Evaluation of Blue^®m Mouthwash vs. Chlorhexidine Mouthwash in Patients with Gingivitis—A Pilot Study

Abstract

Chlorhexidine is widely regarded as a gold standard antiplaque agent, and it is used commonly in periodontal patients. However, due to its side effects, a suitable alternative agent has been searched for several years. The present study compared the efficacy of a novel, oxygen-releasing, natural mouthwash Blue^®m (Bluem Europe, Zwolle, The Netherlands) with chlorhexidine in patients with gingivitis. A total of 50 patients were selected and randomly divided into two groups who received a baseline scaling by a trained periodontist. The test group received Blue^®m mouthwash as an adjunct for 2 weeks, whereas the control group received chlorhexidine mouthwash for 2 weeks. The primary outcomes of the Full-Mouth Gingival Index, Full-Mouth Plaque Index, and a percentage of the bleeding sites were recorded at the baseline. The same parameters were recorded after 2 weeks and 1 month from the baseline. Both the study and control groups exhibited equal efficacy in terms of reduction in the gingival index and bleeding percentage, both at 2 weeks and 1 month post scaling. However, the Blue^®m group displayed statistically significant reduction in plaque index at 1 month as compared with chlorhexidine. As per the objectives of the study, it can be concluded that Blue^®m reported a better antiplaque efficacy compared with chlorhexidine.

1. Introduction

Gingivitis is a highly prevalent oral disease which results from accumulation of dental plaque (also called biofilm) accompanied with enhanced host inflammatory response as well as an inflammation of gingiva [1]. It can have a gradual or sudden onset and may or may not be painful. Gingivitis is the inflammation of the gingiva, leading to color changes, bleeding, and swollen gums. The inflammation is associated with increases in the formation of new capillaries out of the existing blood vessels, which can be measured as micro vessel density (MVD). It has been reported that it is directly proportional with inflammation, and a high MVD corresponds with the most severe form of gingival inflammation. It can involve a few teeth or the entire dentition, depending upon the oral hygiene of the patient. The inflammation remains till the biofilm is in proximity with the gingival tissues, and it subsides after careful removal of the biofilm and irritants like dental calculus. This shift to gingival health is a part of the body’s mechanism to prevent gingivitis turning into its irreversible counterpart, namely periodontitis involving inflammatory bone loss. During this shift, the predominant facultative Gram-positive bacteria turn into anaerobic Gram-negative oral microflora. This is very frequently seen in adults and is predominant in the third decade of life. The traditional management of gingivitis includes a thorough oral prophylaxis with adjunctive use of chemical plaque control mouthwashes. Chlorhexidine is regarded as the gold standard in the antiseptic treatment of gingivitis [2,3].

Chlorhexidine mouthwash very strongly adheres to the surface of teeth and gums, and, due to its high substantivity, it is quite effective in terms of reducing bacterial load [4]. Although it is quite efficacious against dental plaque, it has a lot of side effects, which has led to the search for similar products with minimal or no side effects. With the newer understanding that the mouth rinses used need to modify the oral microbiota, more and more research is going into finding a suitable alternative. It is now understood that the elimination of oral microflora due to rampant usage of chlorhexidine results in dysbiosis, a rise in the population of other pathogenic bacteria, and an alteration of the entire oral microflora [5,6]. Another point of contention is the effect of oral microflora and its impact on systemic health. Although a causal relationship has not been established yet, it is believed that the bacterial by products of the oral cavity travel to distant organs in the body and may cause some systemic illness [7]. Thus, the usage of chlorhexidine should be carefully considered as having potential systemic effects, including those on cardiovascular health [8].

Oxygen therapy (administered systemically or topically) has been used in medicine for centuries now and is known to be effective in inhibiting inflammation and infection, wound healing, and in promoting angiogenesis [9]. Oxygen is essential for metabolic processes and is involved in numerous activities, including the oxidative killing of bacteria, re-epithelization, and collagen production [10,11]. Free radicals and reactive oxygen species (ROS) are essential for the growth of fibroblasts and epithelial cells [12,13]. At lower concentrations, they are beneficial; however, at higher concentrations, they can cause cellular damage. Although the exact concentration is not known, increased ROS can cause irreversible tissue damage and lead to many oral conditions like lichen planus, pemphigus, and periodontal diseases [14]. ROS, like superoxide anion, hydrogen peroxide, and hydroxyl radicals, can cause damage to DNA, proteins, and lipids, and it can also overburden the cellular antioxidant capacity of the individual [15].

A homeostatic imbalance between reactive oxygen species and antioxidant defense systems has been implicated in the pathology of gingivitis [13]. Of late, atypical mouthwashes and gels containing oxygenating technology have been introduced that have antiplaque as well as anti-inflammatory properties [16]. It prevents the formation of plaque biofilm [17], promotes teeth whitening and improves the rate of wound healing. Taking all these properties into account, a novel formulation of topical oxygen therapy, Blue^®m mouthwash, has been developed. The mouthwash is composed of sodium perborate, the glucose oxidase enzyme derived from honey, xylitol, lactoferrin, and other agents [18], all of them having a role in the controlled release and delivery of ROS [13]. Therefore, Blue^®m mouthwash has been proposed to be as effective as chlorhexidine, with minimal side effects.

Upon the literature search, we have found very few studies comparing Blue^®m mouthwash with chlorhexidine and its effect on reducing inflammation and biofilm. Most of the studies evaluated the role of oxygen-releasing mouthwashes in general, or the use of Blue^®m mouthwash as a pre-procedural mouth rinse to evaluate the reduction in bacterial load during surgery or dental implants placement. A solitary study was found in the literature evaluating the role of Blue^®m mouthwash in dental plaque reduction in comparison to chlorhexidine [19]. There were lot of irregularities and discrepancies in the study, and the findings could not be corroborated clinically. Due to an absolute scarcity of studies on the potential role of Blue^®m mouthwash as a regular adjunct with oral prophylaxis, we decided to carry out this comparative study.

Hence, the objective of the study was to analyze and evaluate the efficacy of Blue^®m mouthwash in terms of reducing dental plaque and improving gingival healing in dental-biofilm-induced generalized gingivitis.

2. Materials and Methods

This was a pilot study to assess the efficacy of Blue^®m mouthwash with chlorhexidine mouthwash in gingivitis patients. The study was approved by the Institutional Ethical Committee (No: IEC-IDS/IDS/SOA/2023/1-40). The participants of the study were selected from the out-patient Department of Periodontics & Oral Implantology, Institute of Dental Science, Bhubaneswar. The recruitment took place from April 2024 to June 2024. A total of 50 patients with dental-biofilm-induced generalized gingivitis was selected. The entire study period was 5 months, lasting until August 2024, including recruitment, intervention, and follow up.

2.1. Eligibility Criteria

The inclusion criteria included patients aged between 18 and 60 years, both male and female, patients diagnosed with dental-biofilm-induced generalized gingivitis (according to the World Workshop on Classification of Periodontal and Peri-implant Diseases and Conditions, 2017 [20,21]), patients willing to participate in the study, and patients with at least 28 teeth remaining.

The exclusion criteria included smokers, pregnant and lactating women, patients who have used antibiotics or mouthwash within 6 months, patients who have undergone scaling within 6 months, and systemically compromised patients.

2.2. Study Design

In total, 50 patients were randomly allotted into two groups, study, and control, of 25 patients each using a fair coin toss method. All patients received a complete ultrasonic scaling on their first visit by an expert periodontist.

At the baseline, the following parameters were recorded:

• Full-mouth Plaque Index (PI)—[22].
• Full-mouth Gingival Index (FMGI)—[23].
• Percentage of bleeding on probing sites (% BOP).

Oral hygiene maintenance instructions were given to all the patients, and a similar toothbrush and dentifrice was suggested to all by the same examiner (M.K.). Subsequently, patients were instructed to use 10 mL of Blue^®m mouthwash (Bluem Europe, Zwolle, The Netherlands) (study group) or 10 mL of 0.2% chlorhexidine mouthwash (control group) twice daily for two weeks post scaling. They were instructed to rinse thoroughly with the respective mouthwash for 30–60 s, once in the morning and once before going to bed. After that, they were instructed to spit it out and avoid oral ingestion. They were asked to refrain from eating or drinking for half an hour and to maintain an at least 45 min gap between toothbrushing and mouthwash usage [24].

Subsequently, patients were recalled after 14 and 30 days to evaluate PI, GI, and % BOP parameters.

The primary outcome was to assess the change in the recorded parameters after 2 weeks and 1 month from the baseline.

The secondary outcome was to evaluate the patients’ acceptance of the mouthwash and their tolerability of the side effects. A patient satisfaction survey was conducted wherein questions were asked regarding altered taste sensations, burning sensations, and the staining of teeth. The answers were recorded as “Yes” if present and “No” if absent.

2.3. Statistical Analysis

Sample size estimation was carried out based on a pilot study of 5 subjects to calculate the mean reduction in PI, GI, and % BOP. To achieve a power of 80% with an α error of 0.05, effect size was calculated based on each variable and a required sample size of 25 per group was attained. Collected data on the plaque index, gingival index, and percentage of bleeding in terms of probing from 50 eligible patients (25 for each group) were entered in an Excel sheet. The data were further analyzed in STATA MP (v17.0 for Mac). Initially, a descriptive analysis was conducted on the variables that was presented through the Median and Inter Quartile Range (IQR). The analytical statistics included a Mann–Whitney U test (Wilcoxon Rank sum test), since the number of participants in each group was less than 30. A p-value of < 0.05 was considered significant.

3. Results

In this pilot study, a total of 50 participants were included (Figure 1); among them, 25 were male and the rest 25 were female.

The demographic description of the participants is enumerated in

Table 1. Description of the study participants.

		Chlorhexidine	Blue®m
Sex	Male	12 (48%)	13 (52%)
	Female	13 (52%)	12 (48%)
Age	Median age	28 years	24 years
	Inter quartile range	21–34 years	20–35 years
	Range	19 to 54 years	18 to 47 years

.

After 14 days, the plaque index, gingival index, and bleeding on probing (Figure 2, Figure 3 and Figure 4) were lower among the chlorhexidine group than in the Blue^®m mouthwash group. However, the effect of Blue^®m mouthwash was more significant than chlorhexidine after the end of one month in all the aspects.

At the baseline (day 0), the median plaque index and the gingival index recorded in the chlorhexidine group was 1.13 and 0.82, respectively, whereas these indices in the Blue^®m group were 1.21 and 0.86, respectively. There were no significant differences between the groups for both plaque (p = 0.10) and the gingival index (p = 0.40) (

Table 2. Intergroup comparison of PI, GI, and % BoP at different time intervals in both groups.

Outcome	Time Points	Mouthwash	Median (IQR)	Range	p-Value
Plaque Index	Baseline (Day 0)	Chlorhexidine	1.13 (0.83 to 1.22)	0.64 to 1.54	0.10
		Blue®m	1.21 (1.13 to 1.28)	0.72 to 1.92
	14th day	Chlorhexidine	0.76 (0.68 to 1.08)	0.49 to 1.25	0.22
		Blue®m	0.91 (0.76 to 1.08)	0.56 to 1.60
	30th Day	Chlorhexidine	0.68 (0.53 to 0.95)	0.41 to 1.12	0.01
		Blue®m	0.54 (0.38 to 0.69)	0.20 to 1.03
Gingival Index	Baseline (Day 0)	Chlorhexidine	0.82 (0.69 to 1.02)	0.38 to 1.14	0.40
		Blue®m	0.86 (0.79 to 0.98)	0.67 to 1.10
	14th day	Chlorhexidine	0.62 (0.52 to 0.70)	0.34 to 0.99	0.09
		Blue®m	0.69 (0.62 to 0.79)	0.35 to 0.96
	30th Day	Chlorhexidine	0.53 (0.46 to 0.60)	0.28 to 0.92	0.35
		Blue®m	0.50 (0.42 to 0.62)	0.26 to 0.79
Bleeding on Probing	Baseline (Day 0)	Chlorhexidine	14.3 (12.5 to17.85)	9.6 to 27.58	0.628
		Blue®m	15.7 (12.6 to 18.75)	9.3 to 33.34
	14th day	Chlorhexidine	11.8 (9.5 to 14.28)	6.25 to 20.68	0.607
		Blue®m	12.4 (9.3 to 13.34)	6.67 to 17.85
	30th Day	Chlorhexidine	9.8 (8.4 to 11.2)	6.25 to 20.68	0.001
		Blue®m	6.7 (3.57 to 8.4)	0 to 13.2

). After 14 days, the median plaque index reduced to 0.76 (0.68 to 1.08) in the chlorhexidine group and 0.91 (0.76 to 1.08) in the Blue^®m group. This reduction in plaque index score was not statistically significant (p = 0.22). At the end of the 30th day, the median plaque index fell to 0.68 and 0.54 for chlorhexidine and the Blue^®m group, respectively, and this time, the change in reduction in plaque index from the beginning of the study was statistically significant (p = 0.01). However, though the Blue^®m mouthwash reduced the gingival index at the end of 30 days (Figure 3), the change in gingival index was no longer statistically significant in comparison to the chlorhexidine group after 2 weeks (p = 0.09) and after the 30th day mark (p = 0.35).

The bleeding on probing percentage reduced to 9.8% in the chlorhexidine group and 6.7% in the Blue^®m group, respectively, after 1 month and was statistically significant for both the groups (p < 0.001).

As for the patients’ satisfaction, only 12% of patients reported an altered taste after using Blue^®m mouthwash (

Table 3. Patient satisfaction survey (percentage of patients reporting the issue).

Parameter	Chlorhexidine Group	Blue®m Group
Altered Taste	40%	12%
Burning Sensation	48%	0
Staining of Teeth	32%	0

), whereas those using chlorhexidine reported a burning sensation, altered taste, and teeth staining.

4. Discussion

The present study was conducted to evaluate the efficacy of Blue^®m mouthwash with chlorhexidine in plaque-induced gingivitis. Both the groups were matched for the clinical parameters (plaque index, gingival index, and bleeding on probing percentage) so that any kind of bias could be avoided in the outcome. Chlorhexidine has been used as an antiplaque agent with considerable side effects, such as the brownish staining of teeth, altered taste perceptions, and hypersensitivity, to name a few [2,3,4,8]. Hence, searches for mouthwashes which do not contain alcohol and are naturally derived have been ongoing for years. Blue^®m has been developed with this element in mind, and it is composed of natural ingredients and completely free of alcohol. However, chlorhexidine is much cheaper compared to Blue^®m mouthwash; therefore, studies are required to validate the use of the latter as a worthy alternative to chlorhexidine.

As mentioned before, ROS have an important role in the pathogenesis of gingival and periodontal disease. Blue^®m mouthwash has a positive impact on healing, as it promotes re-epithelization, improved collagen production, and neovascularization, hence the decrease in the parameters seen at the one-month follow up. It has a protective role in controlling gingival inflammation through the controlled release of reactive oxygen species, hence preventing tissue damage due to an increased concentration of the same element [17]. Although scarce, a few studies evaluating the efficacy of topical oxygen therapy in periodontal diseases, including the use of Blue^®m mouthwash, could be found in the literature. Sy et al. [25] in 2020 investigated the use of an oxygen-releasing gel against an antibiotic or antiseptic gel and found that its bactericidal efficacy was almost similar to both of them in terms of eliminating periodontal pathogens. Deliberador et al. [26], in their pilot study comparing the in vitro application of Blue^®m gel vs. chlorhexidine gel in order to reduce Porphyromonas gingivalis, discovered that the inhibitory effect of Blue^®m gel on Porphyromonas gingivalis at a concentration of 100% and 50% was similar to that of chlorhexidine. Also, a study by Shaheen et al. [27] used local oxygen-based therapy (Blue^®m oral gel) as an adjunct to non-surgical therapy to manage peri-implant mucositis and peri-implantitis, concluding that it had a similar efficacy to conventionally used local supplements (antibacterial agents, probiotics, antibiotics) in reducing bleeding on probing and probing pocket depth and increasing radiographic bone levels.

Mattei et al. [28] conducted a study to evaluate the effect of Blue^®m mouthwash on intra oral wounds. In this study, 14 patients were recruited who underwent pre prosthetic surgery to remove hyperplasia of the posterior and anterior maxillary ridge prior to a final prosthesis. They were asked to use Blue^®m mouthwash on the right-side ridge of their mouths as an adjunct therapy, leaving the left-side ridge as control. The subjects applied the product for 7 days thrice daily, after which the pain, taste alteration, and patients’ acceptance were assessed. The results revealed that Blue^®m mouthwash was well accepted by the patients and subsided the pain to a certain extent. Less inflammation on the test side was noted, depicting enhanced healing. The above study concluded that Blue^®m mouthwash was quite helpful in pain management, reducing inflammation, and wound healing after surgery. Also, the efficacy of Blue^®m mouthwash was tested in the study of Ashref et al. [29], where it was used by patients undergoing dental implant surgery. The results showed that Blue^®m mouthwash was equally as effective as chlorhexidine in reducing microbial load post-implant placement. Similar results were achieved by Custodio et al. [30], who proved that this oxygen-releasing mouthwash aids in controlling biofilm and reducing gingival inflammation following implant surgery. Also, Basudan et al. [31] reported that Blue^®m mouthwash was effective in managing both gingivitis and periodontitis when used as an adjunct to mechanical debridement, allowing for achieving a reduction of inflammation following the use of Blue^®m topical oxygen-therapy-based products (toothpaste, mouthwash, and oral gel).

The present study tested Blue^®m mouthwash efficacy in patients with gingivitis in regard to PI, GI, and BOP indices. Despite the plaque reduction at the two-week interval being similar in both the groups, after 30 days, the use of Blue^®m mouthwash resulted in a significantly greater reduction in the plaque index than after using chlorhexidine mouthwash. While assessing the gingival index, the reduction after using Blue^®m mouthwash was similar to the one after chlorhexidine both at the 14th day and at the one-month intervals. The same observation was made in terms of a reduction in the bleeding on probing sites, wherein the reduction in both the groups was similar and comparable.

Our findings corroborate the results of the study conducted by Rajkhowa et al. in 2023 [19] which evaluated the efficacy of Blue^®m mouthwash in reducing plaque calculus and gingival inflammation in comparison to chlorhexidine. The study recruited 20 patients with chronic generalized gingivitis who were asked to rinse their mouths with the respective mouthwashes for one minute, twice daily, for 21 days. The authors concluded that there were no statistically significant differences in efficacy with the Blue^®m and chlorhexidine mouthwashes in regard to reducing the plaque index, Oral Health Index (OHI), and modified gingival index after 3 weeks of usage.

An interesting study was conducted by Sindhusha et al. [32], who evaluated the effect of Blue^®m mouthwash, used by patients as a mouth wash before ultrasonic scaling, on microbial load in the aerosol produced during ultrasonic scaling. It was concluded that Blue^®m had a significant effect on reducing bacterial load in the ultrasonic-scaling-induced aerosol when compared to chlorhexidine.

In our study, Blue^®m mouthwash was well tolerated by all the patients and negligible adverse effects were reported by the participants. In a nutshell, chlorhexidine was found to be the superior mouthwash in terms of reducing plaque and the gingival index, as well as a percentage of the bleeding on probing sites, till the second week of the experiment, while the Blue^®m mouthwash was found to be more effective than chlorhexidine at the end of the month in terms of reducing plaque.

The results of the current study should be considered carefully due to the study’s limitations, which include its small sample size, short follow up period, as well as the fact that the study was conducted at a single center. Additionally, a microbial analysis could have been performed to assess bacterial load after using Blue^®m mouthwash and comparing it with other agents and types of oral hygiene products. Moreover, the studies focusing on the cytotoxicity of oxygen-releasing oral antiseptic products should be continued [17,33,34]. In the future, long-term, multicenter studies involving different groups of populations should be conducted in order for Blue^®m to be considered as an alternative to chlorhexidine.

5. Conclusions

The present study was a pilot study comparing the antiplaque efficacy of Blue^®m mouthwash with chlorhexidine mouthwash that also compared their effects on gingival healing. It would be safe to conclude that Blue^®m mouthwash has better antiplaque efficacy compared to chlorhexidine over a longer follow up period; however there is no difference in terms of gingival index and bleeding reduction between the two. Chlorhexidine has the advantage of being quite economical and available, whereas Blue^®m mouthwash is natural and has little or no side effects.