R. Periodontia - Setembro 2010 - Volume 20 - Número 03
PHASE II STUDY WITH MOUNTHRINSE CONTAINING
5% OF PROPOLIS FOR THREE-MONTHS: COMPLIANCE,
APPRECIATION AND ACCEPTABILITY OF THE PRODUCT
Estudo fase II com colutório contendo própolis 5%: aderência, apreciação e aceitabilidade do
produto
Elizete Maria Rita Pereira¹, Carolina Morsani Mordente¹, Fernando Freitas Silva¹, Mariana Passos De Luca¹, Efigênia Ferreira e
Ferreira², Maria Esperanza Córtes Segura¹, Telma Campos Medeiros Lorentz¹, Vagner Rodrigues Santos¹
RESUMO
A placa dentária é considerada um fator etiológico
chave associado a gengivite decorrente. A sua remoção
pode ser difícil em pacientes que possuam coordenação
motora deficiente ou quaisquer outros problemas. Então, o
uso do bochecho como adjunto da escovação no controle
da placa bacteriana e da gengivite pode aumentar os
benefícios no controle de placa dental. Um estudo de
fase II foi utilizado para avaliar a aderência, a apreciação
e a aceitabilidade de um enxaguatório bucal sem álcool
contendo 5% de própolis verde (EPV 5%) no controle de
placa e gengivite durante três meses. Cada indivíduo, ao
final do estudo, respondeu a um questionário sobre a
apreciação e aceitabilidade do enxaguante bucal. Vinte e
um pacientes completaram o estudo, apesar de a maioria
deles terem considerado o sabor do EPV 5% desagradável.
Eles ficaram satisfeitos com o produto e apontaram as
mudanças positivas na saúde bucal após o período de
tratamento. Sendo assim, a adesão foi satisfatória (≥
80%) sem diferença estatisticamente significante entre os
períodos de bochecho da manhã da noite.
UNITERMOS: aderência ao tratamento, satisfação do
paciente, enxaguante bucal, própolis. R Periodontia 2010;
20:53-59.
¹ Laboratory of Microbiology and Biomaterials, Faculdade de Odontologia da
Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.
² Department of Public Health, Faculdade de Odontologia da Universidade Federal de
Minas Gerais, Belo Horizonte, Brazil.
Recebimento: 07/06/10 - Correção: 15/07/10 - Aceite: 26/08/10
INTRODUction
Dental plaque-induced gingivitis is the most
prevalent disease that affects the periodontium.
Microbial dental plaque is considered the key
etiological factor associated with the development
of gingivitis (1). Plaque removal by mechanical means
(mostly a toothbrush combined with dentifrice) seems
to be a common way of controlling plaque. However,
factors such as dexterity and motivation, can limit the
effectiveness of daily self-performed oral hygiene (2).
To overcome deficiencies in mechanical tooth cleaning
as practiced by many individuals and some minority
groups, the use of an effective antiseptic agent, could
have clear benefits (3).
Thus, the use of a chemical plaque-inhibitory
mouthwash as a substitute or an adjunct to
toothbrushing may have a major effect on improving
the oral health of the individual (4). Although
considerable attention has been given to improve oral
care pratices in recent years, stinging sensation and
taste acceptability and tolerability of oral rinse agents
is a continuing problem in oral care (5). Some patients
may discontinue the oral care regimens prematurely,
affecting their compliance. Outcomes including
compliance and perception of taste by patients using
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mouthwash are important in studies that determine the
feasibility and efficacy of these products.
Natural products have been used for folk medicine
purposes throughout the world for thousands of years. Many
of them have demonstrable pharmacological properties, such
as antimicrobial, anti-inflammatory and cytostatic, among
others.
Propolis, a nontoxic natural resinous substance collected
by Apis mellifera bees from various plant sources, has been
recognized to have several properties that may confer health
benefits to humans, including prevention of oral diseases.
However, its chemical composition and pharmacological
activity are highly variable depending on its botanical origin (6).
The use of propolis in dental practice in Eastern Europe has
been widely described, being advocated as an antiseptic agent
in endodontics and periodontics (7, 8, 9, 10,11). However,
reports of its use are to be found, generally, in publications
which are not widely available. Thus, the use of propolis has
not been assessed by dental researchers outside these areas
to any significant extent (12).
Currently, few studies have been traced to assess the
compliance and subject’s attitudes with regard to the
mouthwash used (2, 3, 5). Besides, there are no published
studies evaluating the compliance of individuals using
a mouthwash containing propolis and their perception.
Then, aim of this study was to determine the compliance,
appreciation and acceptance by the patient in relation to
the use of an alcohol-free mouthwash containing 5% green
propolis for three months.
MATERIAL AND METHODS
Product tested
The alcohol-free mouthwash containing 5% green
propolis (MGP 5%) used in that study was handled according
to our request by PharmaNéctar ® (Belo Horizonte), within
the standards required by ANVISA (Brazil, 2000) and within
the requirements of ISO 9001 and GMP International (Table 4).
Study Design and Subjects
This was an interventional phase II study of three months,
conducted at Faculdade de Odontologia da Universidade
Federal de Minas Gerais, Brazil, from August 2009 to April
2010, after approval from the ethics committee of the
same institution (0600/09). This study is also registered at
ClinicalTrials.gov (NCT01142843).
According to Haynes (13) and ClinicalTrials.gov (14) phase
II study are controlled clinical studies conducted to evaluate
the effectiveness of the drug for a particular indication or
indications in patients with the disease or condition under
study and determine the common side effects and risks in
the short term. You can employ several different designs in
phase II, from case series to randomized controlled trials (RCTs)
or parallel crossed.
Table 4
Chemical composition and markers of Brazilian green propolis obtained by High Performance Liquid Chromatography (HPLC)
Nº
COMPOUNDS
UNIT (mg/g)
RESULTS
1
CUMARINIC ACID
mg/g
3.56
2
CINNAMIC ACID
mg/g
1.66
3
QUERCENTIN
mg/g
1.38
4
KAEMPFEROL
mg/g
1.77
5
ISORHAMNETIN
mg/g
0.91
6
SAKURANETIN
mg/g
5.57
7
PINOBANSKIN-3-ACETATE
mg/g
13.92
8
CHRYSIN
mg/g
3.51
9
GALANGIN
mg/g
9.75
10
KAEMPFERIDE
mg/g
11.60
11
ARTEPILLIN C
(3,5-DIPRENYL-4-HIDROXYCINNAMIC ACID)
mg/g
82.96
Pharmanectar®,2007.
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Figure 1 - Design study
Figure 1
Design study
Assessed for eligibility n = 73.
Excluded n = 48.
Not suitable for inclusion criteria n = 30.
Refused participation n = 18.
Included in the study n = 25.
Discontinued the study n = 1.
Excluded from the study before the
2 nd exam n = 2 ( probably allergy,
carry out dental treatment).
Excluded from the study after the 2nd
exam n = 1 (antibiotic use). Data from
1st and 2nd were used.
Completed the study n = 21.
Analysed n = 22 (21 completed the study and a left after the 2nd exam).
Twenty five subjects, age varying from 18 to 60 years, in
generally good health, not pregnancy and not breastfeeding,
who met the following inclusion criteria, were entered into
the study: a minimum of 20 sound, natural teeth; a mean
modification plaque index (PI) (15,16)of at least 1.5; a mean
modification gingival index (GI) (17,18) of at least 1.0. Subjects
with orthodontic appliances or removable prostheses, tumors
of the soft or hard oral tissues, advanced periodontal disease,
or that received antibiotic therapy during 2 weeks before
the start of the study or that presented hipersensibility of
propolis confirmed were excluded. Third molars and teeth
with cervical restorations or prosthetic crowns were not
included in the tooth count. All subjects read and signed
informed consent forms before the start of the study.
Examinations were performed in three moments: baseline,
45 e 90 days by a single dental examiner trained (Figure 1).
After baseline examination, each subject received a complete
oral prophylaxis, including the removal of supragingival and
subgingival plaque and calculus deposits. Soon after, the
subjects received an alcohol-free mouthwash containing
5% green propolis (Baccharis dracunculifolia) (MGP 5%),
toothbrush and were instructed to rinse their mouths, twice
daily, with 10 ml of the mouthrinse for a minute, immediately
after the brushing in the morning and at night.
also evaluated by a diary of frequency of use and by the
subjects’ self reports. These data was computed based on
the sum of the rinses made with the test product during the
period of 90 days divided by 180 (total number of rinses for 3
months), finding the percentage of individual mouth rising.
Then, performed the average of the percentages found by
considering the level for adequate compliance ≥ 80%. (total
number of rinse) (5). The appreciation and acceptability were
assessed through a questionnaire at the last examination. This
questionnaire contained issues to evaluate subjects’ attitudes
with regard to the product used. For each subject, was
recorded demographic and clinical data (gender, age, usual
oral care pratice, smoking and frequency of sugar on the diet).
Assessing Compliance, appreciation and
acceptability
Participants were required not to use another mouthrinse
throughout the duration of the study. When new supplies
were issued, subjects returned their used materials, so that
compliance with product use could be monitored. It was
Subjects
During the period of study, from August 2009 to
April 2010, 73 subjects were eligible after a selection by
convenience and, because of the inclusion and exclusion
criteria and availability to participate in the study, only a sample
of 25 individuals was possible include in that study, being in
Statistical analysis
The program statistic Excel 2007 and BioEstat 4.0 was
used to make the analysis of the study. The compliance,
appreciation and acceptability were analysed by percentage.
To verify statistically significant differences between the
number of rinses performed in the morning and evening,
featuring a parametric distribution, was used the t-test. The
criteria for statistical significance was set p≤ 0.05 (5).
RESULTS
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Compliance
All subjects that completed the three months of study
achieved an acceptable treatment compliance ≥ 80%. There
was no significant difference between the rinses performed in
the morning and at night, although some participants related
it was hard to follow the protocol to rinse at night (Table 2).
By the time subjects returned their used bottles, the
remaining mouthwash was compared to what they have
registered on the frequency diary, showing accordance
between the both.
agreement with (13), for phase II trials. Twenty one subjects
(10 males and 11 female) completed the period of study. Two
individuals were excluded from the search before the second
exam. One subject visited other dentist during the study
and the other individual had allergy to the product tested.
One subject was excluded after the second exam, because
of taking antibiotics due to illness. One person gave up the
study due to personal issues. Data related to behavior and
habits of life of each patient were recorded (Table 1).
Table 1
Behavior and habits of life.
Oral care pratices
Any
1 time/day
2 times/day
3 times/day
4times/day
sometimes/w
toothbrushing
0
1
4
14
5
1
Use of floss
4
8
8
1
0
4
Always
Often
Sometimes
Scarcely
Never
7
11
4
1
2
Yes
No
ex-smoker
0
20
5
21
4
Consumption of sugar
Smokers
Used some mouthrinse
Table 2
Compliance to the program of mouthwash.
Percentage mean and standard deviation of the number of rinses performed *
Morning
Night
Total
95.33 (3.7)**
92 (12.1)**
93,61 (6.91)
Appreciation and Acceptability
The table 3 summarizes and displays results obtained.
About staining of teeth and tongue, 19% of participants
answered that tongue remained green during use of the
mouthrinse. Some subjects reported feeling a dryness mouth
due to the use of the mouthrinse. Participants were asked
if the personal relationship improved after using the product
and the 28.5% gave a positive response. They were also
questioned about changes in the breath and taste. Most
of them reported that felt changes in the breath and one
patient answered that had loss of taste during three days
of use. Fifty two percent of individuals noted changes in the
oral cavity, but the majority, 54, 5%, were positives changes
(data not showed). They said their oral health became better.
Although most subjects reported the unpleasant taste of the
mouthwash, they said they were satisfied with the product
and would recommend its use to others. Only 23.8% of
individuals reported difficulties on following the protocol of
use.
DISCUSSION
The evaluation of the compliance, appreciation and
acceptance of mouthwash containing 5% green propolis
by subjects in the control of plaque and gingivitis, to date,
had not been assessed in any study (12,19,20,21). The use
of mouthwash should be considered a useful adjunct to
oral hygiene (22). It is important that the product is not
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Table 3
End interview
Questions
n
Yes
%
n
No
%
Stain of teeth or tongue
4
19%
17
81%
Dryness of mouth
3
14%
18
86%
Better personal relationship
6
28,5%
15
71,5%
Change in taste
1
4,7%
20
95,3%
Change in mouth
11
52%
10
48%
Change in breath
12
57%
9
43%
Better oral health
20
95,3%
1
4,7%
Good taste
5
23,8%
16
76%
Satisfaction with the product
21
100%
0
0%
Difficulties in following the protocol
5
23,8%
16
76%
Recomend its use to other
21
100%
0
0%
only effective but also, it should be acceptable. Currently,
although some researchers do not consider the acceptability
and tolerability of oral hygiene measures or antiseptic agents
of clinical significance, attention to this type of evaluation
is important for subjects. So, attention to the acceptability,
tolerability and preference are integral parts of treatment
compliance (5).
The MGP 5% was accepted and tolerated by subjects that
concluded this study. The level of compliance was high, more
than 80%. The periods of using the mouthwash (day/night)
were not mandatory. Individuals were faithful in the reports of
compliance, because these were in agreement with the notes
of frequencies and with the content present on the bottles
returned by them. The protocol of use of the mouthwash and
the amount that was used daily by each subject (10 ml MGP
5%) can be considered as an adequate therapeutic dosage,
in face to the obtained results.
After the last exam (90 days), subjects answered a
questionnaire that assessed appreciation and acceptability
regarding the mouthrinse provided. According to the results,
the changes reported by subjects are in agreement with those
reported in other studies about mouthwashes (23,24,25,26).
There was a little percentage of individuals who reported
changes such as staining of the tongue, dryness mouth and
loss of taste. Most reports on changes in the mouth and
breath were positive changes, and most subjects think they
acquired a better oral health after using the mouthwash.
These are factors that contribute to the acceptability of the
product by the subject. Few individuals reported difficulty
on following the protocol and it was not due to some
type of repulsion to the product or to have a complicated
administration. According to subjects, this difficulty was due
to the forgotness or discouragement of having to rinse before
they slept, sometimes late at night. Although most patients
have found the taste of the mouthrinse unpleasant, it did
not influence the compliance of them to treatment (≥ 80%).
Because of the high satisfaction for the product, based on
the observation of positive changes and oral health after
treatment, these subjects said they would recommend MGP
5% for others.
In conclusion, the mouthwash containing 5% green
propolis was accepted and tolerated by individuals. Although
most subjects find the taste of unpleasant MGP 5%, they
were satisfied with the product, considering the occurrence
of positive changes and oral health which performed better
after the treatment period. The changes mentioned by the
subjects in the questionnaire of perception, due to the use
of MGP 5% were both negative and positive, but positive
occurred more than the negatives. The negative changes were
not serious and are in accordance to those observed during
the use of other mouthwashes. Despite negative changes
mentioned and some individuals have reported difficulty on
following the protocol of mouthwash, adherence to treatment
was satisfactory (≥ 80%) having any statistically significant
difference between the periods of mouthwash in the morning
and at night. The small sample size available for the study
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limits the generalization of the results.
Investigations using a large sample size are needed to
obtain more information about compliance, appreciation and
acceptability of subjects using the mouthwash containing 5%
of green propolis.
Acknowledgements
The authors are grateful to the Conselho Nacional de
Desenvolvimento Científico e Tecnológico (CNPq), Fundação
de Amparo à Pesquisa do Estado de Minas Gerais (FAPEMIG)
and to Silvana Maria de Souza and Bruno Ferreira Lourenço
for technical support.
ABSTRACT
Dental plaque is considered a key etiological factor
associated with arising gingivitis. Its removal can be difficult
in pacients with lack of coordination or any other problems.
Then, the use of mouthrinse as adjunct to toothbrushing in
control of plaque and gingivitis might increase the benefits
of controlling dental plaque. A phase II study was used to
evaluate the compliance, appreciation and acceptability of
an alcohol-free mouthwash contain 5% green propolis (MGP
5%) in control of plaque and gingivitis for three months. Each
subject, at the end of the study, answered a questionnaire
about appreciation and acceptance of the mouthwash.
Twenty one subjects completed the study, although most
of them felt the taste of MGP 5% unpleasant. They were
satisfied with the product, pointing positive changes in the oral
health after the treatment period. Then, the compliance was
satisfactory (≥ 80%) with no statistically significant difference
between the periods of rinsing in the morning and at night.
UNITERMS: propolis mouthrinse, adherence to treatment,
satisfaction, antiseptic agent
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For reprints and all correspondence:
Dr. Vagner Rodrigues Santos
Laboratório de Microbiologia, Faculdade de Odontologia,
Universidade Federal de Minas Gerais, Campus Pampulha.
Av. Presidente Antônio Carlos, 662
CEP: 31270-901 - Belo Horizonte – MG - Brasil
Tel.: + 55-31- 3409-2497; fax: + 55-31-3409-2430
E-mail: [email protected] / [email protected]
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