***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: This study investigated the effect of interdental brushes on the reduction of interproximal bleeding in adults without periodontal disease . Forty-six adults were enrolled in a 3-month , observer-blinded , parallel-group r and omized control trial . The test group used a st and ard manual toothbrush twice daily and an interdental brush daily . The control group used a st and ard manual toothbrush . At each visit , a calibrated colorimetric probe was used in all interdental spaces to determine the appropriate size of the interdental brush required , the brush of the corresponding size was introduced into the interproximal space , and the presence of bleeding was recorded . The outcome was the frequency of bleeding after application of the appropriate interdental brush . All participants were evaluated 1 wk , 1 month , and 3 months after the baseline visit . The overall preventive fraction with respect to bleeding frequency was 46 % at 1 wk and 72 % at 3 months . More bleeding reduction was observed in anterior sites than in posterior sites ( 80 % vs. 69 % , respectively ) . Participants with low baseline bleeding frequency presented with less bleeding ( OR = 2.3 ) . This study shows that daily use of calibrated interdental brushes reduces interdental bleeding . These findings may support interdental cleaning as an effective means to help individuals maintain and /or achieve optimal oral health Background The grading of recommendation , assessment , development and evaluation ( GRADE ) approach is widely implemented in health technology assessment and guideline development organisations throughout the world . GRADE provides a transparent approach to reaching judgements about the quality of evidence on the effects of a health care intervention , but is complex and therefore challenging to apply in a consistent manner . Methods We developed a checklist to guide the research er to extract the data required to make a GRADE assessment . We applied the checklist to 29 meta-analyses of r and omised controlled trials on the effectiveness of health care interventions . Two review ers used the checklist for each paper and used these data to rate the quality of evidence for a particular outcome . Results For most ( 70 % ) checklist items , there was good agreement between review ers . The main problems were for items relating to indirectness where considerable judgement is required . Conclusions There was consistent agreement between review ers on most items in the checklist . The use of this checklist may be an aid to improving the consistency and reproducibility of GRADE assessment s , particularly for inexperienced users or in rapid review s without the re sources to conduct assessment s by two research ers independently AIM The aim of the present study was to evaluate the effectiveness of chlorhexidine ( CHX ) with an antidiscoloration system ( ADS ) on stain , plaque accumulation , and gingivitis .  METHODS A r and omized , controlled clinical trial was conducted in 26 students . After a preparatory period , the students were r and omly assigned to either group P ( placebo ) , group T1 ( 0.12 % CHX without an ADS ) , or group T2 ( 0.12 % CHX with an ADS ) . During the 3-week experimental period , all mechanical oral hygiene was abolished . Rinsing with 10 mL mouthwash or placebo was performed twice daily under supervision . The parameters assessed on days 0 , 7 , 14 , and 21 included the Discoloration Index ( DI ) , Plaque Index ( PII ) , and Gingival Index ( GI ) . RESULTS There were no significant mean differences in the DI , PII , or GI between groups T2 and P. Significant mean differences existed in the DI between groups T2 and T1 on days 14 and 21 . Significant mean differences existed in the PI between groups T2 and T1 on days 7 , 14 , and 21 . Likewise , significant mean differences existed in the GI between groups T2 and T1 on days 14 and 21 . CONCLUSIONS CHX with an ADS did not prevent plaque or gingivitis development . In fact , the CHX mouthwash with an ADS showed no superior effect over placebo on oral hygiene or the prevention of gingivitis BACKGROUND The goal of this study is to evaluate the degree of staining and clinical efficacy of a chlorhexidine mouthwash with an antidiscoloration system ( ADS ) versus 0.2 % chlorhexidine mouthwash ( traditional ) . Secondary objectives are to evaluate the patient " compliance " factor according to patterns assigned by the clinician and to observe the side effects of the two mouthwashes . METHODS This comparative study is carried out on a sample of 15 non-smoking patients with chronic periodontitis at the Department of Periodontology , the International University of Catalunya , Barcelona , Spain . All patients used either 0.2 % chlorhexidine mouthwash ( control group = bottle B ) or chlorhexidine with ADS ( test group = bottle A ) for 15 days . Each patient first rinsed with a r and omly assigned mouthwash for 15 days followed by a 15-day washout period . Subsequently , each patient used a second mouthwash . Before each cycle , a full dental prophylaxis was performed . The plaque , gingival , and Brecx staining indexes were used . RESULTS The results showed less tooth staining with the test group ( P < 0.01 ) . No statistically significant differences were observed in plaque ( P = 0.1496 ) and gingival indexes ( P = 0.1688 ) . Eighty-eight percent of patients followed the instructions outlined in the protocol . In terms of other adverse effects , two patients reported a bad taste with both mouthwashes . CONCLUSIONS The test group with ADS had less staining than the control group during a usage period of 15 days . However , the two mouthwashes seemed to be equally effective as antiplaque and antigingivitis agents In a st and ard periodontal treatment strategy with consecutive root planings ( per quadrant at a one- to two-week interval ) , re-infection of a disinfected area might occur before completion of the treatment . This study examines , both clinical ly and microbiologically , whether a full-mouth disinfection within 24 hours significantly improves the outcome of periodontal treatment . Ten patients with advanced chronic periodontitis were r and omly allocated to a test and a control group . The patients from the control group received scalings and root planings as well as oral hygiene instructions per quadrant at two-week intervals . Full-mouth disinfection in the test group was sought by the removal of all plaque and calculus ( in two visits within 24 hours ) . In addition , at each of these visits , the tongue was brushed with a 1 % chlorhexidine gel for one min and the mouth rinsed with a 0.2 % chlorhexidine solution for two min . Furthermore , subgingival chlorhexidine ( 1 % ) irrigation was performed in all pockets . The recolonization of the pockets was retarded by oral hygiene and 0.2 % chlorhexidine rinses during two weeks . The clinical parameters were recorded , and plaque sample s were taken from the right upper quadrant at baseline and after one and two months . The test group patients showed a significantly higher reduction in probing depth for deep pockets at both follow-up visits ( p < 0.05 ) . At the one-month visit , differential phase-contrast microscopy revealed significantly lower proportions of spirochetes and motile rods in the test group ( p = 0.01 ) . Culturing showed that the test group harbored significantly fewer pathogenic organisms at one month ( p = 0.005 ) . At two months , the same sites harbored singificantly more " beneficial " bacteria ( p = 0.02 ) . Moreover , all sites of the test group initially harboring P. gingivalis ( 6/10 ) became negative after treatment . These findings suggest that it is possible to achieve a significant improvement of the treatment outcome ( both microbiologically and clinical ly ) with a one-stage full-mouth disinfection PURPOSE To evaluate by a clinical spectrophotometric analysis the staining side effect of a 0.2 % chlorhexidine ( CHX ) mouthrinse containing an anti-discoloration system ( ADS ) compared with a 0.12 % and a 0.2 % CHX mouthrinse , after periodontal surgery . The efficacy of the products and the patient 's opinion and acceptance were also assessed . METHODS The study was carried out on 60 subjects scheduled for periodontal flap surgery at the Unit of Periodontology and Dental Hygiene ( University of Trieste , Italy ) . After surgery , the subjects were r and omly prescribed to rinse for 1 week with 10 ml of a 0.12 % CHX ( Group 1 ) , 0.2 % CHX ( Group 2 ) or 0.2 % ADS CHX ( Group 3 ) . Before surgery ( TO ) , 7 days ( T1 ) and 14 days ( T2 ) after surgery , following variables were recorded : gingival parameters at the surgically treated sites ( Full-Mouth Plaque Score , Full-Mouth Bleeding Score and Modified Gingival Index ) , tooth pigmentation measured as AE , patient perception and acceptance of the mouthrinses . RESULTS 53 subjects completed the study . The difference among treatments related to gingival variables was not statistically significant . No statistical differences were found for dental pigmentation among the mouthrinses over time nor for discomfort at each follow-up examination . A slightly less acceptance rate was observed for 0.2 % CHX . The following conclusions were drawn : ( 1 ) 0.2 % CHX with ADS did not cause less brown pigmentation than the 0.2 % CHX or than the 0.12 % CHX ; ( 2 ) 0.2 % ADS CHX was as effective as CHX without ADS in reducing gingival signs of inflammation in the post-surgical early healing phase ; ( 3 ) 0.2 % CHX showed the lowest score in terms of taste acceptance compared with 0.12 % and ADS CHX PURPOSE To determine the efficacy of an anti-discoloration system ( ADS ) in a 0.12 % chlorhexidine ( CHX ) mouthwash to reduce dental discoloration . METHODS A triple-blind , cross-over , r and omized clinical trial was carried out in 22 healthy volunteers asked to perform  oral rinses  , twice a day for 21 days , using 0.12 % CHX mouthwashes containing or not ADS ( wash-out= 21 days ) . Dental discolorations were compared via spectroscopy ( ΔE ) , and direct visual examination performed by the dentist and volunteers themselves . At 6 months , a further visual analysis on clinical images was carried out by the same volunteers and ad hoc recruited dental practitioners . RESULTS A slight discoloration was the most frequent finding , independent of the presence of ADS , while the few severe cases of staining were associated with CHX alone . ( ΔE values comparing dental color before and after treatments were similar for CHX ( 8.4±0.1 ) and CHX+ADS ( 8.6±0.9 ) rinses . Direct visual analysis showed no staining difference between the two mouthwashes . Six months later , volunteers ' self-evaluation of clinical pictures again did not detect any significant difference between treatments , while dental practitioners identified CHX+ADS as less discoloring ( < 0.05 ) . Slight dental discoloration represents the most common side-effect of 0.12 % CHX mouthwash , independent of the presence of ADS . Severe cases are possible , but very rare and mainly associated with CHX alone . CLINICAL SIGNIFICANCE There was no evidence to support the 0.12 % chlorhexidine with anti-discoloration agent to reduce staining UNLABELLED The use of chlorhexidine ( CHX ) has been recommended for a number of clinical applications including plaque control in the post-operative period . However , the use of CHX is burdened by some side effects that could affect the compliance of the patient . The aim of this clinical trial was to evaluate the side effects , the staining in particular , the patient acceptance , and the efficacy of a 0.2 % CHX mouthwash containing an anti discoloration system ( ADS ) compared with a 0.2 % CHX alone , after periodontal flap surgery . MATERIAL AND METHODS This single-centre , cross-over , triple-blind r and omized clinical trial was carried out on 48 consecutive patients . After periodontal flap surgery , the patients were prescribed to rinse two times per day for 1 min for 1 week with 10 ml of test or control CHX , contained in anonymous bottles coded K or M and assigned r and omly . No brushing and interdental cleaning of the surgical area was allowed . At week 1 , after suture removal , patients received full-mouth prophylaxis and were given a second anonymous bottle , reversing the products , with the same instructions as at baseline . Patients resumed tooth-brushing but not interdental cleaning . At the end of week 2 , prophylaxis was repeated , mouth rinsing was discontinued and patients resumed normal oral hygiene . At weeks 1 and 2 , the following variables were recorded : presence of pigmentation , gingival parameters at the surgically treated sites ( gingival inflammation , tissue inflammation around the sutures , gingival swelling and presence of granulation tissue ) , patient perception and acceptance of the 2 mouthwashes . RESULTS Forty-seven patients completed the study . The difference between treatments related to gingival variables was not statistically significant . The test CHX caused consistently less pigmentations than the control CHX in all the evaluated areas of the dental surfaces ( odds ratio (OR)=0.083 p<0.0001 in the incisal area , OR=0.036 p<0.0001 in the approximal area and OR=0.065 p<0.0001 in the gingival area ) . The CHX ADS was found to be more tolerated by patients than the control mouthwash and to cause less food alteration , less alterations to the perception 
    Output:
    
There is moderate quality evidence from non-brushing studies that the addition of an ADS to CHX-MW reduces tooth surface discoloration and does not appear to affect its properties with respect to gingival inflammation and plaque scores .
In brushing- studies there is also moderate quality evidence that ADS does not affect the anti-plaque and anti-gingivitis efficacy of CHX .
The majority of comparisons and the meta- analysis including these indicate no significant effect of ADS on tooth staining in situations where the mouthwash is used in addition to toothbrushing .