# Evaluation of Blue(r)m Mouthwash vs. Chlorhexidine
## 1 Introduction  
Gingivitis is a highly prevalent oral disease which results from accumulation of dental plaque (also called biofilm) accompanied with enhanced host inflammatory response as well as an inflammation of gingiva [1]. It can have a gradual or sudden onset and may or may not be painful. Gingivitis is the inflammation of the gingiva, leading to color changes, bleeding, and swollen gums. The inflammation is associated with increases in the formation of new capillaries out of the existing blood vessels, which can be measured as micro vessel density (MVD). It has been reported that it is directly proportional with inflammation, and a high MVD corresponds with the most severe form of gingival inflammation. It can involve a few teeth or the entire dentition, depending upon the oral hygiene of the patient. The inflammation remains till the biofilm is in proximity with the gingival tissues, and it subsides after careful removal of the biofilm and irritants like dental calculus. This shift to gingival health is a part of the body's mechanism to prevent gingivitis turning into its irreversible counterpart, namely periodontitis involving inflammatory bone loss. During this shift, the predominant facultative Gram-positive bacteria turn into anaerobicGram-negative oral microflora. This is very frequently seen in adults and is predominant in the third decade of life. The traditional management of gingivitis includes a thorough oral prophylaxis with adjunctive use of chemical plaque control mouthwashes. Chlorhexidine is regarded as the gold standard in the antiseptic treatment of gingivitis [2; 3]. Chlorhexidine mouthwash very strongly adheres to the surface of teeth and gums, and, due to its high substantivity, it is quite effective in terms of reducing bacterial load [4]. Although it is quite efficacious against dental plaque, it has a lot of side effects, which has led to the search for similar products with minimal or no side effects. With the newer understanding that the mouth rinses used need to modify the oral microbiota, more and more research is going into finding a suitable alternative. It is now understood that the elimination of oral microflora due to rampant usage of chlorhexidine results in dysbiosis, a rise in the population of other pathogenic bacteria, and an alteration of the entire oral microflora [5; 6]. Another point of contention is the effect of oral microflora and its impact on systemic health. Although a causal relationship has not been established yet, it is believed that the bacterial by products of the oral cavity travel to distant organs in the body and may cause some systemic illness [7]. Thus, the usage of chlorhexidine should be carefully considered as having potential systemic effects, including those on cardiovascular health [8]. Oxygen therapy (administered systemically or topically) has been used in medicine for centuries now and is known to be effective in inhibiting inflammation and infection, wound healing, and in promoting angiogenesis [9]. Oxygen is essential for metabolic processes and is involved in numerous activities, including the oxidative killing of bacteria, re-epithelialization, and collagen production [10; 11]. Free radicals and reactive oxygen species (ROS) are essential for the growth of fibroblasts and epithelial cells [12; 13]. At lower concentrations, they are beneficial; however, at higher concentrations, they can cause cellular damage. Although the exact concentration is not known, increased ROS can cause irreversible tissue damage and lead to many oral conditions like lichen planus, pemphigus, and periodontal diseases [14]. ROS, like superoxide anion, hydrogen peroxide, and hydroxyl radicals, can cause damage to DNA, proteins, and lipids, and it can also overburden the cellular antioxidant capacity of the individual [15]. A homeostatic imbalance between reactive oxygen species and antioxidant defense systems has been implicated in the pathology of gingivitis [13].