The influence of a 0.2% chlorhexidine mouthrinse on plaque regrowth in orthodontic patients. A randomized prospective study. Part II: Bacteriological parameters

Minimum inhibitory concentrations of chlorhexidine- and lactic acid-based teat disinfectants: An intervention trial assessing bacterial selection and susceptibility

Teat disinfection is a recommended preventive tool to improve udder health and to prevent new intramammary infections. However, side effects are discussed, such as bacterial selection of less-susceptible bacteria with the application of certain teat disinfectants. The objective of this study was to assess the species composition and bacterial in vitro susceptibility by means of an interventive trial. For this purpose, 3 different postmilking teat treatments (disinfection with 0.215% chlorhexidine or 3.5% lactic acid, or control group with no dipping) were applied to 28 cows in a 6-d intervention approach using a split-udder design. Milk samples were taken before and after intervention. Bacteria were cultured and differentiated to species or genus level by MALDI-TOF mass spectrometry. Minimum inhibitory concentrations (MIC) were determined, and MIC changes over time were recorded. Susceptibilities to chlorhexidine and lactic acid were compared between species of the genera Staphylococcus, Streptococcus, Corynebacterium, and others. Species composition changed during the intervention. Under the treatment of chlorhexidine and lactic acid, the proportion of coagulase-negative staphylococci (CNS) decreased. An increased proportion of species belonging to the genus Corynebacterium was observed especially under the application of lactic acid. Although both teat disinfectants were basically effective, isolates differed in their susceptibility to both teat disinfectants. Populations of CNS, Staphylococcus aureus, and Corynebacterium spp. showed significantly lower absolute MIC values for chlorhexidine. Compared with other species, Corynebacterium spp. showed the lowest susceptibility for chlorhexidine as well as for lactic acid. A significant increase in MIC values after 6 d of intervention was observed with the lactic acid treatment in all isolates, as well as in CNS. This increase can be interpreted as either adaptation of isolates or displacement of more-susceptible species by less-susceptible species. Further studies using long-term intervention might reveal more pronounced effects on MIC values and species composition.

Current uses of chlorhexidine for management of oral disease: a narrative review

Objectives

Chlorhexidine (CHX) is a commonly used antiseptic mouthwash, used by dental practitioners and the public, due to its antimicrobial effects. The aim of this article was to provide a narrative review of current antimicrobial uses of CHX relevant to dentistry in the context of oral diseases, highlighting need for further studies to support its safe and appropriate use.

Study selection, data and sources

Randomised controlled trials, systematic reviews and national (UK and US) guidelines were consulted where available, with search terms for each subject category entered into MEDLINE, PubMed, Google Scholar and the Cochrane database.

Results

Some evidence existed to support adjunctive short-term use of CHX to manage dental plaque, and reduce clinical symptoms of gingivitis, dry socket, as well as reduce aerosolisation of bacteria. However, use must be weighed alongside the less desirable effects of CHX, including extrinsic staining of teeth, antimicrobial resistance to antiseptic agents and the rare, but fatal, allergic reactions to CHX. Conversely, evidence for the effectiveness of chlorhexidine to manage or prevent periodontitis, dental caries, necrotising periodontal diseases, peri-implantitis, and infections associated with extraction and aerosolised viruses remains less certain.

Conclusions

The use of CHX in dentistry and oral healthcare continues to be widespread and thus it is important that dental practitioners understand that, based on its differential mechanisms of action on different microbes, appropriate clinical and dental use of CHX should be oral disease specific. However, further scientific and clinical research is required before full recommendations can be made.

Combined chlorhexidine-sodiumfluoride mouthrinse for orthodontic patients: Clinical and microbiological study

Background

Orthodontic appliances impede good dental plaque control by brushing. Antimicrobial mouth rinses were suggested to improve this performance. We therefore aimed to investigate the effects of combined mouthrinse containing chlorhexidine (CHX) and sodium fluoride (NaF) on clinical oral hygiene parameters,and plaque bacterial level.

Material and Methods

In this double-blind clinical study, 60 fixed orthodontic patients aged 14-25 years were randomly assigned to one of four mouthrinses groups: 1- combined CHX /NaF 2- CHX 0.06% 3- NaF0.05% 4-placebo. Following baseline examination patients were instructed to use the assigned mouthrinse twice daily for 21 days. Bleeding index (BI), modified gingival index (MGI) and plaque index (PI) were determined at the baselineand after three weeks of rinsing. Samples from supragingival plaque were obtained for the assessment of total bacterial, Streptococcus mutans and Lactobacilli colony counts. Data were analyzed by Wilcoxon, Kruskal-Wallis, and Mann-Whitney tests.

Results

Clinical parameters; All three active mouth rinses induced significant improvements of BI, MGI, and PI (P<0.05). Results of CHX/NaF were slightly, but not significantly, better than CHX. CHX/NaF and CHX induced significantly more changes than NaF and placebo. Microbiological measurements; Except placebo, other mouthrinses reduced total bacterial, Streptococcus mutans, and Lactobacilli counts significantly (P<0.05). CHX/NaF acted against Lactobacilli significantly more than others.

Conclusions

Adding CHX0.06%/NaF0.05% combined mouth rinse to daily oral hygiene regimen of orthodontic patients significantly improved oral hygiene status. Effect of this combined mouth rinse on dental plaque Lactobacilli was remarkable. However, large controlled trials could provide more definitive evidence.

Key words:Mouthrinse, fluoride, chlorhexidine, plaque.

Assessment of the effectiveness of mouthwashes in reducing cariogenic biofilm in orthodontic patients: a systematic review

OBJECTIVES

The use of fixed orthodontic appliances makes it difficult to clean the teeth and accessories associated with it. For this reason, orthodontic patients have used oral antiseptics as coadjuvent means to reduce cariogenic plaque. The aim of this systematic review was to evaluate the effectiveness of oral antiseptics on the reduction of cariogenic plaque on orthodontic patients.

DATA

This review has been registered at PROSPERO--international prospective register of systematic reviews under the number CRD42013006857.

SOURCES

A systematic review of the literature was conducted in the following electronic databases: Scopus, PubMed, Web of Science, Medline, Embase and Cochrane, Grey literature and Clinical Trials, without limitations on the year of publication or language. Clinical studies in patients with fixed orthodontic appliances, who were making use of oral mouthwashes in order to reduce cariogenic plaque, were included. Articles with patients using systemic drugs, syndromic patients, those using mouthwashes for other purposes and/or using different cleaning techniques, and clinical cases were excluded. After selection by title and abstract, potentially eligible articles were read in full. The methodological quality and risk of biases of articles included were evaluated according to the characteristics of the study, measurements and statistical analyses of the study. The methodological quality was classified as high, moderate or low.

STUDY SELECTION

The search identified 2716 articles, of which 15 met the inclusion criteria. Of these, 8 analyzed chlorhexidine-based mouthwashes, while in 1 article Cetylpyridinium was used; 1 analyzed the mouthwash containing sanguinaria; 1 the use of NaF; 2 articles the use of AmF/SnF2; 2 the use of Listerine(®), 1 also analyzed the association between mouthwashes with octenidine and with PVP-I. Of the articles analyzed, 11 were classified as having high and 4 as having moderate methodological quality.

CONCLUSION

There is evidence of effectiveness of the use of oral mouthwashes in the control of cariogenic plaque in patients with fixed orthodontic appliances. The orthodontists may suggest the use of oral antiseptics in the oral hygiene of their patients as coadjuvent means to reduce cariogenic plaque.

CLINICAL SIGNIFICANCE

Given current evidence, orthodontists may prescribe mouthwash as an auxiliary method in the control of cariogenic biofilm in orthodontic patients.

Confusion over live/dead stainings for the detection of vital microorganisms in oral biofilms--which stain is suitable?

BACKGROUND

There is confusion over the definition of the term "viability state(s)" of microorganisms. "Viability staining" or "vital staining techniques" are used to distinguish live from dead bacteria. These stainings, first established on planctonic bacteria, may have serious shortcomings when applied to multispecies biofilms. Results of staining techniques should be compared with appropriate microbiological data.

DISCUSSION

Many terms describe "vitality states" of microorganisms, however, several of them are misleading. Authors define "viable" as "capable to grow". Accordingly, staining methods are substitutes, since no staining can prove viability.The reliability of a commercial "viability" staining assay (Molecular Probes) is discussed based on the corresponding product information sheet: (I) Staining principle; (II) Concentrations of bacteria; (III) Calculation of live/dead proportions in vitro. Results of the "viability" kit are dependent on the stains' concentration and on their relation to the number of bacteria in the test. Generally this staining system is not suitable for multispecies biofilms, thus incorrect statements have been published by users of this technique.To compare the results of the staining with bacterial parameters appropriate techniques should be selected. The assessment of Colony Forming Units is insufficient, rather the calculation of Plating Efficiency is necessary. Vital fluorescence staining with Fluorescein Diacetate and Ethidium Bromide seems to be the best proven and suitable method in biofilm research.Regarding the mutagenicity of staining components users should be aware that not only Ethidium Bromide might be harmful, but also a variety of other substances of which the toxicity and mutagenicity is not reported.

SUMMARY

- The nomenclature regarding "viability" and "vitality" should be used carefully.- The manual of the commercial "viability" kit itself points out that the kit is not suitable for natural multispecies biofilm research, as supported by an array of literature.- Results obtained with various stains are influenced by the relationship between bacterial counts and the amount of stain used in the test. Corresponding vitality data are prone to artificial shifting.- As microbiological parameter the Plating Efficiency should be used for comparison.- Ethidium Bromide is mutagenic. Researchers should be aware that alternative staining compounds may also be or even are mutagenic.

The effect of Triphala and Chlorhexidine mouthwash on dental plaque, gingival inflammation, and microbial growth

The objective of this study was to ascertain the effects of a mouthwash prepared with Triphala on dental plaque, gingival inflammation, and microbial growth and compare it with commercially available Chlorhexidine mouthwash. This study was conducted after ethics committee approval and written consent from guardians (and assent from the children) were obtained. A total of 1431 students in the age group 8–12 years, belonging to classes fourth to seventh, were the subjects for this study. The Knowledge, Attitude and Practice (KAP) of the subjects was determined using a questionnaire. The students were divided into three groups namely, Group I (n = 457) using Triphala mouthwash (0.6%), Group II (n = 440) using Chlorhexidine mouthwash (0.1%) (positive control), and Group III (n = 412) using distilled water (negative control). The assessment was carried out on the basis of plaque scores, gingival scores, and the microbiological analysis (Streptococcus and lactobacilli counts). Statistical analysis for plaque and gingival scores was conducted using the paired sample t-test (for intragroup) and the Tukey's test (for intergroup conducted along with analysis of variance test). For the Streptococcus mutans and Lactobacillus counts, Wilcoxon and Mann–Whitney test were applied for intragroup and intergroup comparison, respectively. All the tests were carried out using the SPSS software. Both the Group I and Group II showed progressive decrease in plaque scores from baseline to the end of 9 months; however, for Group III increase in plaque scores from the baseline to the end of 9 months was noted. Both Group I and Group II showed similar effect on gingival health. There was inhibitory effect on microbial counts except Lactobacillus where Triphala had shown better results than Chlorhexidine. It was concluded that there was no significant difference between the Triphala and the Chlorhexidine mouthwash.

Effect of chlorhexidine pretreatment on the stability of salivary lactobacilli probiotic in six- to twelve-year-old children: a randomized controlled trial

This study aimed to investigate the efficacy of chlorhexidine mouthwash disinfection on the stability of lactobacilli probiotic. This study involved 105 children in 3 groups. Subjects in group A received chlorhexidine for 2 weeks, subjects of group B received probiotic yogurt containing Lactobacillus rhamnosus GG (LGG) at a concentration of 2 × 10(8) colony-forming units per gram for 3 weeks, and subjects in group C received chlorhexidine in the same manner as group A and 24 h after cessation, they received probiotic yogurt in the same manner as group B. Salivary Streptococcus mutans (SM) and LGG were counted at baseline, 24 h, 1 week and 5 weeks after each intervention in all groups. The SM count was reduced 24 h after cessation of chlorhexidine in group A (p < 0.001), and was steady for 5 weeks (p < 0.05). In group B, SM counts did not show significant differences 5 weeks after ending the intake of the probiotic (p > 0.05); LGG counts increased (p < 0.001), but were not steady over 5 weeks. In group C, a significant reduction in SM count was recorded, and the reduced count was steady for 5 weeks; a significant increase in LGG counts was registered (p < 0.001), which was steady for 5 weeks. Intergroup comparison showed a significant increase in LGG counts in groups B and C; however, this increase was not steady in group B. Chlorhexidine treatment before probiotic intake induced more stable colonization with LGG strains than probiotic alone.

[Reciprocal relationships between orthodontics and periodontics: relevance of a synergistic action]

The aim of this article is to review evidence on the reciprocal relationships between orthodontics and periodontics. Normal intra-arch and inter-arch relationships have long been considered as an anatomic prerequisite for the preservation of dental health and function. Certain malocclusion traits are associated with difficulties in maintaining good oral hygiene and as a consequence to poor periodontal condition. Therefore, proper alignment of the teeth provided by orthodontic treatment may promote good control of soft deposit and calculus and subsequent periodontal inflammation. The tendency of orthodontic appliances, particularly the brackets and bands to promote the accumulation of plaque and thus increasing the risk of developing localized periodontal disease must however be constantly emphasized. Periodontitis involves progressive loss of the alveolar bone around the teeth, pathological tooth migration and gingival recession with pathological tooth migration and gingival recession as a possible outcome. The effectiveness of orthodontics in conjunction with periodontics in the management of these esthetic and functional defects is highlighted in this review.

Effect of N-chlorotaurine mouth rinses on plaque regrowth and plaque vitality

The purpose of this 4-day plaque regrowth study was to assess the effect of N-chlorotaurine (NCT) mouth rinses on plaque inhibition and plaque vitality. Eighty volunteers participated in this investigator-blind, randomized, clinical controlled study in parallel groups. No oral hygiene was permitted except rinsing with a 2% or 3% NCT mouth rinse, a positive or a negative control. Primary parameters were the plaque index (Silness and Löe, Acta Odontol Scand, 22:121-135, 1964) and plaque vitality (Netuschil et al., J Clin Periodontol, 16:484-488, 1989) after the final rinse. In addition, another plaque index (Turesky et al., J Periodontol, 41:41-43, 1970), plaque area, and bleeding on probing were recorded. All parameters were taken at baseline and day 5. U test was applied on a 5% error level. No differences in plaque inhibition were found between the two NCT formulations and the negative control. However, a statistically significant reduction of plaque vitality compared to the negative and positive control was observed. Discoloration of the tongue and unpleasant taste were recorded in participants in the NCT groups. NCT mouth rinses did not inhibit plaque regrowth, but they did reduce the vitality of plaque bacteria. Methods of prolonging the substantivity of the NCT mouth rinses should be investigated to enhance the antibacterial properties of these formulations.

How to select the right mouthrinses in periodontal prevention and therapy. Part I. Test systems and clinical investigations

The use of mouthrinses is increasing, especially as adjuncts to the daily mechanical oral hygiene. Different test systems may and can be used to test their antibacterial and clinical effects: bacteriology in vitro, substantivity in vivo, 4-day plaque re-growth, experimental gingivitis and long-term use. The plaque re-growth investigations of a few days are not only of limited use but may also be dangerous because often too extensive conclusions have been drawn from their design. The 'gold standard' test is the experimental gingivitis model to reveal the antiplaque as well as the antigingivitis effects of any mouthrinse preparation during 3 weeks. The last kind of investigations are of several months' duration, where the substances are used as supplements to mechanical oral hygiene measures.

Efficacy of subgingival irrigation using herbal extracts on gingival inflammation

BACKGROUND

The aim of the present study was to investigate the efficacy of an herbal-based mouthrinse in combination with an oral irrigator in reducing gingival inflammation.

METHODS

A total of 89 patients (45 females, 44 males; mean age 49.1 +/- 1.31 years) were included in this prospective, randomized, double-blind clinical study and allocated to 3 treatment groups: group 1 (n = 34), treated with an oral irrigator with subgingival tips and an herbal-based mouthrinse; group 2 (n = 29), the oral irrigator was applied in combination with a conventional mouthwash; and group 3 (n = 26), treated with the conventional mouthwash without subgingival irrigation. Data collected at baseline and after 4, 8, and 12 weeks included gingival index (GI), sulcus bleeding index (SBI), plaque index (PI), and probing depth (PD).

RESULTS

Over a period of 3 months, GI decreased from 1.80 +/- 0.04 to 1.56 +/- 0.04 in group 1; from 1.79 +/- 0.05 to 1.68 +/- 0.04 in group 2; and remained nearly constant in group 3 (from 1.79 +/- 0.05 to 1.81 +/- 0.04). Differences between the groups were significant (analysis of variance, P < 0.05). SBI values in group 1 were reduced from 2.51 +/- 0.06 to 2.13 +/- 0.06 after 3 months and were significantly lower than in group 2 (P = 0.001) and 3 (P = 0.002), with SBIs of 2.44 +/- 0.06 and 2.42 +/- 0.07, respectively, after 12 weeks. A reduction in PI was noted for all 3 groups throughout the follow-up period, with no statistically significant differences. Probing depths were not reduced significantly in any group.

CONCLUSION

Subgingival irrigation with an herbal-based mouthrinse led to a significant reduction in both SBI and GI. This regimen can, therefore, be recommended as an adjunctive procedure to reduce gingival inflammation.

Antibiotic resistance as an indicator of bacterial chlorhexidine susceptibility

The antibiotic and chlorhexidine (CHX) susceptibility of 70 distinct clinical isolates: Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter baumannii, Staphylococcus aureus (not MRSA), Streptococcus pyogenes and Enterococcus faecalis (10 of each) were tested using minimal bactericidal (MBC) and/or minimal inhibitory (MIC) concentrations. Non-fermentative bacteria tolerated CHX at high concentrations; Gram-positive cocci, especially S. pyogenes, were the most susceptible. We found a good correlation between CHX and antibiotic susceptibility in both MIC and MBC among Gram-negative bacteria, and mainly in MBC among Gram-positive bacteria. Resistance to ciprofloxacin, imipenem, cefotaxime, ceftazidime, gentamicin and aztreonam appeared to indicate increased CHX resistance among Gram-negative bacteria. This finding gives clinicians the ability to predict CHX susceptibility according to routine antibiotic resistance testing.

The influence of a 0.2% chlorhexidine mouthrinse on plaque regrowth in orthodontic patients. A randomized prospective study. Part I: clinical parameters

In a prospective plaque regrowth study focusing on oral hygiene during fixed appliance therapy 12 adolescent patients (mean age 14.1 +/- 1.5 years) were evaluated twice over 2-day test periods. In the randomized, double-blind study the influence of a 0.2% chlorhexidine (CHX) mouthrinse (Corsodyl) and a commercially available dentifrice supplementing fluoride (Odol-med-3) were compared intra- and interindividually in a crossover design with regard to plaque and gingivitis. Before starting the first test phase there was a 14-day preliminary phase for upgrading the oral hygiene. Between the 2 test phases was a 5-day "washout". On the last day of the second test phase the patients were asked to fill in a questionnaire concerning their experiences during the study. The 0.2% Corsodyl reduced the plaque index scores significantly (p < 0.001). The gingival index revealed a similar reduction (2nd day of test: p = 0.03). Until the 5th day of washout a clear-cut carryover effect of the chlorhexidine rinse on the gingival index was observed. Both the lower mean values of the 2 clinical parameters at the beginning of the test phases as compared with those at the beginning of the preliminary phase and the evaluation of the questionnaires indicated a possible Hawthorne effect. 0.2% Corsodyl may be employed as an adjunct to other preventive measures such as professional care and patient-oriented instruction on an intermittent basis in order to reduce the plaque-induced iatrogenic side effects and to enhance the efficacy of oral hygiene measures in connection with orthodontic therapy with fixed appliances.