The effects of a chlorhexidine mouthrinse on culturable microorganisms of the tongue and saliva

Clinical Trial for Evaluating the Effectiveness and Safety of a New Dental Plaque Removal Device: Microscale Mist Unit

This study evaluates the effectiveness and safety of a microscale mist unit (MSM-UNIT) that sprays high-speed fine water droplets to remove dental plaque adhering to the oral mucosa (tongue and palate) and tooth surface. Fifteen patients who had difficulty self-managing sufficient oral care were included in this study. Effectiveness was evaluated for at least five patients' tongues, palate mucosas, and tooth surfaces, and safety evaluation was conducted at all three sites for all patients. Effectiveness was evaluated using the rate of degree of dental plaque removal. Safety was evaluated using a numerical rating scale (NRS) for pain and symptoms of inflammation. An operator who performed treatment and an evaluator who evaluated effectiveness and safety were designated. In addition, an image judgment committee judged effectiveness. Although evaluation of the tongue varied between the evaluators and the image judgment committee, the rates of degree for all plaque removal increased in all regions. In addition, low pain NRS results and minimal symptoms of inflammation were observed and within an acceptable range. The MSM-UNIT can be used effectively and safely for removing oral plaque not only from teeth, but also from the oral mucosa.

Chlorhexidine Improves Hygiene Reducing Oral Polymorphonuclear Leukocytes with Antimicrobial Effects at Distinct Microenvironments amongst Subjects Stratified by Health Status

Oral conditions such as gingivitis and oral malodor are commonly reported globally. Objective: This investigation clinically stratified subjects to healthy, malodor and gingivitis groups and enumerated oral polymorphonuclear leukocytes (PMN) as a measure of inflammation prior to and after rinsing with a chlorhexidine (CHX) mouthwash. The study also assessed clinical outcomes (dental plaque and gingival bleeding indices), malodor (halimeter scores, organoleptic and tongue coat index and microbiological parameters (anaerobic and malodor organisms of dental plaque, tongue surface and saliva) for a comprehensive assessment of the oral inflammatory burden. Methods: Consenting adults were stratified into control (n = 17), gingivitis (n = 19) and halitosis (n = 17) groups based on clinical criteria. At baseline, oral samples were examined for PMN in addition to microbiological analysis of dental plaque, saliva and tongue scrapings for anaerobic and malodor bacteria. Subjects were issued a commercially available fluoride toothpaste and a chlorhexidine mouthwash for two-week use prior to post-treatment assessments identical to baseline. Results: At baseline, PMN were lowest in the control that increased amongst the halitosis subjects, with the gingivitis group registering the highest levels (p < 0.05) with these outcomes corresponding with clinical parameters (p < 0.05). CHX use improved outcomes with a 56−61% reduction in PMN with significant differences between groups (p < 0.05). Dental plaque and bleeding indices were lower by 57−78% with oral malodor, demonstrating reductions of 33−59% (p < 0.05). Significant reductions in anaerobic and malodor organisms ranging from 78−96% and 76−94%, respectively, were noted after CHX use (p < 0.05). Conclusions: At study enrollment, PMN scores were lowest in healthy subjects, with increasing numbers amongst halitosis followed by gingivitis. Amongst all subject groups, CHX use significantly reduced oral PMN and corroborated with corresponding decreases in clinical, malodor and bacterial outcomes. Together, these results demonstrate the significant reductions in the oral inflammatory burden following CHX use.

Low-Temperature Plasma as an Approach for Inhibiting a Multi-Species Cariogenic Biofilm

This study aimed to determine how low-temperature plasma (LTP) treatment affects single- and multi-species biofilms formed by Streptococcus mutans, Streptococcus sanguinis, and Streptococcus gordonii formed on hydroxyapatite discs. LTP was produced by argon gas using the kINPen09™ (Leibniz Institute for Plasma Science and Technology, INP, Greifswald, Germany). Biofilms were treated at a 10 mm distance from the nozzle of the plasma device to the surface of the biofilm per 30 s, 60 s, and 120 s. A 0.89% saline solution and a 0.12% chlorhexidine solution were used as negative and positive controls, respectively. Argon flow at three exposure times (30 s, 60 s, and 120 s) was also used as control. Biofilm viability was analyzed by colony-forming units (CFU) recovery and confocal laser scanning microscopy. Multispecies biofilms presented a reduction in viability (log10 CFU/mL) for all plasma-treated samples when compared to both positive and negative controls (p < 0.0001). In single-species biofilms formed by either S. mutans or S. sanguinis, a significant reduction in all exposure times was observed when compared to both positive and negative controls (p < 0.0001). For single-species biofilms formed by S. gordonii, the results indicate total elimination of S. gordonii for all exposure times. Low exposure times of LTP affects single- and multi-species cariogenic biofilms, which indicates that the treatment is a promising source for the development of new protocols for the control of dental caries.

Interventions for managing halitosis

BACKGROUND

Halitosis or bad breath is a symptom in which a noticeably unpleasant breath odour is present due to an underlying oral or systemic disease. 50% to 60% of the world population has experienced this problem which can lead to social stigma and loss of self-confidence. Multiple interventions have been tried to control halitosis ranging from mouthwashes and toothpastes to lasers. This new Cochrane Review incorporates Cochrane Reviews previously published on tongue scraping and mouthrinses for halitosis.

OBJECTIVES

The objectives of this review were to assess the effects of various interventions used to control halitosis due to oral diseases only. We excluded studies including patients with halitosis secondary to systemic disease and halitosis-masking interventions.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 8 April 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 3) in the Cochrane Library (searched 8 April 2019), MEDLINE Ovid (1946 to 8 April 2019), and Embase Ovid (1980 to 8 April 2019). We also searched LILACS BIREME (1982 to 19 April 2019), the National Database of Indian Medical Journals (1985 to 19 April 2019), OpenGrey (1992 to 19 April 2019), and CINAHL EBSCO (1937 to 19 April 2019). The US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (8 April 2019), the World Health Organization International Clinical Trials Registry Platform (8 April 2019), the ISRCTN Registry (19 April 2019), the Clinical Trials Registry - India (19 April 2019), were searched for ongoing trials. We also searched the cross-references of included studies and systematic reviews published on the topic. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) which involved adults over the age of 16, and any intervention for managing halitosis compared to another or placebo, or no intervention. The active interventions or controls were administered over a minimum of one week and with no upper time limit. We excluded quasi-randomised trials, trials comparing the results for less than one week follow-up, and studies including advanced periodontitis.

DATA COLLECTION AND ANALYSIS

Two pairs of review authors independently selected trials, extracted data, and assessed risk of bias. We estimated mean differences (MDs) for continuous data, with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 44 trials in the review with 1809 participants comparing an intervention with a placebo or a control. The age of participants ranged from 17 to 77 years. Most of the trials reported on short-term follow-up (ranging from one week to four weeks). Only one trial reported long-term follow-up (three months). Three studies were at low overall risk of bias, 16 at high overall risk of bias, and the remaining 25 at unclear overall risk of bias. We compared different types of interventions which were categorised as mechanical debridement, chewing gums, systemic deodorising agents, topical agents, toothpastes, mouthrinse/mouthwash, tablets, and combination methods. Mechanical debridement: for mechanical tongue cleaning versus no tongue cleaning, the evidence was very uncertain for the outcome dentist-reported organoleptic test (OLT) scores (MD -0.20, 95% CI -0.34 to -0.07; 2 trials, 46 participants; very low-certainty evidence). No data were reported for patient-reported OLT score or adverse events. Chewing gums: for 0.6% eucalyptus chewing gum versus placebo chewing gum, the evidence was very uncertain for the outcome dentist-reported OLT scores (MD -0.10, 95% CI -0.31 to 0.11; 1 trial, 65 participants; very low-certainty evidence). No data were reported for patient-reported OLT score or adverse events. Systemic deodorising agents: for 1000 mg champignon versus placebo, the evidence was very uncertain for the outcome patient-reported visual analogue scale (VAS) scores (MD -1.07, 95% CI -14.51 to 12.37; 1 trial, 40 participants; very low-certainty evidence). No data were reported for dentist-reported OLT score or adverse events. Topical agents: for hinokitiol gel versus placebo gel, the evidence was very uncertain for the outcome dentist-reported OLT scores (MD -0.27, 95% CI -1.26 to 0.72; 1 trial, 18 participants; very low-certainty evidence). No data were reported for patient-reported OLT score or adverse events. Toothpastes: for 0.3% triclosan toothpaste versus control toothpaste, the evidence was very uncertain for the outcome dentist-reported OLT scores (MD -3.48, 95% CI -3.77 to -3.19; 1 trial, 81 participants; very low-certainty evidence). No data were reported for patient-reported OLT score or adverse events. Mouthrinse/mouthwash: for mouthwash containing chlorhexidine and zinc acetate versus placebo mouthwash, the evidence was very uncertain for the outcome dentist-reported OLT scores (MD -0.20, 95% CI -0.58 to 0.18; 1 trial, 44 participants; very low-certainty evidence). No data were reported for patient-reported OLT score or adverse events. Tablets: no data were reported on key outcomes for this comparison. Combination methods: for brushing plus cetylpyridium mouthwash versus brushing, the evidence was uncertain for the outcome dentist-reported OLT scores (MD -0.48, 95% CI -0.72 to -0.24; 1 trial, 70 participants; low-certainty evidence). No data were reported for patient-reported OLT score or adverse events.

AUTHORS' CONCLUSIONS

We found low- to very low-certainty evidence to support the effectiveness of interventions for managing halitosis compared to placebo or control for the OLT and patient-reported outcomes tested. We were unable to draw any conclusions regarding the superiority of any intervention or concentration. Well-planned RCTs need to be conducted by standardising the interventions and concentrations.

The antimicrobial and antiadhesion activities of micellar solutions of surfactin, CTAB and CPCl with terpinen-4-ol: applications to control oral pathogens

The oral pathogen Streptococcus mutans is involved in tooth decay by a process that initiates with biofilm adhesion and caries development. The presence of other microbes such as Candida albicans may worsen the demineralization process. Since both microbes are virulent to the host and will proliferate under specific host immune deficiencies and systemic diseases, it is important to study antimicrobial substances and their effects on both pathogens. There are several antiseptic agents used to reduce plaque biofilm and its outcome (dental caries and/or periodontal disease). However, some of these have undesired effects. In the current study we investigated the antimicrobial and anti-adhesion properties of micellar solutions of surfactants and the plant natural product terpinen-4-ol (TP). The results revealed an increase in antimicrobial properties of the synthetic surfactants, cetylpyridinium chloride (CPC) and cetyltrimethylammonium bromide (CTAB), when mixed with TP. In addition, although surfactin, a biosurfactant, has little antimicrobial activity, it was demonstrated that it enhanced the effect of TP both as antimicrobial and anti-adhesion compound. Surfactin and the synthetic surfactants promote the antimicrobial activity of TP against S. mutans, the causal agent of tooth decay, suggesting specificity for membrane interactions that may be facilitated by surfactants. This is the first report on the successful use of surfactin in association with TP to inhibit the growth and adhesion of microbial pathogens. Surfactin has other beneficial properties besides being biodegradable, it has antiviral and anti-mycoplasma activities in addition to adjuvant properties and encapsulating capacity at low concentration.

Antibacterial activity of selected commercial products for mouth washing and disinfection, assessed in accordance with PN-EN 1040

Background

Currently, there is a wide range of products for mouth washing on the Polish market. They have different qualitative and quantitative compositions, and they differ particularly in the concentration of active substances. In antisepsis and disinfection, the significant reduction in number of cells of microorganisms in a particular environment is very crucial. The chemical agents should provide a significant decrease in number of microorganisms in a relatively short time. The purpose of this study was to examine the bactericidal activity of selected herbal products used for treatment of inflammation, and disinfection and washing of the mouth, having antibacterial activity as declared by the manufacturers.

Material/Methods

The study included 28 products for mouth washing and disinfection available in Poland. Bactericidal activity was studied using a quantitative suspension test according to the standard PN-EN 1040.

Results

Only 1 of 4 tested herbal products, registered as medicinal products, showed satisfactory antibacterial activity when they were used according to the manufacturer’s recommendations. A total of 13 preparations (48%) complied with the standard requirements against all tested strains. Up to 19% of products showed no bactericidal activity against bacterial strains, and up to 33% were only effective against certain microorganisms.

Conclusions

The informational literature accompanying most antiseptics should be corrected by the manufacturers, providing information about antimicrobial activity consistent with the requirements of applicable standards. The information on the packaging or in the leaflets for antiseptic products should be corrected by the manufacturers to include accurate information on antimicrobial activity.

Effect of essential oils containing and alcohol-free chlorhexidine mouthrinses on cariogenic micro-organisms in human saliva

OBJECTIVE

The aim of this study was to evaluate the effect on mutans streptococci and lactobacilli in saliva of mouthrinsing with essential oils and an alcohol-free chlorhexidine.

MATERIALS AND METHOD

Twenty healthy volunteers (mean age 59 years) participated in the double-blind randomized cross-over study. Three mouthrinses were used in 16 days rinsing periods in addition to their regular mechanical oral hygiene: a solution with essential oils (EO; Listerine), a solution with alcohol-free chlorhexidine (CHX; Paroex) and water (negative control). The mouthrinse periods were separated by 3-month washout periods. At days 0 (baseline) and 17 (end) of each mouthrinse period, paraffin stimulated whole saliva was collected in order to analyse CFU/ml saliva of mutans streptococci and lactobacilli.

RESULTS

Only the CHX rinse showed a significant difference for CFU mutans streptococci between baseline and end (p = 0.004). The CFU mutans streptococci at the end of the rinse periods showed statistically significant differences between CHX vs EO (p = 0.039) and CHX vs water (p = 0.022). The difference in CFU lactobacilli between baseline and end was significant for CHX (p = 0.031), but not for the other rinses. No statistically significant differences for lactobacilli were found at the end of the rinse periods between the mouthrinses.

CONCLUSION

A significant reduction in amount of cariogenic bacteria in saliva was observed after 16 days of alcohol-free chlorhexidine mouthrinse but not after the essential oils rinse. The high number of participant's not changing to a bacterial class with a reduced number of micro-organisms showed that both rinses had little clinical significance as a caries preventing treatment method, which can decrease the number of CFU cariogenic micro-organisms.

Isolation and characterization of bacteriophages specific to hydrogen-sulfide-producing bacteria

The objectives of this study were to isolate and characterize bacteriophages specific to hydrogen-sulfide-producing bacteria (SPB) from raw animal materials, and to develop a SPB-specific bacteriophage cocktail for rendering application. Meat, chicken offal, and feather samples collected from local supermarkets and rendering processing plants were used to isolate SPB (n = 142). Bacteriophages (n = 52) specific to SPB were isolated and purified from the above samples using 18 of those isolated SPB strains as hosts. The host ranges of bacteriophages against 5 selected SPB strains (Escherichia coli, Citrobacter freundii, and Hafnia alvei) were determined. Electron microscopy observation of 9 phages selected for the phage cocktail revealed that 6 phages belonged to the family of Siphoviridae and 3 belonged to the Myoviridae family. Restriction enzyme digestion analysis with endonuclease DraI detected 6 distinguished patterns among the 9 phages. Phage treatment prevented the growth of SPB for up to 10 h with multiplicity of infection ratios of 1, 10, 100, and 1000 in tryptic soy broth at 30 °C, and extended the lag phase of SPB growth for 2 h at 22 °C with multiplicities of infection of 10, 100, and 1000. These results suggest that the selected bacteriophage cocktail has a high potential for phage application to control SPB in raw animal materials destined for the rendering process.

Differential actions of chlorhexidine on the cell wall of Bacillus subtilis and Escherichia coli

Chlorhexidine is a chlorinated phenolic disinfectant used commonly in mouthwash for its action against bacteria. However, a comparative study of the action of chlorhexidine on the cell morphology of gram-positive and gram-negative bacteria is lacking. In this study, the actions of chlorhexidine on the cell morphology were identified with the aids of electron microscopy. After exposure to chlorhexidine, numerous spots of indentation on the cell wall were found in both Bacillus subtilis and Escherichia coli. The number of indentation spots increased with time of incubation and increasing chlorhexidine concentration. Interestingly, the dented spots found in B. subtilis appeared mainly at the hemispherical caps of the cells, while in E. coli the dented spots were found all over the cells. After being exposed to chlorhexidine for a prolonged period, leakage of cellular contents and subsequent ghost cells were observed, especially from B subtilis. By using 2-D gel/MS-MS analysis, five proteins related to purine nucleoside interconversion and metabolism were preferentially induced in the cell wall of E. coli, while three proteins related to stress response and four others in amino acid biosynthesis were up-regulated in the cell wall materials of B. subtilis. The localized morphological damages together with the biochemical and protein analysis of the chlorhexidine-treated cells suggest that chlorhexidine may act on the differentially distributed lipids in the cell membranes/wall of B. subtilis and E. coli.

The application of modified flow-through cell apparatus for the assessment of chlorhexidine dihydrochloride release from lozenges containing sorbitol

The objective of this work was to apply a new apparatus for the assay of the drug release from lozenge tablet with a potential use in the treatment of oral candidosis and another conditions connected to microbial etiopathology in the oral cavity or as an antiplaque factor. Also, an approach to comparison of the applied method with the classical paddle apparatus method was performed. Tablets containing chlorhexidine dihydrochloride were formulated with granulated sorbitol of different grades (diameter of 110, 180, 480, and 650 microm, respectively), lactose, and magnesium stearate as excipients. Tablets were obtained through direct compression, and uniformity of weight, friability, breaking strength, disintegration, and release rate were evaluated. The disintegration times ranged between 10 and 21 min. In the next stage of the study, the release of chlorhexidine from lozenges prepared with granulated sorbitol grade 110 microm and different amounts of lactose and magnesium stearate was assessed. Two stages were observed during the release of chlorhexidine dihydrochloride from the lozenges, assayed by the classical paddle apparatus method II USP. In the first stage, release rates were between 2.6 x 10(-2) and 4.7 x 10(-2) min(-1), in the second stage between 1.7 x 10(-3) and 7.7 x 10(-3) min(-1). In the case of the in-house method, the release was near to first-order kinetics through the entire release experiment, with rate constants between 3.6 x 10(-2) and 6.6 x 10(-2) min(-1). The sorbitol granulate of granules with diameter 110 microm was found to be most suitable for the lozenges with chlorhexidine dihydrochloride and lactose. The in-house release method, proposed in this work, seems to be more realistic for the preliminary assessment of predicted drug concentrations in the oral cavity after the intake of a lozenge.

Reduction of circular stapler-related wound infection in patients undergoing laparoscopic Roux-en-Y gastric bypass, Cleveland clinic technique

BACKGROUND

Circular-stapled anastomosis with trans-oral anvil insertion for the creation of the gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass (LRYGBP) is associated with frequent infections at the abdominal wall site where the circular stapler is inserted.

METHODS

Patients who underwent routine LRYGBP over a 1.5-year period at The Cleveland Clinic Foundation without any concomitant procedures were included. After our initial experience with circular-stapled anastomosis-related wound infections, we implemented measures to reduce the infection rate. Prevention measures included chlorhexidine "swish and swallow," a plastic barrier device over the stapler, wound irrigation, loose skin approximation, and placement of loose packing. We compared wound infection rates in patients before ("no prevention") and after ("prevention") implementing these measures.

RESULTS

Ninety-one patients with mean age of 42 years and average body mass index of 48 kg/m(2) underwent laparoscopic Roux-en-Y gastric bypass. The infection rate was 30% among the "no prevention" (n = 10) group and 1% in the "prevention" (n = 81) group (p < 0.05).

CONCLUSIONS

Trocar site infection related to the circular-stapled anastomosis technique can be significantly reduced with simple prevention measures.

Community-level assessment of the effects of the broad-spectrum antimicrobial chlorhexidine on the outcome of river microbial biofilm development

Chlorhexidine is a common-use antibacterial agent found in a range of personal-care products. We used rotating annular reactors to cultivate river biofilms under the influence of chlorhexidine or its molar equivalent in nutrients. Studies of the degradation of [(14)C]chlorhexidine demonstrated that no mineralization of the compound occurred. During studies with 100 microg liter(-1) chlorhexidine, significant changes were observed in the protozoan and micrometazoan populations, the algal and cyanobacterial biomass, the bacterial biomass, and carbon utilization. Denaturing gradient gel electrophoresis (DGGE) in combination with statistical analyses showed that the communities developing under control and 100 microg liter(-1) chlorhexidine were significantly different. At 10 microg liter(-1) chlorhexidine, there was significantly increased algal and cyanobacterial biomass while the bacterial biomass was not significantly affected (P < 0.05). No significant effects on protozoan or metazoan grazing were detected at the 10-microg liter(-1) chlorhexidine level. Fluorescent in situ hybridization indicated a significant reduction in the abundance of betaproteobacteria and gammaproteobacteria (P < 0.05). Archaeal cell counts were significantly reduced by both chlorhexidine and nutrient treatments. DGGE and statistical analyses indicated that 10 microg liter(-1) chlorhexidine and molar equivalent nutrient treatments were significantly different from control communities. In contrast to community level observations, toxicological testing with a panel of cyanobacteria, algae, and protozoa indicated no detectable effects at 10, 50, and 100 microg liter(-1) chlorhexidine. Thus, community level assessment indicated a risk of low levels of chlorhexidine in aquatic habitats while conventional approaches did not.

Controlled release of chlorhexidine from UDMA-TEGDMA resin

Chlorhexidine salts are available in various formulations for dental applications. This study tested the hypothesis that the release of chlorhexidine from a urethane dimethacrylate and triethylene glycol dimethacrylate resin system can be effectively controlled by the chlorhexidine diacetate content and pH. The filler concentrations were 9.1, 23.1, or 33.3 wt%, and the filled resins were exposed to pH 4 and pH 6 acetate buffers. The results showed that Fickian diffusion was the dominant release mechanism. The rates of release were significantly higher in pH 4 buffer, which was attributed to the increase of chlorhexidine diacetate solubility at lower pH. The higher level of filler loading reduced the degree of polymerization, leading to a greater loss of organic components and higher chlorhexidine release rates.