Effects of chlorhexidine varnish on caries during orthodontic treatment: a systematic review and meta-analysis

OKADA, Elaine Machado Pingueiro; RIBEIRO, Larissa Nogueira Soares; STUANI, Maria Bernadete Sasso; BORSATTO, Maria Cristina; FIDALGO, Tatiana Kelly da Silva; PAULA-SILVA, Francisco Wanderley Garcia de; KÜCHLER, Erika Calvano

doi:10.1590/1807-3107BOR-2016.vol30.0115

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Meta-Analysis • Braz. oral. res. 30 (1) • 2016 • https://doi.org/10.1590/1807-3107BOR-2016.vol30.0115 linkcopy

Effects of chlorhexidine varnish on caries during orthodontic treatment: a systematic review and meta-analysis

Authorship SCIMAGO INSTITUTIONS RANKINGS

This study aimed to perform a systematic review and meta-analysis to evaluate the effectiveness of chlorhexidine varnish on the reduction of caries incidence during fixed orthodontic treatment. The literature searches involved The Cochrane Library, Medline, Scopus, OpenSigle databases and manual searches. The search on OpenSigle did not produce any additional articles. Clinical studies conducted in patients with orthodontic fixed appliances that used professional application of chlorhexidine varnish were included. The effect-size was calculated and a meta-analysis was performed. From 182 abstracts, a total of six articles fulfilled the inclusion criteria. After reading the full articles, one was excluded because of lack of a control group. Three articles were used for continuous data analysis, and two articles were used for the dichotomous data analysis. The pooled meta-analysis with continuous data demonstrated chlorhexidine varnish effectiveness on caries reduction (p = 0.003), with a mean difference and confidence interval of −1.49 [−2.47, −0.51]. On the basis of the pooled meta-analysis of continuous data, we were able to conclude that professional application of chlorhexidine varnish is effective in caries incidence reduction during fixed orthodontic treatment.

Chlorhexidine; Dental Caries; Orthodontics

Author, year	Sample size (CHX/Control)	Comparison groups and type of intervention	Study design	Application frequency	Treated surfaces	Age rage	Caries experience measurement	Effect modifiers	Trial duration	Conclusion
Skold-Larsson et al., 2004¹⁶	24/21	Cervitec (1% CHX and 1% thymol)	Split-mouth	Every 6 weeks until debonding	Molars fissure	12–18	WSL using Diagnodent Laser fluorescence	Rinse daily 0,05% NaF + fluoride toothpaste and oral hygiene reinforcement	48 weeks	Caries were lower in CHX in the continuous variable analyses (p ‹ 0.05)
Skold-Larsson et al., 2004¹⁶	24/21	Placebo	Split-mouth	Every 6 weeks until debonding	Molars fissure	12–18	WSL using Diagnodent Laser fluorescence		48 weeks
Ogaard et al., 2001¹⁷	110/110	Cervitec (1% CHX/1% thymol) + fluoride varnish (0.7% F)	Case-control	Every 6 weeks until debonding	Around OFA and proximal	12–15	WSL index of Gorelick	Fluoride toothpaste and oral hygiene reinforcement	75 weeks	Not significant
Ogaard et al., 2001¹⁷	110/110	Placebo + fluoride varnish	Case-control	Every 6 weeks until debonding	Around OFA and proximal	12–15	WSL index of Gorelick	Fluoride toothpaste and oral hygiene reinforcement	75 weeks	Not significant
Jenatschke et al., 2001¹⁸	18/15	EC-40 (40% CHX)	Case-control	Every 8 weeks until debonding	All	11–18	DMFS index system	Rinse daily 0,05% NaF + fluoride toothpaste and oral hygiene reinforcement	103 weeks	Not significant
Jenatschke et al., 2001¹⁸	18/15	Placebo	Case-control	Every 8 weeks until debonding	All	11–18	DMFS index system		103 weeks	Not significant
Madléna and Vitalyos, 2000¹⁹	24/24	Cervitec (1% CHX/1% thymol)	Split-mouth	Every 13 weeks until debonding	Around OFA	12–23	DMFS index system	Oral hygiene reinforcement (fluoride exposure was unclear)	54 weeks	Caries were lower in CHX compared to placebo (p ‹ 0.05)
Madléna and Vitalyos, 2000¹⁹	24/24	Placebo	Split-mouth	Every 13 weeks until debonding	Around OFA	12–23	DMFS index system	Oral hygiene reinforcement (fluoride exposure was unclear)	54 weeks	Caries were lower in CHX compared to placebo (p ‹ 0.05)
Ogaard et al., 1997²⁰	101/97	Cervitec (1% CHX/1% thymol) + fluoride varnish (0.7% F)	Case-control	Every 6 weeks until debonding	Around OFA and proximal	12–15	WSL index of Gorelick	Fluoride toothpaste and oral hygiene reinforcement	24 weeks	Not significant
Ogaard et al., 1997²⁰	101/97	Placebo + fluoride varnish (0.7% F)	Case-control	Every 6 weeks until debonding	Around OFA and proximal	12–15	WSL index of Gorelick	Fluoride toothpaste and oral hygiene reinforcement	24 weeks	Not significant
Twetman et al., 1995²¹	18/18	Cervitec (1% CHX/1% thymol)	Split-mouth	First week, 4th and 13^th week	Around OFA	11–18	WSL index	Rinse daily (0,025%) NaF, fluoride toothpaste	27 weeks	Not significant
Twetman et al., 1995²¹	18/18	Placebo	Split-mouth	First week, 4th and 13^th week	Around OFA	11–18	WSL index	Rinse daily (0,025%) NaF, fluoride toothpaste	27 weeks	Not significant

Component	Definition	Skold-Larsson et al., 2004 ¹⁶	Ogaard et al., 2001¹⁷	Jenatschke et al., 2001¹⁸	Madléna and Vitalyos, 2000¹⁹	Ogaard et al., 1997²⁰	Twetman et al., 1995²¹
1. Study design	Description of study design	NE	E	NE	NE	NE	NE
2. Participants	Eligibility criteria for participants	E	E	E	E	E	E
2. Participants	Entry criteria and exclusion	E	E	E	E	E	E
3. Interventions	Sufficient details	E	E	E	E	E	P
3. Interventions	Description of modifier effects	E	E	E	E	E	E
4. Outcomes	Completely defined	E	E	E	E	E	E
5. Sample size	How sample size was determined	NE	NE	NE	NE	NE	NE
6. Randomization	Method used	P	P	NE	NE	E	NE
7. Blinding	Who was blinded and how	NE	NE	NE	NE	NE	NE
8. Control group acceptable	Definition of control	E	E	E	E	E	E
9. Statistical methods	Statistical methods used	E	E	E	E	E	E
9. Statistical methods	Methods for additional analyses	E	E	E	E	E	E
10. Participant flow	For each group, losses and exclusions	E	E	E	E	E	E
11. Baseline data	Baseline clinical of each group	E	E	E	NE	E	NE
12. Numbers analyzed	For each group	E	E	E	E	E	E
13. Interpretation	Consistent with results	E	E	E	E	E	E

Author, year	Exposure	d	r	Type of effect
Skold-Larsson et al., 2004¹⁶	CHX	0.159	0.079	Low increase
Skold-Larsson et al., 2004¹⁶	Control	0.769	0.359	Medium increase
Ogaard et al., 2001¹⁷	CHX	0.221	0.110	Medium increase
Ogaard et al., 2001¹⁷	Control	0.320	0.158	Medium increase
Jenatschke et al., 2001¹⁸	CHX	0.557	0.268	Medium increase
Jenatschke et al., 2001¹⁸	Control	0.610	0.292	Medium increase
Madléna and Vitalyos, 2000¹⁹	CHX	1.140	0.487	High increase
Madléna and Vitalyos, 2000¹⁹	Control	1.467	0.590	High increase
Ogaard et al., 1997²⁰	CHX	0	0	Low increase
Ogaard et al., 1997²⁰	Control	0	0	Low increase

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[TFN1] CHX: chlorhexidine; OFA: Orthodontic fixed appliances.