaque and gingivitis in patients with mental retardation who are unable to brush their own teeth.

lthough mechanical plaque control by toothbrushing has been used traditionally in institutions for the developmentally disabled, the maintenance of adequate oral hygiene has continued to be a major problem. In this study, the daily application of a plaque inhibitory agent via spray was evaluated as an adjunct to daily toothbrushing. One group of eight males received 0.12% chlorhexidine gluconate solution (Peridex) twice daily. A second group of eight males received placebo spray in the same manner. Nurses were blinded as to solutions. The chlorhexidine group showed a significant decrease ( P = 0.002) in plaque at 4 weeks; the placebo had no effect ( P = 0.67). Gingival color, tone, and bleeding indexes showed significant improvement in the chlorhexidine group ( P = 0.09,0.02, and 0.03, respectively, vs baseline);the placebo group showed no improvements. Residual effects of chlorhexidine were noted four weeks after the last administration. These results indicate that administration of chlorhexidine via pump spray can effectively reduce plaque and gingivitis in severely and profoundly mentally retarded patients who are unable to brush their own teeth. Preventive measures are important when planning for the oral health care of the severely and profoundly retarded.1,2After teeth are lost due to dental disease, it is often difficult to replace them because these patients are unable to cooperate during dental procedures, or to use and care for an intraoral prosthesis properly. AIso, prosthodontics is often


contraindicated in this population due to the high incidence of seizure disorders. The preventive measures used in an institutional setting typically include sealants, topical fluoride applications, fluoridated water, dietary counseling, periodic professionaI prophylaxis, daily oral hygiene, mouth guards, and protective helmets for those with seizure disorders. Of primary importance is the daily maintenance of oral hygiene. Although daily oral hygiene activities are mandated by state and federal regulations, oral hygiene among mentally retarded individuaIs residing in state institutions is generally inadand depends directly on the patient’s physical and mental abilitieslOJ1and cooperativeness,2and the workload and motivation of the support staff .8,9 Until recently, the mechanical removal of plaque by toothbrushing has been the primary means available for daily oral hygiene. This procedure has proven less than optimal for the reasons previously ~ t a t e d . ~Within - ’ ~ the past 5 years, adjunctive measures, namely chemical plaque inhibitory agents, have become available in the United States. Although several chemical plaque control agents have shown potential, chlorhexidine digluconate has been the most effective. Chlorhexidine was first used in 1954 in Great Britain as an antiseptic cream for skin wounds and currently, more than 20 chlorhexidinecontaining products are available for a variety of antibacterial purpose^.'^,'^ Mouthrinses with 0.1% to 0.2% chlorhexidine control supragingival plaque.15J6 The use of chlorhexidine oral rinse

Special Care in Dentistry, Vol 11No 3 1991 97

to reduce plaque and gingivitis in mentally handicapped individuals has been advocated since 1973, particuAs early as 1977, larly in S~andinavia.'~ Storhaug2suggested that chemical plaque control using chlorhexidine digluconate was possibly the only answer to the handicapped patient's oral hygiene problem. Chlorhexidine efficacy has been established regardless of the vehicle used for delivery, for example, mouthrinse, dentifrice, gel, or spray.9 The selection of the vehicle becomes an important issue whenever the agent is being used in special population groups. A mouthrinse may not be an appropriate vehicle because the mentally retarded are unable to rinse their mouths in the prescribed manner and often experience swallowing problems."' Likewise, a gel could be swallowed or aspirated. A dentifrice may prove inefficient given the resistance to toothbrushing displayed by some individuals within this group. This study, therefore, determined the effectiveness of a chlorhexidine spray in reducing plaque and gingival inflammation when administered in conjunction with daily mechanical plaque control techniques.

Materials and methods Sixteen institutionalized males with severe and profound mental retardation (28 to 45 years of age) participated in this study. To be selected for participation, the subjects had to: 1. Display a level of cooperation that would permit the accurate collection of data without the use of sedation. 2. Be negative for hepatitis B. 3. Be male to avoid the influence of hormonal changes. 4. Have at least four anterior teeth present in each arch. 5. Be free of phenytoin-induced gingival overgrowth. 6. Have moderate to heavy accumulation of plaque, and moderate to severe gingivitis. 7. Have a legal guardian willing to give informed consent. To ensure that baseline values reflected their existing oral hygiene conditions, the subjects did not receive a baseline prophylaxis, nor were their

98 Special Care in Dentistry, Vol 11 No 3 1991

required to complete each assessment varied from 5 to 15 minutes, depending on each subject's behavior.

daily oral hygiene programs altered. The 16 subjects were randomly assigned to two groups. During the 4week study period, Group I received 0.12% chlorhexidine digluconate twice daily and Group I1 received a placebo consisting of bottled water colored to resemble the medicated solution. The solutions were administered by the nurses during their rounds (7:OO am and 7:OO pm). Forty minims of solution (2.4 mL) were sprayed onto the facial surfaces of the anterior teeth and associated gingival tissues during each administration. This quantity is one-sixth of the normal dose recommended when chlorhexidine is used as a rinse. To ensure that the solutions were administered according to the protocol schedule, a prescription was written for each subject. In addition, a training session was conducted to prepare the nurses to administer the sprays appropriately. Each spray bottle was covered to protect the contents from light and to mask the contents from the nurses. Pharmaceutical safety seals were used to prevent tampering. Furthermore, using a graduated cylinder, each spray bottle was calibrated to deliver 20 minims of solution (1.2mL) with each actuation of the the pump spray. During the study, daily oral hygiene procedures conducted at the residential units were not interrupted, and none of the subjects received a professional prophylaxis. A prophylaxis was performed, however, for each subject after the study. Plaque accumulation and the condition of gingival tissues were evaluated using the Plaque Index of Silness and Loe, and a modified Gingival Index of Loe and Silnessl8 whereby gingival color, tone, and bleeding were separately' Examinations at and 4 weeks were performed in the same operatbry under identical lighting conditions, with a mirror, explorer, and periodontal probe. The subjects were evaluated at the same time of day throughout the study by the same examiner, who was experienced

Color Tone

in treating


retarded patients. The length of time

Results Plaque accumulation, gingival color, gingival tone, and gingival bleeding at baseline were similar for both groups (Table 1).After 4 weeks, however, oral hygiene and gingival health improved greatly in the group receiving chlorhexidine, whereas no significant changes were observed in the group receiving the placebo (Table 1). The baseline plaque scores for both the placebo group (PI = 2.5) and the chlorhexidine group (PI = 2.3) indicate that all subjects had moderate to heavy accumulations of plaque in their anterior sextants, reflecting the poor oral hygiene commonly observed in this population. Gingival color, tone and bleeding scores a t baseline (Table 1) indicated gingival tissues that were moderately inflamed. Clinically, the tissues showed erythema, edema, and bleeding on gentle probing of the sulci. At the end of the 4-week study, no significant changes were observed in plaque accumulation or gingival health among subjects receiving the placebo. In the,chlorhexidine group, however, plaque accumulation was reduced by 35%. Concomitantly, an overall improvement in gingival health was observed, as reflected in the indexes for gingival color, tone, and bleeding. Interestingly, subsequent observations of the individuals who received chlorhexidine indicated that the effects of this agent were residual for approximately 4 weeks.

Discussion Dental health maintenance in the

Table 1.Comparison between placebo group and chlorhexidine group at baseline and four weeks.

Placebo group lndex ~


Chlorhexidine group



base- four line weeks ~


base- four line weeks


2.5 2.6 2.5 1.2

2.4 2.4 2.2 1.1

0.67 0.59 0.39 0.49

2.3 2.3 2.1 1.O

P __

1.5 0.002 1.8 0.09 1.S 0.02 0.8 0.03

(substantivity).19,20Furthermore, a vadevelopmentally disabled is directly of vehicles is suitable for deliverriety related to plaque control effectiveness. ing chlorhexidine to the oral environYet many severely and profoundly ment. Because of the problems mentally retarded persons are unable encountered with swallowing and asto achieve adequate levels of plaque control because of physical and mental piration among the institutionalized population, a pump spray was chosen limitations.]”Plaque removal is a skill as the vehicle for delivery in the that can be mastered only when an inpresent study (Figure 1). dividual ha5 the dexterity to manipulate a toothbrush and floss effectively, and understands the objective of the activity. Lesser” states that it is unlikely that severely retarded individuals can ever learn to brush their teeth satisfactorily,even by means of an electric toothbrush. As an alternative, the responsibility for daily oral hygiene is delegated to support staff.8,yHowever, the support Fig 1.Calibrated pump spray bottle. staff, who typically occupy the lowest pay grades, often experience difficulty For this 4-week study, a chlorhexin performing this task caused by the idine spray was added to the daily oral uncooperative behavior of residents.2 hygiene routine of the test group, Moreover, the amount and degree of while a control group received a plaphysical restraint that may be used by cebo. Chlorhexidine effected a dethe staff is limited by governmental crease in plaque accumulation in the regulation. test group, causing the observed imObviously, given the myriad of provement in gingival health. Not only tasks that must be performed by the were the results of the 4-week trial sigdirect care staff, and the resistant benificantly favorable in the chlorhexhavior of the residents, oral hygiene procedures might receive low priority. idine group, but the residual beneficial effects continued for 4 weeks after the Interestingly, the provision of this serfinal administration. vice by support staff is contrary to the Side effects21,22 were minimal; no ulcurrent philosophy of ”optimal indeceration or desquamation of the oral pendent functioning” for mentally retissues was noted. There was minor extarded individuals. trinsic staining of the,teeth, which was Controlling dental plaque chaleasily removed during prophylaxis. lenges individuals with developmental disabilities, their caretakers, and the According to the nurses who administered the medication, the subjects’ acinterdisciplinary team of service proceptance of the procedure was favorviders, and will continue to be an imable and no incidents of aspiration or portant issue in health care planning choking occurred. and preventive programs for such inWhen chlorhexidine is used in the dividuals. For the reasons stated previmanner described, it is essential to ously, it has been difficult to achieve have the full cooperation of the direct and maintain acceptable levels of oral care staff. In this study, training seshygiene among this population using sions, a complete explanation of the conventional methods of mechanical protocol, and frequent monitoring of plaque control. Effective measures that the solution administration proved are easily applicable are needed. helpful. Numerous studies have shown For the purposes of this study, only chlorhexidine to be an effective chemithe anterior teeth were evaluated. Furcal plaque control agent. Its effectivether research needs to focus on the apness is due, in part, to the property of plication of chlorhexidine to the postebinding reversibly to the oral tissues rior teeth and the evaluation of and subsequently being released into residual effects of the medication. the saliva in bacteriostatic concentrations over an extended period

Summary and conclusions Until recently, only mechanical measures were available for controlling dental plaque in developmentally disabled populations. In this study, a chemical plaque control agent was tested as an adjunctive measure. Sixteen male subjects residing in an institution for the developmentally disabled were randomly assigned to two groups. One group received chlorhexidine while the other group received a placebo via spray twice daily. Using accepted indexes of plaque formation and gingival health, the findings for chlorhexidine were favorable. Although plaque accumulation and gingival health were unchanged in the group receiving a placebo, plaque accumulation was reduced and gingival conditions reflected reduced inflammation in the chlorhexidine group. The spray delivery system proved to be an efficacious and acceptable method of application, while using only one-sixth of the recommended rinsing dose. Adverse effects associated with the agent and the method of delivery were minimal. The success of this procedure depends on the cooperation of the direct care staff, and requires in-service training and frequent monitoring. Further studies are necessary to determine whether chlorhexidine spray can be delivered effectively to posterior oral segments. This project was supported by the Florida Department of Health and Rehabilitative Services, and USPHS grant DE-06671 from the National Institute of Dental Research. The authors thank Genevieve Starling; Ruby Bush; Yvonne London; Diane Godman, IZDH; and Marilyn Linderman, RDH. The authors also thank Mr. D. Garsh and the Proctor & Gamble Company for providing Peridex for this study. Dr. Burtner is assistant professor, Department of Community Dentistry, J . Hillis Miller Health Center, College of Dentistry, Box 1-404, University of Florida, Gainesville 32610. Dr. McNeal is professor and chairman, Department of Community Dentistry, College of Dentistry, university of Florida. Dr. Hassell is professor and chairman, Department of Periodontology, College of Dentistry, University of Florida. Dr. Smith is clinical lecturer, Department of Pharmacy Practice, College of Pharmacy, University of Florida. Address requests for reprints to Dr. Burtner.

Special Care in Dentistry, Vol 11 No 3 1991 99

9. Francis JR, Addy M, Hunter B. A comparison of three delivery methods of chlorhexidine in handicapped children. 1. Effects on plaque, gingivitis and toothstaining. J Periodontol 1987;58:451-5. 10. Russell BG, Bay LM. Oral use of chlorhexidine gluconate toothpaste in epileptic children. Scand J Dent Res 1978;86:52-7. 11. Lesser SP, Gelbier LDS. A preventive measure for mentally handicapped: mouthrinsing with chlorhexidine. Dent Health 1973;12:15-7. 12. Loesche WJ. Plaque control in the handicapped: the treatment of specific plaque infections. J Can Dent Assoc 1981;10:649-56. 13. Katz S. The use of fluoride and chlorhexidine for the prevention of radiation caries. JADA 1982;104:164-70. 14. Gabler WL, Bullock WW, Creamer HR. Chlorhexidine: not a drug for all reasons. J Oreg Dent Assoc 1987;56:24-6. 15. Bay LM, Russell BG. Effects of chlorhexidine on dental plaque and gingivitis in mentally retarded children. Community Dent Oral Epidemiol 1975;3~267-70.

1. Hobson P. The treatment of medically handicapped children. Int 'Dent J 1980;30:613. 2. Storhaug K. Hibitane in oral disease in handicapped patients. J Clin Periodontol 1977;4:702-7. 3. Usher PJ. Oral hygiene in mentally handicapped children. Br Dent J 1975;138:217-21. 4. Preest M, Gelbier S. Dental health and treatment of a group of physically handicapped adults. Community Health 1977;9:29-34. 5. Swallow JN, Swallow BG. Dentistry for physically handicapped children in the international year of the child. Int Dent J 1980;30:1-5. 6. Melville MRB, Poole DM, Jaffe EC. A dental service for handicapped children. Br Dent J 1981;151:259-61. 7. Morton ME. Dental disease in a group of mentally handicapped patients. Public Health 1977;91:23-32. 8. Dever JG. Oral hygiene in mentally handicapped children. A clinical trial using chlorhexidine spray. Aust Dent J 1979;24:301-5.

16. Schiott CR, Loe H, Jensen SB, and others. The effect of chlorhexidine mouthrinse on the human oral flora. J Periodont Res 1970;534-9. 17. Flotra L. Different modes of chiorhexidine application and related local side effects. J Periodont Res (suppl) 1973;1241-4. 18. Loe H. The gingival index, the plaque index and the retention index systems. J Periodontol (suppl) 1967;38:610-6. 19. Gallagher IHC, Cutress TW. Clinical trial in mentally retarded of chlorhexidine gel: bacteriology. Community Dent Oral Epidemioll977;5: 1-6. 20. Rolla G, Loe H, Schiott R. Retention of chlorhexidine in the human oral cavity. Arch Oral Biol1971;16:1109-15. 21. Flotra L, Gjermo P, Rolla G, and others. Side effects of chlorhexidine mouthwashes. Scand J Dent Res 1971;79:119-25. 22. Heyden G. Relation between locally high concentration of chlorhexidine and staining as seen in the clinic. J Periodont Res (suppl) 1973;12:76-80. ~

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100 Special Care in Dentistry, Vol 11No 3 1991

Effects of chlorhexidine spray on plaque and gingival health in institutionalized persons with mental retardation.

In this study, eight institutionalized males received a 0.12% chlorhexidine gluconate spray twice daily. A second group of eight males received a plac...
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