Comparing the Impact of Mouthwashes on Patients With Fixed Orthodontic Appliances: A Network Meta‐Analysis

BACKGROUND: Orthodontic patients are at an elevated risk for gingivitis due to the challenges of maintaining oral hygiene with fixed appliances. This network meta-analysis evaluates the comparative effectiveness of various mouthwashes in managing gingivitis among these patients. OBJECTIVES: To assess the efficacy of different mouthwashes on Plaque Index and Gingival Index scores in orthodontic patients, utilizing both direct and indirect evidence from randomized controlled trials. SEARCH METHODS: Comprehensive searches were conducted in PubMed, Embase, Cochrane Library, Web of Science, Ovid, and grey literature for studies published up to November 2024. SELECTION CRITERIA: Only randomized controlled trials involving mouthwash use in orthodontic patients were included. DATA COLLECTION AND ANALYSIS: Data extraction was performed independently by two reviewers and the methodological quality of included studies was assessed using the Cochrane Risk of Bias tool. RESULTS: Nine RCTs involving 376 participants were included. Aloe vera and Persica showed the highest SUCRA values (both 91.7%), followed by Chlorhexidine and NaF (74.4%). In the PI network, Persica ranked highest (90.0%), followed by Aloe vera (77.6%) and Chlorhexidine and NaF (74.8%). For PI, node-splitting identified two estimable comparisons and did not detect significant inconsistency between direct and indirect evidence. For GI, no estimable node-splitting comparison was available in the final network. CONCLUSIONS: Within the limitations of the available evidence, Aloe vera and Persica ranked highest for reducing gingival inflammation, while Persica ranked highest for reducing plaque accumulation in orthodontic patients with fixed appliances. However, these findings should be interpreted cautiously because the evidence base was limited and heterogeneous. TRIAL REGISTRATION: The study protocol was registered with PROSPERO (ID CRD42023472995) on 27/10/2023.