Effect of two antimicrobial rinses and oral prophylaxis on preoperative degerming of saliva

Preprocedural mouth rinses for preventing transmission of infectious diseases through aerosols in dental healthcare providers

BACKGROUND

Aerosols and spatter are generated in a dental clinic during aerosol-generating procedures (AGPs) that use high-speed hand pieces. Dental healthcare providers can be at increased risk of transmission of diseases such as tuberculosis, measles and severe acute respiratory syndrome (SARS) through droplets on mucosae, inhalation of aerosols or through fomites on mucosae, which harbour micro-organisms. There are ways to mitigate and contain spatter and aerosols that may, in turn, reduce any risk of disease transmission. In addition to personal protective equipment (PPE) and aerosol-reducing devices such as high-volume suction, it has been hypothesised that the use of mouth rinse by patients before dental procedures could reduce the microbial load of aerosols that are generated during dental AGPs.

OBJECTIVES

To assess the effects of preprocedural mouth rinses used in dental clinics to minimise incidence of infection in dental healthcare providers and reduce or neutralise contamination in aerosols.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 4 February 2022.

SELECTION CRITERIA

We included randomised controlled trials and excluded laboratory-based studies. Study participants were dental patients undergoing AGPs. Studies compared any preprocedural mouth rinse used to reduce contaminated aerosols versus placebo, no mouth rinse or another mouth rinse. Our primary outcome was incidence of infection of dental healthcare providers and secondary outcomes were reduction in the level of contamination of the dental operatory environment, cost, change in mouth microbiota, adverse events, and acceptability and feasibility of the intervention.

DATA COLLECTION AND ANALYSIS

Two review authors screened search results, extracted data from included studies, assessed the risk of bias in the studies and judged the certainty of the available evidence. We used mean differences (MDs) and 95% confidence intervals (CIs) as the effect estimate for continuous outcomes, and random-effects meta-analysis to combine data  MAIN RESULTS:  We included 17 studies with 830 participants aged 18 to 70 years. We judged three trials at high risk of bias, two at low risk and 12 at unclear risk of bias.  None of the studies measured our primary outcome of the incidence of infection in dental healthcare providers.  The primary outcome in the studies was reduction in the level of bacterial contamination measured in colony-forming units (CFUs) at distances of less than 2 m (intended to capture larger droplets) and 2 m or more (to capture droplet nuclei from aerosols arising from the participant's oral cavity). It is unclear what size of CFU reduction represents a clinically significant amount. There is low- to very low-certainty evidence that chlorhexidine (CHX) may reduce bacterial contamination, as measured by CFUs, compared with no rinsing or rinsing with water. There were similar results when comparing cetylpyridinium chloride (CPC) with no rinsing and when comparing CPC, essential oils/herbal mouthwashes or boric acid with water. There is very low-certainty evidence that tempered mouth rinses may provide a greater reduction in CFUs than cold mouth rinses. There is low-certainty evidence that CHX may reduce CFUs more than essential oils/herbal mouthwashes. The evidence for other head-to-head comparisons was limited and inconsistent.  The studies did not provide any information on costs, change in micro-organisms in the patient's mouth or adverse events such as temporary discolouration, altered taste, allergic reaction or hypersensitivity. The studies did not assess acceptability of the intervention to patients or feasibility of implementation for dentists.  AUTHORS' CONCLUSIONS: None of the included studies measured the incidence of infection among dental healthcare providers. The studies measured only reduction in level of bacterial contamination in aerosols. None of the studies evaluated viral or fungal contamination. We have only low to very low certainty for all findings. We are unable to draw conclusions regarding whether there is a role for preprocedural mouth rinses in reducing infection risk or the possible superiority of one preprocedural rinse over another. Studies are needed that measure the effect of rinses on infectious disease risk among dental healthcare providers and on contaminated aerosols at larger distances with standardised outcome measurement.

Biofilm as a risk factor in implant treatment

This article summarizes the microbiological findings at dental implants, drawing distinctions between the peri-implant microbiome and the periodontal microbiome, and summarizes what is known regarding biofilm as a risk factor for specific stages of implant treatment. Targeted microbial analysis is reviewed as well as the latest results from open-ended sequencing of the peri-implant flora. At this time there remains a lack of consensus for a specific microbial profile that is associated with peri-implantitis, suggesting that there may be other factors which influence the microbiome such as titanium surface dissolution. Therapeutic interventions to address the biofilm are presented at the preoperative, perioperative, and postoperative stages. Evidence supports that perioperative chlorhexidine reduces biofilm-related implant complications and failure. Regular maintenance for dental implants is also shown to reduce peri-implant mucositis and implant failure. Maintenance procedures should aim to disrupt the biofilm without damaging the titanium dioxide surface layer in an effort to prevent further oxidation. Evidence supports the use of glycine powder air polishing as a valuable adjunct to conventional therapies for use at implant maintenance visits. For the treatment of peri-implantitis, nonsurgical therapy has not been shown to be effective, and while surgical intervention is not always predictable, it has been shown to be superior to nonsurgical treatment for decontamination of the implant surface that is not covered by bone.

Transplantation of Autogenous Bone Block With an Osseointegrated Implant: Seedling Technique With Twelve-Month Follow-Up

OBJECTIVE

Loss of teeth frequently results in compound horizontal and vertical alveolar bone defects. An appropriate bone structure is the key for implant placement and bony support of soft tissues. Advanced bone augmentation techniques are required for the reconstruction of these defects. This report will present a new bone block grafting technique with 12-month follow-up.

METHOD

The seedling technique was used to augment the alveolar bone 3-dimensionally with autologous bone block and an osseointegrated implant in a 2-stage procedure. Horizontal and vertical bone loss is revealed after cone beam radiographic examination in the right maxillary lateral incisor area. Initially, the implant was placed at the right maxillary tuber area, where the bone was abundant. After 2-months healing phase, the osseointegrated implant was harvested with the surrounding bone and transplanted to the anterior region of maxilla to augment the horizontal and the vertical components of the recipient site. Transplanted implant inserted into autogenous bone block was fixed with mini plate to the adjacent native bone. Prosthetic restoration was applied 4 months after the transplantation.

RESULTS

Seven months after the first surgery, treatment of anterior bone deficiency was accomplished. The patient was fully satisfied with the function and the esthetics of the restoration. The radiological and clinical examinations at 1-year follow-up evaluation showed successful outcome of transplanted autogenous bone block without any resorption.

CONCLUSION

This clinical report demonstrated that anterior maxillary single-tooth replacement, according to seedling concept of autogenous bone block with osseointegrated implant, is a successful and predictable treatment modality.

Evaluation of the perioperative use of 0.2% chlorhexidine gluconate for the prevention of alveolar osteitis after the extraction of impacted mandibular third molars: a clinical study

PURPOSE

To clinically evaluate the perioperative use of 0.2% chlorhexidine gluconate for the prevention of alveolar osteitis, to assess the patient compliance to chlorhexidine and to prepare a comprehensive treatment plan to prevent alveolar osteitis after removal of an impacted third molar extraction.

METHODS

A prospective study was done on 50 patients with bilaterally impacted lower third molars which were indicated for extraction. Extraction of impacted mandibular third molar on one side was done without using any mouthrinse. While extracting the third molar on the other side, patients were instructed to use chlorhexidine 0.2% mouth rinse for 8 days, 1 day preceding and 7 days following the surgery. They were instructed to use chlorhexidine 0.2% (Rexidine) mouth rinse for 30 s twice a day (before breakfast and after dinner) with 15 ml of the rinse with 1:1 dilution with clean water. All the patients were evaluated for pain, presence or absence of clot and condition of the alveolar bone for the diagnosis of dry socket.

RESULTS

Incidence of dry sockets was 8%, when patients did not use 0.2% chlorhexidine gluconate perioperatively which is statistically significant.

CONCLUSIONS

It appeared that the incidence of dry socket can be reduced significantly by using 0.2% chlorhexidne gluconate mouth rinse perioperatively (twice daily, 1 day before and 7 days after surgical extraction.

Asepsis during periodontal surgery involving oral implants and the usefulness of peri-operative antibiotics: a prospective, randomized, controlled clinical trial

OBJECTIVES

This randomized clinical trial compares the usefulness of pre- and post-operative antibiotics while strict asepsis was followed during periodontal surgery.

MATERIAL AND METHODS

Two groups of 40 consecutive patients each with fully or partially edentulous jaws were enrolled. Antibiotics group (GrAB(+)): 23 men, mean age 60, 128 implants, received oral amoxicillin 1 g, 1 h pre-operatively and 2 g for 2 days post-operatively. Non-antibiotics group (GrAB(-)): 20 men, mean age 57, 119 implants, received no antibiotics. Bacterial samples were taken from the peri-oral skin before and at the end of surgery. In 12 patients in each group, samples were also taken from the nares. A VAS questionnaire evaluated symptoms of infection/inflammation by both the patient and the periodontologist at suture removal.

RESULTS

There were no significant differences between both groups, neither for the clinical parameters nor for the microbiota. Staphylococcus aureus was detected in the nares of one patient only. The patients' subjective perception of post-operative discomfort was significantly smaller in the group receiving antibiotics. Three patients lost one or two implants.

CONCLUSIONS

Antibiotics do not provide significant advantages concerning post-operative infections in case of proper asepsis. It also does not reduce peri-oral microbial contamination. It does on the other hand reduce post-operative discomfort.

Microbial Analysis of the Autogenous Bone Collected by Bone Filter During Oral Surgery: A Clinical Study

PURPOSE

The purposes of the study presented are to identify the microbial content of the collected bone debris and to determine the antibacterial efficiency of chlorhexidine mouth rinse in reducing the microbial content of the collected bone debris.

PATIENTS AND METHODS

Twenty-five patients who had asymptomatic fully impacted mandibular third molars bilaterally underwent surgical removal for prophylactic and orthodontic considerations. Immediately before surgery all patients rinsed with 10 mL of their assigned solution (chlorhexidine or sterile saline) for 2 minutes. Before surgical removal of the teeth, bone debris was collected with a stringent aspiration protocol from the ramus by bone filter. The microbial content of the bone debris was assessed and the bacterial levels between the 2 groups were compared statistically.

RESULTS

All samples from both groups (chlorhexidine or sterile saline) yielded viable microorganisms. There was no significant difference between the mean/median colony-forming units (CFU)/g values of both group samples, for aerobes (Streptococcus salivarius) and anaerobes (Bacteroides, Peptococcus, Peptostreptococcus, and Veillonella species). With regard to total microorganisms, the mean CFU/g derived from the chlorhexidine group samples were 1.5 x 10(8) CFU/g per bone sample compared with 1.5 x 10(9) CFU/g for the sterile saline control group (P < .05).

CONCLUSION

Although chlorhexidine rinsing immediately before surgery reduced the levels of total microorganisms when compared with stringent aspiration protocol alone, it has not been found effective on aerobic Streptococcus salivarius and, importantly, on anaerobes. The reduced bacterial levels may still carry high infectious risk and may lead to failure in autogenous grafting procedures in oral surgery.

Mit Knochenkollektor bei dentaler Implantation gewonnenes Knochenmaterial

BACKGROUND

Simultaneous implantation and augmentation using autogenous bone collected during implant surgery is a well-established procedure in oral implantology. The aims of this study were (1) to identify any bacterial contamination of bone obtained with a bone collector, and (2) to verify the antimicrobial effect of rinsing the bone collector with a 0.1% chlorhexidine solution prior to augmentation.

MATERIAL AND METHODS

A total of 39 patients undergoing a simultaneous implantation and augmentation procedure were examined. All patients rinsed their mouths with a 0.1% chlorhexidine solution for 2 min prior to surgery. Bone was collected with the Osseous Coagulum Trap, while saliva was collected with a separate suction tip. Once bone collection was complete a microbiological swab was taken from the bone collector (sample 1); before the bone was taken from it 200 ml of a 0.1% chlorhexidine solution was aspirated into the collector, after which the bone was removed and the collector sieve was (sample 2) sent for microbiological analysis which included aerobic and anaerobic cultivation of microorganisms and their identification and semiquantitative assessment of microbial growth.

RESULTS

Before the collector was rinsed with chlorhexidine microbial contamination was found in 34 (82.7%) of the 39 samples, and 37 different microbial species were identified in cultures. When the collector had been rinsed with 200 ml 0.1% chlorhexidine a significantly lower rate of microbial contamination was found: 66.7% of the samples were sterile.

CONCLUSIONS

Despite separate suction techniques for bone dust and saliva and preoperative use of a chlorhexidine mouthwash, bacterial contamination of bone obtained from the mouth with a bone collector has to be anticipated. Not only the physiological bacteria of the oral flora, but also the microorganisms frequently associated with implant failure can be found. Rinsing the bone collector with 200 ml of a 0.1% chlorhexidine solution significantly reduces microbial contamination. The effects on bone vitality must be studied before routine rinsing with chlorhexidine can be recommended.

The effects of an immediately pre-surgical chlorhexidine oral rinse on the bacterial contaminants of bone debris collected during dental implant surgery

Dental implant surgery produces bone debris that can be used in the "simultaneous augmentation" technique. Although this debris is contaminated with oral bacteria, a stringent aspiration protocol has been shown to reduce the levels of contamination. Chlorhexidine mouthrinse is a well-proven antibacterial rinse that has been shown to reduce infectious complications associated with dental implants. This study examined the effect of pre-operative rinsing with a 0.1% chlorhexidine digluconate mouthrinse on the bacterial contaminants present in collected bone debris bone (CBD). Twenty partially edentate patients were randomly allocated into equal groups and underwent bone collection using the Frios Bone Collector (FBC) during the insertion of two dental implants. In group T a pre-operative chlorhexidine rinse was used, whilst in group C sterile water was used. For both groups, a stringent bone collection protocol was used. Bone samples were immediately transported for microbial analysis. Colonial and microscopic morphology, gaseous requirements and identification kits were utilised for identification of the isolated microbes. Thirty-nine species were identified including a number associated with disease, in particular Actinomyces odontolyticus, Clostridium bifermentans, Prevotella intermedia, and Propionibacterium propionicum. Samples from group T (chlorhexidine mouthrinse) yielded significantly fewer organisms (P < 0.001) than in group C (sterile water mouthrinse). Gram-positive cocci dominated the isolates from both groups. It is concluded that if bone debris is to be used for the purpose of immediate simultaneous augmentation, a preoperative chlorhexidine mouthrinse should be utilised in conjunction with a stringent aspiration protocol to reduce further the bacterial contamination of CBD.

Infectious risks for oral implants: a review of the literature

The use of oral implants in the rehabilitation of partially and fully edentulous patients is widely accepted even though failures do occur. The chance for implants to integrate can for example be jeopardised by the intra-oral presence of bacteria and concomitant inflammatory reactions. The longevity of osseointegrated implants can be compromised by occlusal overload and/or plaque-induced peri-implantitis, depending on the implant geometry and surface characteristics. Animal studies, cross-sectional and longitudinal observations in man, as well as association studies indicate that peri-implantitis is characterised by a microbiota comparable to that of periodontitis (high proportion of anaerobic Gram-negative rods, motile organisms and spirochetes), but this does not necessarily prove a causal relationship. However, in order to prevent such a bacterial shift, the following measures can be considered: periodontal health in the remaining dentition (to prevent bacterial translocation), the avoidance of deepened peri-implant pockets, and the use of a relatively smooth abutment and implant surface. Finally, periodontitis enhancing factors such as smoking and poor oral hygiene also increase the risk for peri-implantitis. Whether the susceptibility for periodontitis is related to that for peri-implantitis may vary according to the implant type and especially its surface topography.

Effect of chlorhexidine and toothbrushing on the presence of bacteria on gingival and buccal epithelial cells

Swabs of buccal and gingival epithelial cells from healthy young adult donors were washed in physiological saline solution, smeared on glass slides and stained with acridine orange. The presence of bacteria attached onto epithelial cells was examined under a fluorescence microscope. Four hours after a chlorhexidine rinse, the number of cells with > 50 attached bacteria had almost completely vanished. The degree of bacterial colonization seemed to re-establish at a level exceeding the baseline. One week after chlorhexidine treatment the degree of colonization was still over the control level. Toothbrushing with a conventional toothpaste reduced immediately the number of cells with > 50 bacteria. The colonization had re-established to the pre-washing levels at the buccal sites at 1 h and at the gingival sites at 4 h after toothbrushing. A method for the evaluating of the antimicrobial power of oral hygiene products is presented.

Decontamination of the oral cavity. Effect of six local anti-microbial preparations in comparison to water and parafilm as controls

Six preparations (four liquid and two solid) were tested in a double-blind crossover design for their anti-bacterial effect on aerobic and anaerobic bacteria in saliva of 12 volunteers. The four liquid preparations contained either tyrothricin, hexetidine, hydrogen peroxide or ethanol and were tested against a rinse with water as control. The two solid preparations, in the form of lozenges, contained tyrothricin in doses of 4 or 10 mg and were tested against parafilm. A single rinse with either tyrothricin or hexetidine resulted in a significant reduction of aerobic and anaerobic bacteria in saliva which lasted for the whole 1 h observation period and was considerably more effective than hydrogen peroxide or ethanol. Similar results were seen with the solid preparations. The lozenge containing 10 mg tyrothricin was the most effective and was the only formulation capable of reducing oral aerobic bacterial counts by a factor of approximately 100.

Postoperative complications after surgical removal of mandibular third molars. Effects of penicillin V and chlorhexidine

A random material of 112 patients, was investigated after surgical removal of impacted lower third molars. 2 experimental groups and 1 control group were studied. Prophylactic medication with penicillin V combined with preoperative rinsing using 0.2% chlorhexidine gluconate (Hibitane) was found to reduce postoperative symptoms, when compared with preoperative rinsing alone. In both cases, patients were compared with the control group.