the role of dental plaque in the aetiology of dental diseases is well recognised . thus there is evidence which demonstrates that improving oral hygiene and gingival health has been associated with a decreasing incidence of periodontal disease . on the basis that plaque - induced gingivitis always precedes the occurrence and recurrence of periodontitis , the mainstay of primary and secondary prevention of periodontal diseases is the control of supragingival plaque . until now , mechanical cleansing is the most widely used method of supragingival plaque control and is effective in areas where access to plaque deposits is possible . evidences exist that the degree of motivation and skill required with the oral hygiene products such as toothbrushes , dental floss , toothpicks , and interdental brushes may be beyond the ability of majority of the patients . there are also groups of individuals such as temporarily disabled individuals including non - ambulatory patients and handicapped people , for whom adequate oral hygiene is a problem . the major problem of these substances has been the relatively short period of contact between active agent and the teeth , and existence of the side effects . chlorhexidine ( chx ) is the chemical agent which seems to be most effective in plaque control . its effect is prolonged and it has the ability to inhibit plaque formation to a large degree . it is used as mouthwash , gel , sprays , varnish , and in toothpastes . though chx is considered as the best agent for plaque control and gingivitis , many patients find its initial bitter taste unpleasant , and repeated use often produces stains and taste disturbances . because of this , daily rinsing with chx is not promoted . it would , however , be desirable to have the possibility to use chx over an extended period of time . the absence of stain formation could improve patient compliance and reduce the time necessary to clean the dentition during recall . oxygenating agents have been employed for supragingival plaque control and in the treatment of acute ulcerative gingivitis without any harmful side effects on the tissues . hydrogen peroxide ( h2o2 ) 1.5% has been shown to have a good stain removing capability both in vitro and in vivo . the mechanism of stain removal includes oxygen - releasing mechanical cleansing actions and oxidation or reduction reactions . free radicals released by hydrogen peroxide break the electron - rich alkene double bonds which are responsible for discoloration , resulting in stain removal . the use of h2o2 as an adjunct to chx has been found to be very effective in reducing plaque scores , and in preventing the stain development . the purpose of this study was to investigate whether the use of a hydrogen peroxide mouth rinse as an adjunct to chlorhexidine mouth rinse compared to chlorhexidine alone is efficacious in inhibiting the development of plaque and gingivitis , along with its ability to reduce the stains . this 21 days duration study was conducted in the department of periodontics , of the institution . a total of 105 subjects participated in the study , out of which 55 ( 57.75% ) were females and 50 ( 52.5% ) were males . the subjects included bds and dental hygienist students of the college , and the patients visiting the outpatient department of periodontics . inclusion criteria were : ( a ) healthy patients of age group between 18 and 30 years , ( b ) no history of smoking,(c ) minimum of 24 teeth present , ( d ) no pockets > 5 mm present , ( e ) no antibiotics intake for last 3 months , and ( f ) no systemic disease . exclusion criteria were : ( 1 ) presence of fixed or removable orthodontic appliance or prosthesis , ( 2 ) allergy to chlorhexidine or hydrogen peroxide , and ( 3 ) pregnant females . scaling with ultrasonic scaler and polishing with fine grit prophylaxis paste was done for all the subjects to establish the baseline . all the subjects were given the demonstration of bass method of tooth brushing and were asked to follow the same using stim soft toothbrush and colgate toothpaste prior to rinsing . the selected candidates were randomly divided into one of the three treatment groups ; each group comprises 35 subjects . group i was instructed to rinse with 0.2% chx ( hexidine ) twice daily ( 60 s ) for 3 weeks after brushing . group ii was instructed to rinse with 0.2% chx ( 60 s ) followed by 1.5% h2o2 ( 60 s ) twice daily for 3 weeks after brushing . group iii was asked to rinse with 1.5% h2o2 ( 60 s ) followed by 0.2% chx ( 60 seconds ) twice daily for 3 weeks after brushing . the subjects were asked to return after the end of first , second and third week for the evaluation , to check the compliance and to issue more mouthwash . the subjects were instructed to add 2.5 ml of hydroxyl mouthwash ( 6% ) to 7.5 ml of water to make it 1.5% with the measuring cap provided with the mouthwash , just before every rinse . the name , age , gender , and address of the subjects were recorded in the performa . they were examined clinically with a mouth mirror , unc15 periodontal probe and explorer . the scoring procedure used to assess stain area and intensity was the lobene index modified by koertge and gunsolley ( gmsi ) with the following criteria : stain intensity : 0 = no stain present , natural tooth coloration , 1 = faint stain 2 = clearly visible stain , orange to brown , 3 = dark stain , deep brown to black . stain area 1 = thin line , can be continuous , 2 = thick line or band , 3 = covering the total area . plaque index ( pi):- the clinical scoring procedure used to assess plaque formation was the turesky modification of the quigley - hein plaque index . a disclosing agent ( alpha plaque ) was used to score plaque on a numerical scale according to the following criteria : 0 = no plaque , 1 = separate flecks of plaque at the cervical margin of the tooth , 2 = a thin , continuous band of plaque ( up to 1 mm ) at the cervical margin , 3 = a band of plaque wider than 1 mm but covering less than one - third of the crown , 4 = plaque covering at least one - third but less than two - thirds of the crown and 5 = plaque covering two - thirds or more of the crown . mean of all the individual subject scores at the end of 1 , 2 , and 3 week was calculated for stain intensity , stain area , and plaque . for intra - group comparison , the subjects were instructed to add 2.5 ml of hydroxyl mouthwash ( 6% ) to 7.5 ml of water to make it 1.5% with the measuring cap provided with the mouthwash , just before every rinse . the name , age , gender , and address of the subjects were recorded in the performa . they were examined clinically with a mouth mirror , unc15 periodontal probe and explorer . the scoring procedure used to assess stain area and intensity was the lobene index modified by koertge and gunsolley ( gmsi ) with the following criteria : stain intensity : 0 = no stain present , natural tooth coloration , 1 = faint stain 2 = clearly visible stain , orange to brown , 3 = dark stain , deep brown to black . stain area 1 = thin line , can be continuous , 2 = thick line or band , 3 = covering the total area . plaque index ( pi):- the clinical scoring procedure used to assess plaque formation was the turesky modification of the quigley - hein plaque index . a disclosing agent ( alpha plaque ) was used to score plaque on a numerical scale according to the following criteria : 0 = no plaque , 1 = separate flecks of plaque at the cervical margin of the tooth , 2 = a thin , continuous band of plaque ( up to 1 mm ) at the cervical margin , 3 = a band of plaque wider than 1 mm but covering less than one - third of the crown , 4 = plaque covering at least one - third but less than two - thirds of the crown and 5 = plaque covering two - thirds or more of the crown . mean of all the individual subject scores at the end of 1 , 2 , and 3 week was calculated for stain intensity , stain area , and plaque . for intra - group comparison , paired comparison test was applied . for inter - group comparison , general linear model , and multiple comparison test mean scores for each group comprising of 35 subjects were calculated at the end of 1 , 2 , and 3 weeks . table 1 shows the intra - group comparison of mean stain area , intensity , and plaque scores after 1 , 2 , and 3 weeks in all the groups . in all the groups , there was a significant increase in the mean stain area and mean stain intensity after 2 weeks in comparison to the 1 week . after the end of 3 week , the mean stain area was significantly more than the scores at the end of 2 week in group i and group ii . whereas there was a non - significant increase in mean stain intensity after 3 in comparison with the scores at 2 weeks in group i and group iii . intra - group comparison of mean stains and plaque scores between 1 and 2 , and 2 and 3 weeks in all the three groups , there was a reduction in mean plaque score at the end of 2 weeks in comparison with scores at the end of 1 week and was significant in group i. at the end of 3 weeks also , there was further reduction in plaque scores in comparison with the scores at 2 weeks in all three groups . inter group comparison of the mean scores at the end of 1 , 2 , and 3 weeks was done between group i and ii , i and iii , and ii and iii as shown in tables 24 . after the end of 1 week [ table 2 ] , the mean stain area was significantly more in group i and group iii in comparison to group ii . after 2 and 3 weeks also , the mean stain area was more in group i and group iii in comparison to group ii , but it was not significant . inter - group comparisons of mean stain intensity after 1 , 2 , and 3 weeks inter - group comparisons of mean stain intensity after 1 , 2 , and 3 weeks inter - group comparisons of mean plaque scores after 1 , 2 , and 3 weeks table 3 demonstrates the comparisons of mean intensity scores between the 3 groups . at the end of 2 and 3 week , in comparison to group i , there was significantly less mean stain intensity in group ii ( p values 0.025 and 0.005 , respectively ) . group ii also had fewer amounts of stains than group iii after 2 and 3 week but the difference was non - significant ( p values 0.061 and 0.306 , respectively ) . the mean stain intensity was less in group iii after 1 , 2 , and 3 weeks in comparison to group i but it was non - significant . there was less amount of plaque formed in group ii than group i after the end of 1 , 2 , and 3 week and the difference was highly significant ( p values : 000 , 0.000 , and 0.000 , respectively [ table 4 ] . after the end of second and third week , there was a significant reduction in plaque scores in group ii in comparison with group iii ( p values , 0.002 and 0.008 , respectively ) . in comparison to group i , there was significantly less amount of plaque formed in group iii after the end of first ( p value , 0.000 ) and second week ( 0.017 ) . after the end of 3 weeks also , the plaque scores were less in group iii than group i but it was not significant ( p value , 0.104 ) . the association between dental plaque and gingivitis has been well established , and the importance of effective plaque control has been emphasized over the years . till date , mechanical plaque elimination with assorted devices remains the primary and most widely accepted means of controlling plaque and maintaining good oral hygiene . as an adjunct to mechanical methods , chemical plaque control comprising of a variety of chemotherapeutic agents have been beneficial and desirable . the greatest success has been with chlorhexidine , which is now considered the gold standard against which other potential antiplaque agents are measured . however , the local side effects of chlorhexidine , particularly extrinsic staining and taste aberrations , have limited its long - term use in oral hygiene products . the present study was initiated to evaluate the inhibitory properties of h2o2 on extrinsic stains induced by rinsing with chx . the effect of h2o2 when used in combination with chx on reducing plaque formation was also evaluated . the results of the present study show a tendency toward less stain development when chx is used in combination with h2o2 as compared to using it alone , as is evident from tables 2 and 3 . at the end of 2 week , the intensity of stains was significantly less in group ii in comparison with group i. at the end of 1 week , group ii showed significantly less stain intensity in comparison to group iii ; thus indicating more efficiency of chx + h2o2 regimen over h2o2 + chx regimen . , in a group of 50 military recruits . in a double - blind experimental design , the combination of 0.2% chlorhexidine and 1% peroxymonosulfate solution resulted in a marked reduction in extrinsic tooth discoloration along with maintained plaque preventive capacity of chlorhexidine . similar results were obtained in the study done by grundemann et al . , who demonstrated that combination of chlorhexidine and peroxyborate ( chx + per ) resulted in less stains than chx alone at the end of 14 days of rinsing . there is however no doubt that chlorhexidine readily binds food dyes and chromogens to surfaces . eriksen et al . , indicated that chlorhexidine treatment alters the incorporation into plaque of a natural sulphur - containing organic component of saliva or bacteria . this natural component appears to readily interact with transition metals , particularly iron , producing stained material . both ferric and stannic these colors correlate well with clinically observed extrinsic discolorations . in a more oxidized state , these sulfide compounds transform into sulfates which generally become greyish / white and soluble . this may be an explanation of why rinsing with an oxidizing solution inhibits the staining of teeth . our study compared three different regimens : post - brushing rinsing twice daily with chlorhexidine ( chx : chx ) , chlorhexidine 0.2% followed by hydrogen peroxide 1.5% ( chx + h2o2:chx + h2o2 ) ; and hydrogen peroxide followed by chlorhexidine ( h2o2 + chx : h2o2 + chx ) . the regimens chx + h2o2:chx + h2o2 and h2o2 + chx : h2o2 + chx were more effective in inhibiting plaque than regimen chx : chx . the mean plaque scores in group ii and group iii after the end of 1and 2 weeks were significantly less than group i as shown in table 4 . after 3 weeks , there was a non - significant difference in plaque scores between group i and group iii ; group iii being better of the two . however , in group ii , the plaque scores were significantly less than the other two groups after the end of 1 , 2 , and 3 weeks . in which an adjunctive effect of sodium - perborate on the plaque - reducing effect of chlorhexidine was found . the results of present study show that the therapeutic action of chlorhexidine 0.2% to inhibit supragingival plaque does not seem to be disturbed when it is used together with hydrogen peroxide solution . rather rinsing with chlorhexidine with hydrogen peroxide combination even enhances plaque inhibition . this could be an additive effect since both chemicals have a different action with regards to bacterial killing . as an antiplaque mouth rinse , seymour and heasman in 1992 stated that killing of bacterial cells is initially dependant on the drug having access to the cell walls . the therapeutic action of hydrogen peroxide is obtained by the release of oxygen that instantly kills the obligate anaerobes implicated in oral infections . it has been hypothesized that sodium lauryl sulphate ( sls ) , the most widely used detergent in dentifrice , may counteract with chlorhexidine . a study was done by van strydonck et al . , in 2004 and 2006 to compare the plaque inhibitory effect of a 0.2% chlorhexidine digluconate rinse when preceded by ordinary tooth brushing with a 1.5% sls - containing dentifrice to the effect of the same rinse when used alone or when preceded by rinsing with an sls - containing slurry . the study showed that the anti - plaque efficacy of a 0.2% chx rinse was not reduced when preceded by everyday tooth brushing with a sls - containing dentifrice . from this study , it can be concluded that a combination of chx + h2o2 is superior to chx alone , when used as mouthwash as an adjunct to routine mechanical tooth cleansing . a twice daily rinsing with chx + h2o2 combination can be safely recommended to minimize extrinsic tooth discoloration without affecting the plaque inhibiting efficacy of chx since the removal of stains caused by using chx alone , especially in pits and fissures , is a tedious procedure for a periodontist .
aim : to investigate whether the use of an oxidizing mouth rinse as an adjunct to chlorhexidine is efficacious in reducing stains and plaque.materials and methods : this study had a single - blind , three - group ( n = 35 each ) parallel design , including a 21 days experimental period during which group i rinsed with chlorhexidine ( chx ) 0.2% alone , group ii used chlorhexidine ( chx ) followed by hydrogen peroxide ( h2o2 ) 1.5% . 
 group iii rinsed with the same mouthwashes in reverse order . 
 patients were randomly assigned to one of the three groups . the examination for plaque , and stains 
 was done after 1 , 2 , and 3 weeks of rinsing.results:group ii showed significantly less stain intensity in comparison with group i after 14 and 21 days ( p values 0.025 and 0.005 , respectively ) . 
 the proportion of stained surfaces was less in the group ii than in the group i and was significant at the end of 1 week . 
 the plaque formation was significantly less in groups ii and iii than group i at 7 , 14 , and 21 days.conclusion:the adjunctive use of hydrogen peroxide to chlorhexidine proved to be superior to chlorhexidine alone with regard to the inhibition of plaque and development of stains .