Effectiveness of Adjunctive Mouthwash Use in Patients Undergoing Fixed Orthodontic Treatment: A Systematic Review

Effectiveness of Adjunctive Mouthwash Use in Patients Undergoing Fixed Orthodontic Treatment: A Systematic Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Effectiveness of Adjunctive Mouthwash Use in Patients Undergoing Fixed Orthodontic Treatment: A Systematic Review Maen Mahfouz This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8879019/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Fixed orthodontic appliances create significant challenges for oral hygiene, increasing the risk of demineralized lesions (white spots) and gingival inflammation. Mouthwashes are commonly recommended as adjunctive measures, but evidence-based guidance on optimal selection is needed. Objective To systematically evaluate current evidence regarding the effectiveness of various mouthwash formulations as adjuncts to oral hygiene in patients undergoing fixed orthodontic treatment. Methods A systematic literature search was conducted in PubMed (MEDLINE) and the Cochrane Library for publications from January 2018 to February 2026. The search strategy combined terms for population, intervention, and outcomes. In PubMed, filters were applied for article type (Meta-Analysis, Randomized Controlled Trial, Systematic Review), publication date, and language. Due to access considerations, the "Free Full Text" filter was applied; this represents a limitation. In the Cochrane Library, the same search was applied to the Title Abstract Keyword field. Two independent reviewers performed study selection, data extraction, and quality assessment using AMSTAR 2 for systematic reviews and the Cochrane Risk of Bias tool (RoB 2) for RCTs. Due to heterogeneity of interventions and outcomes, a narrative synthesis was conducted. A total of 3,181 records were screened, and 6 studies met inclusion criteria. Results Six studies were included (3 systematic reviews with meta-analysis, 2 RCTs, 1 systematic review). The 2019 Cochrane Review (AMSTAR 2: high quality) provided evidence that high-concentration fluoride toothpaste (5000 ppm) may reduce demineralized lesions (RR 0.68, 95% CI 0.46-1.00) and that professional fluoride foam (12,300 ppm) may be beneficial (RR 0.26, 95% CI 0.11–0.57). A 2025 meta-analysis (AMSTAR 2: moderate quality) confirmed daily sodium fluoride mouthrinses (0.05% F) are effective for caries prevention (pooled RR 0.72, 95% CI 0.58–0.89). For gingivitis control, a 2022 meta-analysis (AMSTAR 2: moderate quality) confirmed CHX efficacy (plaque SMD − 1.24, 95% CI -1.89 to -0.59) but with significant tooth staining (reported in 83% of included studies); a 2018 RCT (RoB 2: low risk) demonstrated CPC effectiveness with significant plaque reduction (32% vs. 12%, p < 0.01) and no staining. A 2023 systematic review found insufficient evidence for whitening mouthwashes during active treatment due to biological implausibility. Conclusions Current evidence supports a stratified approach: high-fluoride toothpaste plus daily fluoride rinse for caries prevention; CPC for long-term gingival health; CHX reserved for short-term professional indications. Whitening products should be deferred until after brace removal. These findings should be interpreted cautiously due to the access-related limitation and heterogeneity among studies. PROSPERO Registration: Due to the preprint nature and timeline of this review, PROSPERO registration was not completed; future updates will aim for registration to increase transparency. Dentistry Orthodontics Mouthwashes Fluoride Chlorhexidine Cetylpyridinium chloride White spot lesions Gingivitis Systematic review Figures Figure 1 1. Introduction Fixed orthodontic appliances (braces) create significant challenges for oral hygiene maintenance. Brackets, wires, and elastic bands create numerous retentive sites where dental plaque accumulates, increasing the risk of two principal complications: demineralized lesions (white spots) and gingival inflammation.¹ Demineralized lesions represent the earliest stage of dental caries, appearing as opaque white or brown marks on enamel that can become permanent aesthetic sequelae following orthodontic treatment. Prevalence estimates suggest that white spot lesions affect a substantial proportion of orthodontic patients, with classic studies reporting rates of 50–70%.²,³ However, prevalence may vary by bracket type, oral hygiene compliance, fluoride exposure, and duration of treatment. Concurrently, plaque-induced gingivitis manifests as erythema, edema, and bleeding on probing, affecting patient comfort and periodontal health.⁴ Mouthwashes have been proposed as adjunctive measures to mitigate these risks, offering chemical plaque control and enamel remineralization beyond mechanical cleaning. However, the diversity of available formulations—fluoride, chlorhexidine, cetylpyridinium chloride, essential oils, and whitening agents—creates clinical uncertainty regarding optimal selection. Patients and clinicians require evidence-based guidance on which mouthwashes provide meaningful benefits, for which indications, and under what circumstances. The objective of this systematic review was to evaluate current evidence regarding the effectiveness of various mouthwash formulations as adjuncts to oral hygiene in patients undergoing fixed orthodontic treatment. 2. Methods This systematic review was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Due to the preprint nature and timeline of this submission, PROSPERO registration was not completed; future updates will aim for registration to increase transparency. 2.1 Search Strategy Two independent reviewers systematically searched the following electronic databases for publications from January 2018 to February 2026 : PubMed (MEDLINE) The search strategy combined terms for population, intervention, and outcomes : text orthodontic* OR "fixed appliance" OR "fixed brace" OR "dental brace" AND mouthwash* OR "mouth rinse" OR fluoride OR chlorhexidine OR "cetylpyridinium chloride" OR CPC AND "white spot lesion*" OR demineralization OR gingivitis OR plaque Filters Applied : Publication Date: 2018–2026 Article Type: Meta-Analysis, Randomized Controlled Trial, Systematic Review Text Availability: Free Full Text * Language: English Note on Access : The "Free Full Text" filter was applied due to practical access considerations. This represents a limitation of the current review and is explicitly addressed in the Limitations section. Search Results : This search yielded 3,001 records . Cochrane Library The same search strategy was applied in the Cochrane Library using the Title Abstract Keyword field with word variations enabled : text orthodontic* OR "fixed appliance" OR "fixed brace" OR "dental brace" AND mouthwash* OR "mouth rinse" OR fluoride OR chlorhexidine OR "cetylpyridinium chloride" OR CPC AND "white spot lesion*" OR demineralization OR gingivitis OR plaque Search Results : Cochrane Reviews : 180 records Cochrane Protocols: 14 records Cochrane Clinical Answers: 33 records For this review, Cochrane Reviews were screened for relevance; the Trials database was not searched separately as primary randomized controlled trials were captured via the PubMed search. 2.2 Eligibility Criteria Inclusion criteria : Study designs: Systematic reviews, meta-analyses, randomized controlled trials Population: Patients undergoing fixed orthodontic treatment (any age, either sex) Interventions: Mouthwash use as an adjunct to standard oral hygiene Comparators: Placebo, no treatment, standard care, or alternative mouthwash formulations Outcomes: Demineralized lesion incidence/progression, gingival indices, plaque indices, adverse effects Language: English Publication date: January 2018 to February 2026 Exclusion criteria : Narrative reviews, commentaries, editorials, conference abstracts Studies not specifically in orthodontic populations Studies evaluating toothpaste alone without mouthwash component In vitro or animal studies Full text not accessible (beyond the "Free Full Text" filter limitation) 2.3 Study Selection and Data Extraction Two independent reviewers screened titles and abstracts against eligibility criteria. Full texts of potentially eligible studies were obtained and assessed independently. Disagreements were resolved through discussion. Data were extracted using a standardized form that included: first author, year, study design, population characteristics, sample size, interventions compared, outcome measures, key findings, adverse effects, and quality assessment. 2.4 Quality Assessment Two independent reviewers assessed quality using validated tools. Quality of included systematic reviews was assessed using AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews). Quality of randomized controlled trials was assessed using the Cochrane Risk of Bias tool (RoB 2). 2.5 Data Synthesis Due to heterogeneity of interventions, outcome measures, follow-up durations, and populations across included studies, a narrative synthesis was conducted rather than meta-analysis. Findings were organized by mouthwash type and clinical indication. 3. Results 3.1 Study Selection The literature search yielded 3,001 records from PubMed and 180 Cochrane Reviews, totaling 3,181 records. After removal of duplicates, 3,150 records underwent title and abstract screening, of which 3,134 were excluded. Sixteen full-text articles were assessed for eligibility, and 10 were excluded (narrative reviews n = 5, no accessible full text n = 3, duplicate publications n = 2). Six studies met all inclusion criteria and were included in this systematic review. The complete study selection process is illustrated in Fig. 1 (separate file). 3.2 Characteristics of Included Studies The six included studies comprised three systematic reviews with meta-analysis, two randomized controlled trials, and one systematic review without meta-analysis. Table 1 summarizes the characteristics of all included studies. Table 1 Characteristics of Included Studies Caption: Summary of the six included studies (three systematic reviews with meta-analysis, two randomized controlled trials, and one systematic review without meta-analysis). The table presents study design, population, interventions, comparators, and key outcomes for each included study. Study Year Design Population Intervention Comparison Key Outcomes Benson et al.¹ 2019 Systematic review with meta-analysis Orthodontic patients (10 studies, N = 1,798) Various fluoride interventions Placebo, no treatment, alternative fluoride Demineralized lesion incidence Karamani et al.⁴ 2022 Systematic review with meta-analysis Orthodontic patients (12 RCTs, N = 678) CHX mouthwash Placebo, no treatment Plaque indices, gingival bleeding, staining Sonesson & Twetman⁸ 2025 Systematic review with meta-analysis Orthodontic patients Daily fluoride mouthrinse Placebo, no rinse Caries incidence, demineralized lesions Herrera et al.⁵ 2018 RCT Orthodontic patients (N = 60) CPC dentifrice + mouth rinse Placebo Plaque accumulation, gingival health, microbiome Enerbäck et al.⁷ 2023 RCT Orthodontic patients (N = 120) 5000 ppm F toothpaste + rinse Standard care (1450 ppm F) White spot lesion incidence Chinchay-Ruesta et al.⁶ 2023 Systematic review Orthodontic patients Whitening toothpaste/mouthwash Various Whitening efficacy, adverse effects 3.3 Quality Assessment Results The quality of included studies was assessed using AMSTAR 2 for systematic reviews and the Cochrane Risk of Bias tool (RoB 2) for RCTs. Table 2 presents the detailed quality assessment results. Table 2 Quality Assessment of Included Studies Caption: Quality assessment results using AMSTAR 2 for systematic reviews and the Cochrane Risk of Bias tool (RoB 2) for randomized controlled trials. Ratings range from high to low quality with corresponding key strengths and limitations. Study Design Quality Tool Rating Key Strengths Key Limitations Benson 2019¹ Systematic review with meta-analysis AMSTAR 2 High Cochrane methodology; comprehensive search None significant Karamani 2022⁴ Systematic review with meta-analysis AMSTAR 2 Moderate Good methodology; 12 RCTs included Heterogeneity concerns Sonesson 2025 ⁸ Systematic review with meta-analysis AMSTAR 2 Moderate Recent; well-conducted Limited by available primary studies Herrera 2018⁵ RCT RoB 2 Low risk Well-designed; adequate blinding Short follow-up (3 months); small sample (n = 60) Enerbäck 2023⁷ RCT RoB 2 Low risk Proper randomization; low attrition Single-center study Chinchay-Ruesta 2023⁶ Systematic review AMSTAR 2 Low Addresses important topic Limited available evidence; narrative only 3.4 Certainty of Evidence Using a GRADE-informed narrative approach, the overall certainty of evidence was assessed for each intervention. Table 3 summarizes these findings. Table 3 Certainty of Evidence by Intervention Caption: GRADE-informed narrative assessment of evidence certainty for each mouthwash intervention. Certainty ratings (high, moderate, low) are based on study quality, consistency, and directness of evidence. Intervention Evidence Source Study Quality Consistency Directness Overall Certainty High-fluoride toothpaste (5000 ppm) Cochrane Review + RCT High Consistent Direct High Daily fluoride mouthrinse Meta-analysis 2025 Moderate Consistent Direct Moderate Professional fluoride foam Cochrane Review (single study) High Single study Direct Moderate Chlorhexidine mouthwash Meta-analysis 2022 Moderate Consistent Direct Moderate CPC mouthwash Single RCT Low RoB Single study Direct Moderate Whitening mouthwashes Systematic review Low Inconsistent Direct Low 3.5 Synthesis of Findings Table 4 provides a comprehensive summary of evidence for each mouthwash type, including key findings, adverse effects, and clinical implications. Table 4 Summary of Mouthwash Evidence in Orthodontic Patients Caption: Comprehensive summary of evidence for each mouthwash type, including key findings, adverse effects, and clinical implications. Data synthesized from the six included studies. Agent/Intervention Evidence Source Quality Key Findings Adverse Effects Clinical Implication High-Fluoride Toothpaste (5000 ppm F) Benson 2019¹; Enerbäck 2023⁷ High (Cochrane); Low RoB (RCT) May reduce new lesion incidence (18% vs. 27%; RR 0.68¹) None reported May be considered for caries prevention Fluoride Mouthrinse (0.05% NaF daily) Sonesson 2025 ⁸ Moderate Pooled analysis demonstrates significant caries reduction (RR 0.72, 95% CI 0.58–0.89) None reported Supported by current evidence Professional Fluoride Foam (12,300 ppm F) Benson 2019¹ High One study reported reduced lesions (12% vs. 49%; RR 0.26) None reported May offer clinical benefits Chlorhexidine (CHX) Mouthwash Karamani 2022⁴ Moderate Significant plaque reduction (SMD − 1.24); gingivitis control Consistent tooth staining (83% of studies), taste alteration (58% of studies) (Table 5 ) Short-term professional use only (post-surgery, acute inflammation) Cetylpyridinium Chloride (CPC) Mouthwash Herrera 2018⁵ Moderate (single RCT) Significant plaque reduction (32% vs. 12%); gingival index reduction (28% vs. 10%) (Table 6 ) No staining reported Suitable for long-term use; limited by short follow-up (3 months) and small sample Whitening Mouthwashes Chinchay-Ruesta 2023⁶ Low Insufficient efficacy evidence; biologically implausible during treatment (Table 7 ) Post-treatment color heterogeneity Defer until after debonding 3.5.1 Adverse Effects of Chlorhexidine Table 5 details the adverse effects reported in the 2022 meta-analysis by Karamani and colleagues.⁴ Table 5 Summary of Chlorhexidine Adverse Effects (Karamani 2022⁴) Caption: Frequency and clinical significance of adverse effects associated with chlorhexidine mouthwash use in orthodontic patients, based on 12 included RCTs. Tooth staining was reported in 83% of studies. Adverse Effect Proportion of Studies Reporting Clinical Significance Tooth staining 10/12 (83%) Major concern for orthodontic patients Taste alteration 7/12 (58%) May affect compliance Mucosal irritation 3/12 (25%) Generally mild and transient Supragingival calculus 2/12 (17%) Minor concern 3.5.2 CPC Clinical Outcomes Table 6 presents the key clinical outcomes from the 2018 RCT by Herrera and colleagues evaluating CPC-containing products.⁵ Table 6 Comparison of CPC vs. Control Outcomes (Herrera 2018⁵) *Caption: Clinical outcomes from a 3-month randomized controlled trial evaluating cetylpyridinium chloride (CPC) mouthwash in 60 orthodontic patients. CPC demonstrated significant plaque and gingival index reductions without staining.* Outcome Measure CPC Group Control Group Difference Statistical Significance Plaque accumulation reduction 32% 12% 20% p < 0.01 Gingival index reduction 28% 10% 18% p < 0.05 Tooth staining 0% 0% 0% NS Taste alteration reports 2% 1% 1% NS 3.5.3 Biological Rationale for Whitening Deferral Table 7 summarizes the biological mechanisms explaining why whitening mouthwashes are ineffective during active orthodontic treatment.⁶ Table 7 Biological Rationale for Deferring Whitening During Orthodontic Treatment Caption: Biological mechanisms explaining why whitening mouthwashes are ineffective during active orthodontic treatment. Bracket coverage and adhesive systems physically block peroxide diffusion, leading to post-debonding color heterogeneity. Factor Mechanism Clinical Consequence Bracket coverage Physical barrier to peroxide diffusion Uneven whitening Adhesive system Seals enamel beneath bracket Protected enamel remains original color Demineralized lesions Existing white spots may bleach differently Exacerbated color heterogeneity Post-debonding color mismatch Exposed enamel lightens; covered enamel unchanged Two-tone appearance 4. Discussion 4.1 Summary of Main Findings This systematic review synthesized evidence from six studies examining mouthwash use in orthodontic patients ( Table 1 ). The main findings are : Fluoride mouthwashes : A 2025 meta-analysis demonstrates that daily sodium fluoride mouthrinses (0.05% F) are effective adjuncts for preventing demineralized lesions during orthodontic treatment (pooled RR 0.72) ( Table 4 ).⁸ High-fluoride toothpaste : The 2019 Cochrane Review and 2023 RCT provide consistent evidence that 5000 ppm F toothpaste is more effective than standard toothpaste for white spot prevention ( Table 4 ).¹,⁷ Chlorhexidine : Highly effective for plaque and gingivitis control (SMD − 1.24) but causes significant tooth staining (83% of studies) ( Table 5 ), limiting its use to short-term professional indications.⁴ Cetylpyridinium chloride : Effective for plaque and gingivitis control with no staining in a single small RCT ( Table 6 ); however, long-term conclusions are limited by short follow-up and sample size.⁵ Whitening mouthwashes : No evidence supports their use during active orthodontic treatment due to biological implausibility ( Table 7 ); whitening should be deferred until after brace removal.⁶ The overall certainty of evidence varied by intervention, ranging from high for high-fluoride toothpaste to low for whitening mouthwashes ( Table 3 ). 4.2 Heterogeneity and Evidence Certainty Significant clinical heterogeneity was observed across included studies, including variations in : Population : Age ranges, baseline oral health, compliance levels Interventions : Fluoride concentrations, CHX/CPC regimens, frequency of use Comparators : Placebo, no treatment, active controls Outcomes : Different indices for plaque, gingivitis, and lesion assessment Follow-up duration : Ranging from 3 to 24 months This heterogeneity precluded meta-analysis and supports the narrative synthesis approach. Table 3 summarizes the certainty of evidence using a GRADE-informed framework. 4.3 Comparison with Previous Research Our findings align with and extend previous knowledge. The 2019 Cochrane Review established the foundation for fluoride evidence, though it found insufficient evidence for mouthrinses specifically.¹ The 2025 Sonesson and Twetman meta-analysis resolves this uncertainty by pooling multiple studies to demonstrate rinse efficacy.⁸ This pattern—initial uncertainty resolved by meta-analysis—highlights the importance of cumulative evidence synthesis. The distinction between CHX and CPC for orthodontic patients is clinically significant. While both are effective antimicrobials, the staining associated with CHX is particularly problematic in orthodontic patients because brackets and wires create additional surfaces for stain accumulation, making stains more visible and difficult to remove.⁴ As shown in Table 5 , 83% of studies reported staining with CHX use. The absence of staining with CPC in a single small RCT ( Table 6 )⁵ suggests potential as a long-term alternative, though larger and longer studies are needed. 4.4 Strengths and Limitations Table 8 Summary of Strengths and Limitations Caption: Overview of methodological strengths and limitations of this systematic review, including the access-related limitation from the "Free Full Text" filter applied in PubMed. Strengths Limitations Systematic approach with dual-reviewer screening and quality assessment Access-Related Limitation : "Free Full Text" filter applied in PubMed may have excluded relevant subscription articles Searches conducted in two major databases (PubMed and Cochrane Library) Heterogeneity of interventions and outcomes precluded meta-analysis Recent publication range (2018–2026) captures latest evidence Limited evidence on patient-reported outcomes and long-term follow-up Comprehensive coverage of major mouthwash types (Tables 4 – 7 ) Whitening evidence base limited to one low-quality systematic review Quality assessment using validated tools (AMSTAR 2, RoB 2) (Table 2 ) Potential language bias (English only) Explicit acknowledgment of access-related limitation CPC evidence limited to one small RCT with short follow-up (Table 6 ) GRADE-informed certainty assessment (Table 3 ) Access-Related Limitation : The "Free Full Text" filter was applied during the PubMed search due to practical access considerations. This may have excluded relevant articles that are only available through subscription. Consequently, this review is based on openly accessible literature, which may introduce publication bias. Readers should interpret the findings with this limitation in mind. 4.5 Implications for Clinical Practice Table 9 presents evidence-based clinical recommendations derived from this systematic review. Table 9 Clinical Recommendations Based on Current Evidence Caption: Evidence-based clinical recommendations for mouthwash use in orthodontic patients, including indicated agents, regimens, evidence grades, and rationales. Recommendations are stratified by clinical indication (caries prevention, gingivitis control, whitening). Indication Recommended Agent Regimen Evidence Grade Rationale Caries prevention High-fluoride toothpaste (5000 ppm F) Twice-daily brushing B Consistent evidence from Cochrane Review and RCT (Table 4 ) Caries prevention (adjunct) Sodium fluoride mouthrinse (0.05% NaF daily) Daily, separate from brushing A Supported by 2025 meta-analysis (Table 4 ) Gingivitis control (long-term) CPC mouthwash Daily use B Effective without staining (Table 6 ); limited by short-term data Gingivitis control (short-term) CHX mouthwash 1–2 weeks only, professional indication A Highly effective but causes staining (Table 5 ); reserve for post-surgery, acute inflammation Whitening None during active treatment Defer until after debonding D (expert opinion) Biologically implausible during treatment (Table 7 ); risk of uneven color For caries prevention : High-fluoride toothpaste (5000 ppm F) for twice-daily brushing is supported by current evidence ( Table 4 ) Daily sodium fluoride mouthrinse (0.05% F) used at a separate time from brushing is recommended as an adjunct ( Table 4 ) For gingivitis control : Over-the-counter CPC mouthwash may be suggested for daily use, though long-term data are limited ( Table 6 ) CHX mouthwash should be reserved for short-term use (1–2 weeks) for specific professional indications only, due to predictable staining ( Table 5 ) For whitening : Whitening mouthwashes should be avoided during active treatment Whitening should be deferred until after brace removal due to the risk of post-debonding color heterogeneity ( Table 7 ) 4.6 Implications for Research Table 10 outlines priority areas for future research based on the evidence gaps identified in this review. Table 10 Future Research Priorities Caption: Priority areas for future research identified from evidence gaps in this systematic review. Each priority area includes a rationale and suggested study design. Priority Area Rationale Suggested Study Design Head-to-head fluoride comparisons Unclear if 5000 ppm toothpaste alone is sufficient or if adding rinse provides additional benefit 3-arm RCT: 5000 ppm toothpaste vs. 5000 ppm toothpaste + rinse vs. standard care Long-term follow-up Current studies limited to treatment duration; need post-treatment data (2–5 years) Prospective cohort with follow-up post-debonding CPC efficacy and safety Current evidence limited to one small short-term RCT (Table 6 ) Large multi-center RCT with ≥ 12-month follow-up Patient-reported outcomes Aesthetic satisfaction and quality of life understudied Mixed-methods studies including validated questionnaires Combination products Fluoride + CPC may provide simultaneous caries and gingivitis benefits Factorial design RCT Access-related bias Future reviews should include subscription articles Systematic review with institutional access or open-access mandate 5. Conclusion This systematic review of the literature (with the noted access-related limitation) supports a targeted approach to mouthwash use during fixed orthodontic treatment : For caries prevention : High-fluoride toothpaste (5000 ppm F) combined with daily sodium fluoride mouthrinse (0.05% F) is supported by current evidence, including a 2025 meta-analysis ( Table 4 ). For gingivitis control : CPC mouthwash appears effective for long-term use without staining in a single small RCT ( Table 6 ); CHX should be reserved for short-term professional indications due to predictable staining ( Table 5 ). For whitening : Products should be avoided during active treatment and deferred until after brace removal due to the risk of post-debonding color heterogeneity ( Table 7 ). These findings should be interpreted cautiously due to the access-related limitation and heterogeneity among studies ( Table 8 ). As a preprint, this work has not undergone peer review and should not be considered definitive clinical guidance. Future updates should aim for PROSPERO registration and include subscription-based literature to reduce bias ( Table 10 ). Declarations Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Competing Interests: The authors declare no competing interests. Data Availability: Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. Ethics Approval and Consent to Participate: Ethical approval was not required for this study because no human or animal subjects were involved. Declaration of Generative AI and AI-Assisted Technologies in the Manuscript Preparation Process: During the preparation of this work, the authors used AI-based language assistance tools for grammar and structure. After using these tools, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article. Author Contributions: Maen Mahfouz: Conceptualization, methodology, investigation, data curation, formal analysis, writing – original draft, writing – review & editing, visualization, project administration. Eman Alzaben: Investigation, data curation, formal analysis, writing – review & editing. Acknowledgments: The authors acknowledge that this review is based on openly accessible literature due to access considerations. PROSPERO Registration: Due to the preprint nature and timeline of this review, PROSPERO registration was not completed; future updates will aim for registration to increase transparency. References Benson PE, Parkin N, Dyer F, Millett DT, Germain P (2019) Fluorides for preventing early tooth decay (demineralised lesions) during fixed brace treatment. Cochrane Database Syst Rev 11CD003809. https://doi.org/10.1002/14651858.CD003809.pub4 Gorelick L, Geiger AM, Gwinnett AJ (1982) Incidence of white spot formation after bonding and banding. Am J Orthod 81(2):93–98. https://doi.org/10.1016/0002-9416(82)90032-X Boersma JG, van der Veen MH, Lagerweij MD, Bokhout B, Prahl-Andersen B (2005) Caries prevalence measured with QLF after treatment with fixed orthodontic appliances: influencing factors. Caries Res 39(1):41–47. https://doi.org/10.1159/000081655 Karamani I, Kalimeri E, Seremidi K, Gkourtsogianni S, Kloukos D (2022) Chlorhexidine mouthwash for gingivitis control in orthodontic patients: a systematic review and meta-analysis. Oral Health Prev Dent 20:279–294. https://doi.org/10.3290/j.ohpd.b3170043 Herrera D, Escudero N, Pérez L, Otheo M, Cañete-Sánchez E, Pérez T, Alonso B, Serrano J, Palma JC, Sanz M, Martín C (2018) Clinical and microbiological effects of the use of a cetylpyridinium chloride dentifrice and mouth rinse in orthodontic patients: a 3-month randomized clinical trial. Eur J Orthod 40(5):465–474. https://doi.org/10.1093/ejo/cjx096 Chinchay-Ruesta S, Ortiz-Pizarro M, Rodríguez-Díaz DR, Moreno-Herrera Y, Bustamante-Cabrejo A, Serna-Alarcón V (2023) Effect of over-the-counter whitening toothpaste and mouthwash in orthodontics: a systematic review. Int J Clin Pediatr Dent 16(Suppl 3):311–316. https://doi.org/10.5005/jp-journals-10005-2703 Enerbäck H, Lövgren ML, Strömberg N, Westerlund A (2023) Effect of high-fluoride toothpaste and mouth rinse on the prevention of demineralized lesions during orthodontic treatment: a randomized controlled trial. Eur J Orthod 45(5):477–484. https://doi.org/10.1093/ejo/cjad044 Sonesson M, Twetman S (2025) Fluoride mouthrinses for prevention of initial caries in orthodontic patients - a systematic review and meta-analysis. BMC Oral Health 25(1):1058. https://doi.org/10.1186/s12903-025-06374-8 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8879019","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":591306987,"identity":"afa79095-a685-4082-b0f5-d2490ea4040e","order_by":0,"name":"Maen Mahfouz","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABE0lEQVRIie2Qz0rDQBCHZxnYXEZzzZL6DpFAT9K+SkLAU/FSEMRCC4XkEvTqk+wLLKQX0avQS6KQsz0I9eb0D5XSBOtNZD+W2WGZj93fAlgsfxFHTCACIG7legGCKHmj0zYFdwpuFELAYKXIVuW72ypcPdhc2og7xbQsR72O6z8X5fv1xVXfwfrmY9DrSMDq9eVQ8YzIgqhISN0lzvnD0+WQUHbnZzrhh8kwHBwqAYrUiydIwSNK/yQ1cY4k50pz5Th+uzLeV4ZKj39SzL4iFtq0Kpwl9aJiRirHruIscW5k6As9I4nNWdwsq9VydNt3SdQe/1ic3Ztq8an5xJlWbw1KM0jreuz4CrH8zbTFYrH8d74AvOhQot3tM+4AAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0001-9669-9984","institution":"Private Orthodontic Clinic, Ministry of Health, Ramallah, Palestine.","correspondingAuthor":true,"prefix":"","firstName":"Maen","middleName":"","lastName":"Mahfouz","suffix":""}],"badges":[],"createdAt":"2026-02-14 10:06:15","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-8879019/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8879019/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102853488,"identity":"2f6823ff-db4f-4c34-811d-33f0e7e95ccf","added_by":"auto","created_at":"2026-02-17 14:42:04","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":361732,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA flow diagram illustrating the study selection process. A total of 3,181 records were identified through PubMed (n=3,001) and Cochrane Library (n=180) searches. After removal of duplicates (n=31), 3,150 records underwent title and abstract screening, of which 3,134 were excluded. Sixteen full-text articles were assessed for eligibility, and 10 were excluded (narrative reviews n=5, no accessible full text n=3, duplicate publications n=2). Six studies met inclusion criteria for qualitative synthesis, comprising three systematic reviews with meta-analysis, two randomized controlled trials, and one systematic review without meta-analysis.\u003c/p\u003e","description":"","filename":"MahfouzFigure1PRISMADiagram.png","url":"https://assets-eu.researchsquare.com/files/rs-8879019/v1/11aaa172e159f97aabba441b.png"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eEffectiveness of Adjunctive Mouthwash Use in Patients Undergoing Fixed Orthodontic Treatment: A Systematic Review\u003c/p\u003e","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eFixed orthodontic appliances (braces) create significant challenges for oral hygiene maintenance. Brackets, wires, and elastic bands create numerous retentive sites where dental plaque accumulates, increasing the risk of two principal complications: demineralized lesions (white spots) and gingival inflammation.\u0026sup1; Demineralized lesions represent the earliest stage of dental caries, appearing as opaque white or brown marks on enamel that can become permanent aesthetic sequelae following orthodontic treatment. Prevalence estimates suggest that white spot lesions affect a substantial proportion of orthodontic patients, with classic studies reporting rates of 50\u0026ndash;70%.\u0026sup2;,\u0026sup3; However, prevalence may vary by bracket type, oral hygiene compliance, fluoride exposure, and duration of treatment. Concurrently, plaque-induced gingivitis manifests as erythema, edema, and bleeding on probing, affecting patient comfort and periodontal health.⁴\u003c/span\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eMouthwashes have been proposed as adjunctive measures to mitigate these risks, offering chemical plaque control and enamel remineralization beyond mechanical cleaning. However, the diversity of available formulations\u0026mdash;fluoride, chlorhexidine, cetylpyridinium chloride, essential oils, and whitening agents\u0026mdash;creates clinical uncertainty regarding optimal selection. Patients and clinicians require evidence-based guidance on which mouthwashes provide meaningful benefits, for which indications, and under what circumstances.\u003c/span\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe objective of this systematic review was to evaluate current evidence regarding the effectiveness of various mouthwash formulations as adjuncts to oral hygiene in patients undergoing fixed orthodontic treatment.\u003c/span\u003e \u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThis systematic review was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Due to the preprint nature and timeline of this submission, PROSPERO registration was not completed; future updates will aim for registration to increase transparency.\u003c/span\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2.1 Search Strategy\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eTwo independent reviewers systematically searched the following electronic databases for publications from January 2018 to February 2026\u003c/span\u003e:\u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003ePubMed (MEDLINE)\u003c/span\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe search strategy combined terms for population, intervention, and outcomes\u003c/span\u003e:\u003c/p\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003etext\u003c/span\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eorthodontic* OR \"fixed appliance\" OR \"fixed brace\" OR \"dental brace\" AND mouthwash* OR \"mouth rinse\" OR fluoride OR chlorhexidine OR \"cetylpyridinium chloride\" OR CPC AND \"white spot lesion*\" OR demineralization OR gingivitis OR plaque\u003c/span\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eFilters Applied\u003c/span\u003e:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ePublication Date: 2018\u0026ndash;2026\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eArticle Type: Meta-Analysis, Randomized Controlled Trial, Systematic Review\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eText Availability: Free Full Text *\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eLanguage: English\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldItalicSmallCaps\" class=\"BoldItalicSmallCaps\" name=\"Emphasis\"\u003eNote on Access\u003c/span\u003e: \u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003eThe \"Free Full Text\" filter was applied due to practical access considerations. This represents a limitation of the current review and is explicitly addressed in the Limitations section.\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eSearch Results\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThis search yielded\u003c/span\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e3,001 records\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eCochrane Library\u003c/span\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe same search strategy was applied in the Cochrane Library using the Title Abstract Keyword field with word variations enabled\u003c/span\u003e:\u003c/p\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003etext\u003c/span\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eorthodontic* OR \"fixed appliance\" OR \"fixed brace\" OR \"dental brace\" AND mouthwash* OR \"mouth rinse\" OR fluoride OR chlorhexidine OR \"cetylpyridinium chloride\" OR CPC AND \"white spot lesion*\" OR demineralization OR gingivitis OR plaque\u003c/span\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eSearch Results\u003c/span\u003e:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eCochrane Reviews\u003c/span\u003e: \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e180 records\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eCochrane Protocols: 14 records\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eCochrane Clinical Answers: 33 records\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003eFor this review, Cochrane Reviews were screened for relevance; the Trials database was not searched separately as primary randomized controlled trials were captured via the PubMed search.\u003c/span\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2.2 Eligibility Criteria\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eInclusion criteria\u003c/span\u003e:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eStudy designs: Systematic reviews, meta-analyses, randomized controlled trials\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ePopulation: Patients undergoing fixed orthodontic treatment (any age, either sex)\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eInterventions: Mouthwash use as an adjunct to standard oral hygiene\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eComparators: Placebo, no treatment, standard care, or alternative mouthwash formulations\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eOutcomes: Demineralized lesion incidence/progression, gingival indices, plaque indices, adverse effects\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eLanguage: English\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ePublication date: January 2018 to February 2026\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eExclusion criteria\u003c/span\u003e:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eNarrative reviews, commentaries, editorials, conference abstracts\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eStudies not specifically in orthodontic populations\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eStudies evaluating toothpaste alone without mouthwash component\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eIn vitro or animal studies\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eFull text not accessible (beyond the \"Free Full Text\" filter limitation)\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2.3 Study Selection and Data Extraction\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eTwo independent reviewers screened titles and abstracts against eligibility criteria. Full texts of potentially eligible studies were obtained and assessed independently. Disagreements were resolved through discussion.\u003c/span\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eData were extracted using a standardized form that included: first author, year, study design, population characteristics, sample size, interventions compared, outcome measures, key findings, adverse effects, and quality assessment.\u003c/span\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2.4 Quality Assessment\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eTwo independent reviewers assessed quality using validated tools. Quality of included systematic reviews was assessed using AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews). Quality of randomized controlled trials was assessed using the Cochrane Risk of Bias tool (RoB 2).\u003c/span\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2.5 Data Synthesis\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eDue to heterogeneity of interventions, outcome measures, follow-up durations, and populations across included studies, a narrative synthesis was conducted rather than meta-analysis. Findings were organized by mouthwash type and clinical indication.\u003c/span\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e3.1 Study Selection\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe literature search yielded 3,001 records from PubMed and 180 Cochrane Reviews, totaling 3,181 records. After removal of duplicates, 3,150 records underwent title and abstract screening, of which 3,134 were excluded. Sixteen full-text articles were assessed for eligibility, and 10 were excluded (narrative reviews n\u0026thinsp;=\u0026thinsp;5, no accessible full text n\u0026thinsp;=\u0026thinsp;3, duplicate publications n\u0026thinsp;=\u0026thinsp;2). Six studies met all inclusion criteria and were included in this systematic review.\u003c/span\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe complete study selection process is illustrated in\u003c/span\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eFig.\u0026nbsp;1\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e(separate file).\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e3.2 Characteristics of Included Studies\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe six included studies comprised three systematic reviews with meta-analysis, two randomized controlled trials, and one systematic review without meta-analysis.\u003c/span\u003e Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003esummarizes the characteristics of all included studies.\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eCharacteristics of Included Studies\u003c/span\u003e \u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003eCaption: Summary of the six included studies (three systematic reviews with meta-analysis, two randomized controlled trials, and one systematic review without meta-analysis). The table presents study design, population, interventions, comparators, and key outcomes for each included study.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYear\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDesign\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePopulation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eComparison\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eKey Outcomes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBenson et al.\u0026sup1;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSystematic review with meta-analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOrthodontic patients (10 studies, N\u0026thinsp;=\u0026thinsp;1,798)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eVarious fluoride interventions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePlacebo, no treatment, alternative fluoride\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eDemineralized lesion incidence\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKaramani et al.⁴\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSystematic review with meta-analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOrthodontic patients (12 RCTs, N\u0026thinsp;=\u0026thinsp;678)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCHX mouthwash\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePlacebo, no treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePlaque indices, gingival bleeding, staining\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSonesson \u0026amp; Twetman⁸\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSystematic review with meta-analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOrthodontic patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDaily fluoride mouthrinse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePlacebo, no rinse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCaries incidence, demineralized lesions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHerrera et al.⁵\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOrthodontic patients (N\u0026thinsp;=\u0026thinsp;60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCPC dentifrice\u0026thinsp;+\u0026thinsp;mouth rinse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePlacebo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePlaque accumulation, gingival health, microbiome\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnerb\u0026auml;ck et al.⁷\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOrthodontic patients (N\u0026thinsp;=\u0026thinsp;120)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5000 ppm F toothpaste\u0026thinsp;+\u0026thinsp;rinse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStandard care (1450 ppm F)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eWhite spot lesion incidence\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChinchay-Ruesta et al.⁶\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSystematic review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOrthodontic patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWhitening toothpaste/mouthwash\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eVarious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eWhitening efficacy, adverse effects\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e3.3 Quality Assessment Results\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe quality of included studies was assessed using AMSTAR 2 for systematic reviews and the Cochrane Risk of Bias tool (RoB 2) for RCTs.\u003c/span\u003e Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003epresents the detailed quality assessment results.\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eQuality Assessment of Included Studies\u003c/span\u003e \u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003eCaption: Quality assessment results using AMSTAR 2 for systematic reviews and the Cochrane Risk of Bias tool (RoB 2) for randomized controlled trials. Ratings range from high to low quality with corresponding key strengths and limitations.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDesign\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuality Tool\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRating\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eKey Strengths\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eKey Limitations\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBenson 2019\u0026sup1;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic review with meta-analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAMSTAR 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCochrane methodology; comprehensive search\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone significant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKaramani 2022⁴\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic review with meta-analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAMSTAR 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGood methodology; 12 RCTs included\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHeterogeneity concerns\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSonesson \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2025\u003c/span\u003e⁸\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic review with meta-analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAMSTAR 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRecent; well-conducted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLimited by available primary studies\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHerrera 2018⁵\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRoB 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWell-designed; adequate blinding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eShort follow-up (3 months); small sample (n\u0026thinsp;=\u0026thinsp;60)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnerb\u0026auml;ck 2023⁷\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRoB 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eProper randomization; low attrition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSingle-center study\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChinchay-Ruesta 2023⁶\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAMSTAR 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAddresses important topic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLimited available evidence; narrative only\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e3.4 Certainty of Evidence\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eUsing a GRADE-informed narrative approach, the overall certainty of evidence was assessed for each intervention.\u003c/span\u003e Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003esummarizes these findings.\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eCertainty of Evidence by Intervention\u003c/span\u003e \u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003eCaption: GRADE-informed narrative assessment of evidence certainty for each mouthwash intervention. Certainty ratings (high, moderate, low) are based on study quality, consistency, and directness of evidence.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEvidence Source\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStudy Quality\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eConsistency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDirectness\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOverall Certainty\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh-fluoride toothpaste (5000 ppm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCochrane Review\u0026thinsp;+\u0026thinsp;RCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eConsistent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDirect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eHigh\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDaily fluoride mouthrinse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMeta-analysis 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eConsistent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDirect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eModerate\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProfessional fluoride foam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCochrane Review (single study)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSingle study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDirect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eModerate\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChlorhexidine mouthwash\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMeta-analysis 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eConsistent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDirect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eModerate\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCPC mouthwash\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle RCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLow RoB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSingle study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDirect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eModerate\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhitening mouthwashes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInconsistent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDirect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eLow\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e3.5 Synthesis of Findings\u003c/span\u003e\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eprovides a comprehensive summary of evidence for each mouthwash type, including key findings, adverse effects, and clinical implications.\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eSummary of Mouthwash Evidence in Orthodontic Patients\u003c/span\u003e \u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003eCaption: Comprehensive summary of evidence for each mouthwash type, including key findings, adverse effects, and clinical implications. Data synthesized from the six included studies.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgent/Intervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEvidence Source\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuality\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKey Findings\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAdverse Effects\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eClinical Implication\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHigh-Fluoride Toothpaste (5000 ppm F)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBenson 2019\u0026sup1;; Enerb\u0026auml;ck 2023⁷\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh (Cochrane); Low RoB (RCT)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMay reduce new lesion incidence (18% vs. 27%; RR 0.68\u0026sup1;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNone reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMay be considered for caries prevention\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFluoride Mouthrinse (0.05% NaF daily)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSonesson \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2025\u003c/span\u003e⁸\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePooled analysis demonstrates significant caries reduction (RR 0.72, 95% CI 0.58\u0026ndash;0.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNone reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSupported by current evidence\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProfessional Fluoride Foam (12,300 ppm F)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBenson 2019\u0026sup1;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOne study reported reduced lesions (12% vs. 49%; RR 0.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNone reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMay offer clinical benefits\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChlorhexidine (CHX) Mouthwash\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKaramani 2022⁴\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSignificant plaque reduction (SMD\u0026thinsp;\u0026minus;\u0026thinsp;1.24); gingivitis control\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eConsistent tooth staining (83% of studies), taste alteration (58% of studies) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eShort-term professional use only (post-surgery, acute inflammation)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCetylpyridinium Chloride (CPC) Mouthwash\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHerrera 2018⁵\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate (single RCT)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSignificant plaque reduction (32% vs. 12%); gingival index reduction (28% vs. 10%) (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo staining reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSuitable for long-term use; limited by short follow-up (3 months) and small sample\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWhitening Mouthwashes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChinchay-Ruesta 2023⁶\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInsufficient efficacy evidence; biologically implausible during treatment (Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePost-treatment color heterogeneity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDefer until after debonding\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e3.5.1 Adverse Effects of Chlorhexidine\u003c/span\u003e\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003edetails the adverse effects reported in the 2022 meta-analysis by Karamani and colleagues.⁴\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eSummary of Chlorhexidine Adverse Effects (Karamani 2022⁴)\u003c/span\u003e \u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003eCaption: Frequency and clinical significance of adverse effects associated with chlorhexidine mouthwash use in orthodontic patients, based on 12 included RCTs. Tooth staining was reported in 83% of studies.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdverse Effect\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProportion of Studies Reporting\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical Significance\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTooth staining\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10/12 (83%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMajor concern for orthodontic patients\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTaste alteration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7/12 (58%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMay affect compliance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMucosal irritation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3/12 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGenerally mild and transient\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSupragingival calculus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2/12 (17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMinor concern\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e3.5.2 CPC Clinical Outcomes\u003c/span\u003e\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003epresents the key clinical outcomes from the 2018 RCT by Herrera and colleagues evaluating CPC-containing products.⁵\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eComparison of CPC vs. Control Outcomes (Herrera 2018⁵)\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e*Caption: Clinical outcomes from a 3-month randomized controlled trial evaluating cetylpyridinium chloride (CPC) mouthwash in 60 orthodontic patients. CPC demonstrated significant plaque and gingival index reductions without staining.*\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome Measure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCPC Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDifference\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStatistical Significance\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlaque accumulation reduction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGingival index reduction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTooth staining\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTaste alteration reports\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e3.5.3 Biological Rationale for Whitening Deferral\u003c/span\u003e\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003esummarizes the biological mechanisms explaining why whitening mouthwashes are ineffective during active orthodontic treatment.⁶\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eBiological Rationale for Deferring Whitening During Orthodontic Treatment\u003c/span\u003e \u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003eCaption: Biological mechanisms explaining why whitening mouthwashes are ineffective during active orthodontic treatment. Bracket coverage and adhesive systems physically block peroxide diffusion, leading to post-debonding color heterogeneity.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMechanism\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical Consequence\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBracket coverage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical barrier to peroxide diffusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUneven whitening\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdhesive system\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSeals enamel beneath bracket\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProtected enamel remains original color\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemineralized lesions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExisting white spots may bleach differently\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExacerbated color heterogeneity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-debonding color mismatch\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExposed enamel lightens; covered enamel unchanged\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTwo-tone appearance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e4.1 Summary of Main Findings\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThis systematic review synthesized evidence from six studies examining mouthwash use in orthodontic patients (\u003c/span\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e). The main findings are\u003c/span\u003e:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eFluoride mouthwashes\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eA 2025 meta-analysis demonstrates that daily sodium fluoride mouthrinses (0.05% F) are effective adjuncts for preventing demineralized lesions during orthodontic treatment (pooled RR 0.72) (\u003c/span\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e).⁸\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eHigh-fluoride toothpaste\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe 2019 Cochrane Review and 2023 RCT provide consistent evidence that 5000 ppm F toothpaste is more effective than standard toothpaste for white spot prevention (\u003c/span\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e).\u0026sup1;,⁷\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eChlorhexidine\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eHighly effective for plaque and gingivitis control (SMD\u0026thinsp;\u0026minus;\u0026thinsp;1.24) but causes significant tooth staining (83% of studies) (\u003c/span\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e), limiting its use to short-term professional indications.⁴\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eCetylpyridinium chloride\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eEffective for plaque and gingivitis control with no staining in a single small RCT (\u003c/span\u003eTable\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e); however, long-term conclusions are limited by short follow-up and sample size.⁵\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eWhitening mouthwashes\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eNo evidence supports their use during active orthodontic treatment due to biological implausibility (\u003c/span\u003eTable\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e); whitening should be deferred until after brace removal.⁶\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe overall certainty of evidence varied by intervention, ranging from high for high-fluoride toothpaste to low for whitening mouthwashes (\u003c/span\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e).\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e4.2 Heterogeneity and Evidence Certainty\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eSignificant clinical heterogeneity was observed across included studies, including variations in\u003c/span\u003e:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003ePopulation\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eAge ranges, baseline oral health, compliance levels\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eInterventions\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eFluoride concentrations, CHX/CPC regimens, frequency of use\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eComparators\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ePlacebo, no treatment, active controls\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eOutcomes\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eDifferent indices for plaque, gingivitis, and lesion assessment\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eFollow-up duration\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eRanging from 3 to 24 months\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThis heterogeneity precluded meta-analysis and supports the narrative synthesis approach.\u003c/span\u003e Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003esummarizes the certainty of evidence using a GRADE-informed framework.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e4.3 Comparison with Previous Research\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eOur findings align with and extend previous knowledge. The 2019 Cochrane Review established the foundation for fluoride evidence, though it found insufficient evidence for mouthrinses specifically.\u0026sup1; The 2025 Sonesson and Twetman meta-analysis resolves this uncertainty by pooling multiple studies to demonstrate rinse efficacy.⁸ This pattern\u0026mdash;initial uncertainty resolved by meta-analysis\u0026mdash;highlights the importance of cumulative evidence synthesis.\u003c/span\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe distinction between CHX and CPC for orthodontic patients is clinically significant. While both are effective antimicrobials, the staining associated with CHX is particularly problematic in orthodontic patients because brackets and wires create additional surfaces for stain accumulation, making stains more visible and difficult to remove.⁴ As shown in\u003c/span\u003e Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e83% of studies reported staining with CHX use. The absence of staining with CPC in a single small RCT (\u003c/span\u003eTable\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e)⁵ suggests potential as a long-term alternative, though larger and longer studies are needed.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e4.4 Strengths and Limitations\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eSummary of Strengths and Limitations\u003c/span\u003e \u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003eCaption: Overview of methodological strengths and limitations of this systematic review, including the access-related limitation from the \"Free Full Text\" filter applied in PubMed.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStrengths\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLimitations\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystematic approach with dual-reviewer screening and quality assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAccess-Related Limitation\u003c/b\u003e: \"Free Full Text\" filter applied in PubMed may have excluded relevant subscription articles\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSearches conducted in two major databases (PubMed and Cochrane Library)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHeterogeneity of interventions and outcomes precluded meta-analysis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecent publication range (2018\u0026ndash;2026) captures latest evidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLimited evidence on patient-reported outcomes and long-term follow-up\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComprehensive coverage of major mouthwash types (Tables\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhitening evidence base limited to one low-quality systematic review\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuality assessment using validated tools (AMSTAR 2, RoB 2) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePotential language bias (English only)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExplicit acknowledgment of access-related limitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCPC evidence limited to one small RCT with short follow-up (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGRADE-informed certainty assessment (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eAccess-Related Limitation\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe \"Free Full Text\" filter was applied during the PubMed search due to practical access considerations. This may have excluded relevant articles that are only available through subscription. Consequently, this review is based on openly accessible literature, which may introduce publication bias. Readers should interpret the findings with this limitation in mind.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e4.5 Implications for Clinical Practice\u003c/span\u003e\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab9\" class=\"InternalRef\"\u003e9\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003epresents evidence-based clinical recommendations derived from this systematic review.\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab9\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 9\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eClinical Recommendations Based on Current Evidence\u003c/span\u003e \u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003eCaption: Evidence-based clinical recommendations for mouthwash use in orthodontic patients, including indicated agents, regimens, evidence grades, and rationales. Recommendations are stratified by clinical indication (caries prevention, gingivitis control, whitening).\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndication\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecommended Agent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRegimen\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEvidence Grade\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRationale\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCaries prevention\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh-fluoride toothpaste (5000 ppm F)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTwice-daily brushing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eConsistent evidence from Cochrane Review and RCT (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCaries prevention (adjunct)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSodium fluoride mouthrinse (0.05% NaF daily)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDaily, separate from brushing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSupported by 2025 meta-analysis (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGingivitis control (long-term)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCPC mouthwash\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDaily use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEffective without staining (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e); limited by short-term data\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGingivitis control (short-term)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCHX mouthwash\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u0026ndash;2 weeks only, professional indication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHighly effective but causes staining (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e); reserve for post-surgery, acute inflammation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWhitening\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone during active treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDefer until after debonding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eD (expert opinion)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBiologically implausible during treatment (Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e); risk of uneven color\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\u003cp\u003eFor caries prevention\u003c/span\u003e:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eHigh-fluoride toothpaste (5000 ppm F) for twice-daily brushing is supported by current evidence (\u003c/span\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e)\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eDaily sodium fluoride mouthrinse (0.05% F) used at a separate time from brushing is recommended as an adjunct (\u003c/span\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e)\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eFor gingivitis control\u003c/span\u003e:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eOver-the-counter CPC mouthwash may be suggested for daily use, though long-term data are limited (\u003c/span\u003eTable\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e)\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eCHX mouthwash should be reserved for short-term use (1\u0026ndash;2 weeks) for specific professional indications only, due to predictable staining (\u003c/span\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e)\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eFor whitening\u003c/span\u003e:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eWhitening mouthwashes should be avoided during active treatment\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eWhitening should be deferred until after brace removal due to the risk of post-debonding color heterogeneity (\u003c/span\u003eTable\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e)\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e4.6 Implications for Research\u003c/span\u003e\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab10\" class=\"InternalRef\"\u003e10\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eoutlines priority areas for future research based on the evidence gaps identified in this review.\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab10\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 10\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eFuture Research Priorities\u003c/span\u003e \u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003eCaption: Priority areas for future research identified from evidence gaps in this systematic review. Each priority area includes a rationale and suggested study design.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePriority Area\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRationale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSuggested Study Design\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHead-to-head fluoride comparisons\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnclear if 5000 ppm toothpaste alone is sufficient or if adding rinse provides additional benefit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3-arm RCT: 5000 ppm toothpaste vs. 5000 ppm toothpaste\u0026thinsp;+\u0026thinsp;rinse vs. standard care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLong-term follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCurrent studies limited to treatment duration; need post-treatment data (2\u0026ndash;5 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective cohort with follow-up post-debonding\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCPC efficacy and safety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCurrent evidence limited to one small short-term RCT (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLarge multi-center RCT with \u0026ge;\u0026thinsp;12-month follow-up\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient-reported outcomes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAesthetic satisfaction and quality of life understudied\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMixed-methods studies including validated questionnaires\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCombination products\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFluoride\u0026thinsp;+\u0026thinsp;CPC may provide simultaneous caries and gingivitis benefits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFactorial design RCT\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAccess-related bias\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFuture reviews should include subscription articles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSystematic review with institutional access or open-access mandate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThis systematic review of the literature (with the noted access-related limitation) supports a targeted approach to mouthwash use during fixed orthodontic treatment\u003c/span\u003e:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eFor caries prevention\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eHigh-fluoride toothpaste (5000 ppm F) combined with daily sodium fluoride mouthrinse (0.05% F) is supported by current evidence, including a 2025 meta-analysis (\u003c/span\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e).\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eFor gingivitis control\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eCPC mouthwash appears effective for long-term use without staining in a single small RCT (\u003c/span\u003eTable\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e); CHX should be reserved for short-term professional indications due to predictable staining (\u003c/span\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e).\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eFor whitening\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eProducts should be avoided during active treatment and deferred until after brace removal due to the risk of post-debonding color heterogeneity (\u003c/span\u003eTable\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e).\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThese findings should be interpreted cautiously due to the access-related limitation and heterogeneity among studies (\u003c/span\u003eTable\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e). As a preprint, this work has not undergone peer review and should not be considered definitive clinical guidance. Future updates should aim for PROSPERO registration and include subscription-based literature to reduce bias (\u003c/span\u003eTable\u0026nbsp;\u003cspan refid=\"Tab10\" class=\"InternalRef\"\u003e10\u003c/span\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e).\u003c/span\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability:\u003c/strong\u003e Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate:\u003c/strong\u003e Ethical approval was not required for this study because no human or animal subjects were involved.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Generative AI and AI-Assisted Technologies in the Manuscript Preparation Process:\u003c/strong\u003e During the preparation of this work, the authors used AI-based language assistance tools for grammar and structure. After using these tools, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eMaen Mahfouz:\u003c/strong\u003e Conceptualization, methodology, investigation, data curation, formal analysis, writing \u0026ndash; original draft, writing \u0026ndash; review \u0026amp; editing, visualization, project administration.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eEman Alzaben:\u003c/strong\u003e Investigation, data curation, formal analysis, writing \u0026ndash; review \u0026amp; editing.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e The authors acknowledge that this review is based on openly accessible literature due to access considerations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePROSPERO Registration:\u003c/strong\u003e Due to the preprint nature and timeline of this review, PROSPERO registration was not completed; future updates will aim for registration to increase transparency.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBenson PE, Parkin N, Dyer F, Millett DT, Germain P (2019) Fluorides for preventing early tooth decay (demineralised lesions) during fixed brace treatment. Cochrane Database Syst Rev 11CD003809. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/14651858.CD003809.pub4\u003c/span\u003e\u003cspan address=\"10.1002/14651858.CD003809.pub4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGorelick L, Geiger AM, Gwinnett AJ (1982) Incidence of white spot formation after bonding and banding. Am J Orthod 81(2):93\u0026ndash;98. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/0002-9416(82)90032-X\u003c/span\u003e\u003cspan address=\"10.1016/0002-9416(82)90032-X\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoersma JG, van der Veen MH, Lagerweij MD, Bokhout B, Prahl-Andersen B (2005) Caries prevalence measured with QLF after treatment with fixed orthodontic appliances: influencing factors. Caries Res 39(1):41\u0026ndash;47. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1159/000081655\u003c/span\u003e\u003cspan address=\"10.1159/000081655\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaramani I, Kalimeri E, Seremidi K, Gkourtsogianni S, Kloukos D (2022) Chlorhexidine mouthwash for gingivitis control in orthodontic patients: a systematic review and meta-analysis. Oral Health Prev Dent 20:279\u0026ndash;294. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3290/j.ohpd.b3170043\u003c/span\u003e\u003cspan address=\"10.3290/j.ohpd.b3170043\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHerrera D, Escudero N, P\u0026eacute;rez L, Otheo M, Ca\u0026ntilde;ete-S\u0026aacute;nchez E, P\u0026eacute;rez T, Alonso B, Serrano J, Palma JC, Sanz M, Mart\u0026iacute;n C (2018) Clinical and microbiological effects of the use of a cetylpyridinium chloride dentifrice and mouth rinse in orthodontic patients: a 3-month randomized clinical trial. Eur J Orthod 40(5):465\u0026ndash;474. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/ejo/cjx096\u003c/span\u003e\u003cspan address=\"10.1093/ejo/cjx096\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChinchay-Ruesta S, Ortiz-Pizarro M, Rodr\u0026iacute;guez-D\u0026iacute;az DR, Moreno-Herrera Y, Bustamante-Cabrejo A, Serna-Alarc\u0026oacute;n V (2023) Effect of over-the-counter whitening toothpaste and mouthwash in orthodontics: a systematic review. Int J Clin Pediatr Dent 16(Suppl 3):311\u0026ndash;316. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.5005/jp-journals-10005-2703\u003c/span\u003e\u003cspan address=\"10.5005/jp-journals-10005-2703\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEnerb\u0026auml;ck H, L\u0026ouml;vgren ML, Str\u0026ouml;mberg N, Westerlund A (2023) Effect of high-fluoride toothpaste and mouth rinse on the prevention of demineralized lesions during orthodontic treatment: a randomized controlled trial. Eur J Orthod 45(5):477\u0026ndash;484. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/ejo/cjad044\u003c/span\u003e\u003cspan address=\"10.1093/ejo/cjad044\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSonesson M, Twetman S (2025) Fluoride mouthrinses for prevention of initial caries in orthodontic patients - a systematic review and meta-analysis. BMC Oral Health 25(1):1058. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12903-025-06374-8\u003c/span\u003e\u003cspan address=\"10.1186/s12903-025-06374-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Private Orthodontic Practice -Ministry Of Health -Palestine ","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Orthodontics, Mouthwashes, Fluoride, Chlorhexidine, Cetylpyridinium chloride, White spot lesions, Gingivitis, Systematic review","lastPublishedDoi":"10.21203/rs.3.rs-8879019/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8879019/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFixed orthodontic appliances create significant challenges for oral hygiene, increasing the risk of demineralized lesions (white spots) and gingival inflammation. Mouthwashes are commonly recommended as adjunctive measures, but evidence-based guidance on optimal selection is needed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo systematically evaluate current evidence regarding the effectiveness of various mouthwash formulations as adjuncts to oral hygiene in patients undergoing fixed orthodontic treatment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA systematic literature search was conducted in PubMed (MEDLINE) and the Cochrane Library for publications from January 2018 to February 2026. The search strategy combined terms for population, intervention, and outcomes. In PubMed, filters were applied for article type (Meta-Analysis, Randomized Controlled Trial, Systematic Review), publication date, and language. Due to access considerations, the \"Free Full Text\" filter was applied; this represents a limitation. In the Cochrane Library, the same search was applied to the Title Abstract Keyword field. Two independent reviewers performed study selection, data extraction, and quality assessment using AMSTAR 2 for systematic reviews and the Cochrane Risk of Bias tool (RoB 2) for RCTs. Due to heterogeneity of interventions and outcomes, a narrative synthesis was conducted. A total of 3,181 records were screened, and 6 studies met inclusion criteria.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSix studies were included (3 systematic reviews with meta-analysis, 2 RCTs, 1 systematic review). The 2019 Cochrane Review (AMSTAR 2: high quality) provided evidence that high-concentration fluoride toothpaste (5000 ppm) may reduce demineralized lesions (RR 0.68, 95% CI 0.46-1.00) and that professional fluoride foam (12,300 ppm) may be beneficial (RR 0.26, 95% CI 0.11–0.57). A 2025 meta-analysis (AMSTAR 2: moderate quality) confirmed daily sodium fluoride mouthrinses (0.05% F) are effective for caries prevention (pooled RR 0.72, 95% CI 0.58–0.89). For gingivitis control, a 2022 meta-analysis (AMSTAR 2: moderate quality) confirmed CHX efficacy (plaque SMD − 1.24, 95% CI -1.89 to -0.59) but with significant tooth staining (reported in 83% of included studies); a 2018 RCT (RoB 2: low risk) demonstrated CPC effectiveness with significant plaque reduction (32% vs. 12%, p \u0026lt; 0.01) and no staining. A 2023 systematic review found insufficient evidence for whitening mouthwashes during active treatment due to biological implausibility.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCurrent evidence supports a stratified approach: high-fluoride toothpaste plus daily fluoride rinse for caries prevention; CPC for long-term gingival health; CHX reserved for short-term professional indications. Whitening products should be deferred until after brace removal. These findings should be interpreted cautiously due to the access-related limitation and heterogeneity among studies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePROSPERO Registration:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDue to the preprint nature and timeline of this review, PROSPERO registration was not completed; future updates will aim for registration to increase transparency.\u003c/p\u003e","manuscriptTitle":"Effectiveness of Adjunctive Mouthwash Use in Patients Undergoing Fixed Orthodontic Treatment: A Systematic Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-17 14:39:41","doi":"10.21203/rs.3.rs-8879019/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"14444f99-726e-425b-aac5-f76e96224577","owner":[],"postedDate":"February 17th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":62927047,"name":"Dentistry"}],"tags":[],"updatedAt":"2026-02-17T14:39:45+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-17 14:39:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8879019","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8879019","identity":"rs-8879019","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}