Chlorhexidine mouthwash and sodium lauryl sulphate dentifrice: do they mix effectively or interfere?

Novel anionic surfactant-modified chlorhexidine and its potent antimicrobial properties

Chlorhexidine dodecyl sulfate (CHX-DS) was synthesized and characterized via single-crystal X-ray diffraction (SC-XRD), 1H nuclear magnetic resonance (NMR) spectroscopy, 1H nuclear Overhauser effect spectroscopy (NOESY), and attenuated total reflectance Fourier-transform infrared spectroscopy (ATR-FTIR). The solid-state structure, comprising a 1 : 2 stoichiometric ratio of chlorhexidine cations [C22H30Cl2N10]2+ to dodecyl sulfate anions [C12H25SO4]-, is the first report of chlorhexidine isolated with a surfactant. CHX-DS exhibits broad-spectrum antibacterial activity and demonstrates superior efficacy for reducing bacteria-generated volatile sulfur compounds (VSCs) as compared to chlorhexidine gluconate (CHG). The minimum inhibitory concentrations (MICs) of CHX-DS were 7.5, 2.5, 2.5, and 10 μM for S. enterica, E. coli, S. aureus, and S. mutans, respectively. Furthermore, MIC assays for E. coli and S. mutans demonstrate that CHX-DS and CHX exhibit a statistically significant efficacy enhancement in 2.5 μM treatment as compared to CHG. CHX-DS was incorporated into SBA-15, a mesoporous silica nanoparticle (MSN) framework, and its release was qualitatively measured via UV-vis in aqueous media, which suggests its potential as an advanced functional material for drug delivery applications.

Is Chlorhexidine in Dentistry an Ally or a Foe? A Narrative Review

Chlorhexidine has been one of the most effective and popular antiseptic substances used in medicine for decades. In dentistry, it has been used in endodontics, periodontology, surgery, and general dentistry. It is also widely used daily by patients in mouth rinses, gels, or toothpastes. Because of its multiple uses, we should follow all types of research reporting its potential adverse effects. This article aims to review the most up-to-date studies regarding chlorhexidine and its possible side effects, in the period of the SARS-CoV-2 pandemic, as the use of different antiseptic substances has rapidly increased.

Differences in chlorhexidine mouthrinses formulations influence the quantitative and qualitative changes in in-vitro oral biofilms

OBJECTIVE

Chlorhexidine mouthrinses are marketed in different formulations. This study aimed at investigating qualitative and quantitative changes in in-vitro multispecies oral biofilms, induced by different chlorhexidine-containing mouthrinses.

BACKGROUND DATA

Earlier studies comparing chlorhexidine mouthrinses are either clinical studies or in-vitro studies assessing the antimicrobial efficacy of the mouthrinses. However, no clear investigations are available regarding ecological impact of different chlorhexidine formulations on in-vitro multispecies oral biofilms after rinsing with different chlorhexidine formulations.

METHODS

Nine commercially available chlorhexidine mouthrinses were selected. Multispecies oral communities (14 species) were grown for 48 h in a Biostat-B Twin bioreactor. After that, they were used to develop biofilms on the surface of hydroxyapatite disks in 24-well pates for 48 h. Biofilms were then rinsed once or multiple times with the corresponding mouthrinse. Biofilms were collected before starting the rinsing experiment and every 24 h for 3 days and vitality quantitative PCR was performed. The experiment was repeated 3 independent times on 3 different days and the results were analyzed using a linear mixed model.

RESULTS

The mouthrinses provoked different effects in terms of change in total viable bacterial load (VBL), ecology, and community structure of the multispecies biofilms. There was no relation between chlorhexidine concentrations, presence, or absence of cetylpyridinium chloride and/or alcohol, and the observed effects. Some tested chlorhexidine mouthrinses (MC, HG, HH, and HI) strongly lowered the total VBL (≈10⁰⁷ Geq/ml), but disrupted biofilm symbiosis (≥40% of the biofilms communities are pathobionts). On the other hand, other tested chlorhexidine mouthrinses (MD, ME, and HF) had limited impact on total VBL (≥10¹⁰ Geq/ml), but improved the biofilm ecology and community structure (≤10% of the biofilms communities are pathobionts).

CONCLUSION

Not all chlorhexidine mouthrinses have the same effect on oral biofilms. Their effect seems to be strongly product dependent and vary according to their compositions and formulations.

Do natural ingredients in a dentifrice contribute to prevention of plaque and gingivitis?

OBJECTIVE

To test the effectiveness of a dentifrice containing the turmeric and licorice extract compared to a control for preventing plaque and gingivitis over a four-month period.

MATERIAL AND METHODS

Ninety (non-dental) participants with moderate gingival inflammation(≥40%) were selected. The triple blind study consisted of two phases, namely at first a 3-week pre-experimental phase of using an oxygenating and chlorhexidine (CHX) mouthrinse. Secondly, a 4-months experimental period in which participants were randomly assigned to a test or control group. All were instructed to brush their teeth twice daily for 2 minutes with their assigned dentifrice. Gingival bleeding(BI), plaque(PI) and gingivitis(GI) were assessed.

RESULTS

Eighty participants completed the protocol. At the first assessment in the pre-experimental phase, the mean scores of all indices showed no differences for the two groups. At the second session, the values of all three parameters had decreased significantly (p<0.001). At the last session the BI values were 0.52(0.25) for the test group and 0.56(0.25) for the control, the mean GI was 0.27(0.17) for the test group and 0.31 0.16) for the control, and for PI the scores were 1.89(0.46) for the test group and 1.98(0.43) for the control group. Statistical comparison of the scores for the two groups at each stage of the study showed no significant difference for any of the parameters.

CONCLUSION

Within the limits of the current study design, dentifrice formulation and concentration of turmeric/licorice extracts the results show that the adjuvant effect of the natural ingredients in the test dentifrice was not evident on clinical parameters of gingivitis and plaque.

Does chlorhexidine mouthwash, with an anti-discoloration system, reduce tooth surface discoloration without losing its efficacy? A systematic review and meta-analysis

OBJECTIVES

To investigate whether chlorhexidine mouthwash (CHX-MW), with an anti-discoloration system(ADS), is effective in preventing extrinsic tooth surface discoloration. Additionally, this paper seeks to evaluate whether CHX combined with an ADS maintains its efficacy with respect to reducing plaque and gingivitis scores.

MATERIAL AND METHODS

MEDLINE-PubMed and Cochrane-Central were searched up to October 2018 to identify eligible studies. Papers evaluating the effect of CHX-MW+ADS compared to CHX without an ADS were included. A descriptive analysis and when feasible a meta-analysis was performed.

RESULTS

Screening resulted in 13 eligible publications, presenting 16 comparisons. Six of these evaluated the MW in a non-brushing model and ten as an adjunct to toothbrushing. A descriptive analysis demonstrated that the majority showed no differences in bleeding, gingivitis and plaque scores. This was confirmed by the meta-analysis. In non-brushing experiments, the difference-of-means (DiffM) for plaque scores was 0.10 (P = 0.45, 95%CI: [-0.15; 0.34]) and for the gingival index 0.04 (P = 0.15,95%CI: [-0.02; 0.11]). The DiffM in brushing studies for plaque scores was 0.01 (P = 0.29, 95%CI: [-0.01; 0.02]) and for the gingival index 0.00 (P = 0.87,95%CI: [-0.05; 0.06]). With respect to staining scores, the meta-analysis revealed that in non-brushing studies, the standardized mean difference was 3.19 (P = 0.0005,95%CI: [-3.98; -1.41]) while in brushing studies, the DiffM was 0.12 (P = 0.95,95%CI: [-3.32; 3.55]).

CONCLUSION

There is moderate quality evidence from non-brushing studies that the addition of an ADS to CHX-MW reduces tooth surface discoloration and does not appear to affect its properties with respect to gingival inflammation and plaque scores. In brushing studies, there is also moderate quality evidence that ADS does not affect the anti-plaque and anti-gingivitis efficacy of CHX. The majority of comparisons and the meta-analysis including these indicate no significant effect of ADS on tooth staining in situations where the mouthwash is used in addition to toothbrushing.

Effect of a Toothpaste/Mouthwash Containing Carica papaya Leaf Extract on Interdental Gingival Bleeding: A Randomized Controlled Trial

Clinical research on herbal-based dentifrice +/− mouth rinse products is very limited compared with the plethora of research on conventional oral care products under normal oral hygiene conditions. The aim of this study was to determine the anti-inflammatory effects of a novel plant Carica papaya leaf extract (CPLE) on interdental bleeding in healthy subjects. In this randomized, single-blind parallel-design study, the eligible subjects were generally healthy non-smokers, aged 18–26, who exhibited healthy periodontal conditions upon study entry. The participants were equally randomized into the following four groups: CPLE dentifrice, CPLE dentifrice and mouthwash, sodium lauryl sulfate (SLS)-free enzyme-containing dentifrice and SLS-free enzyme-containing dentifrice with essential oil (EO) mouthwash. Subjects were instructed to brush their teeth twice a day without changing their other brushing habits. Interdental bleeding (BOIP) was measured from inclusion (T₀) until the fourth week (T₄) of the study. Clinical efficacy was assessed after one, two, three and four weeks of home use. The analyses compared BOIP between groups and were then restricted to participants with ≥70% and then ≥80% bleeding sites at T₀. Pairwise comparisons between groups were performed at T₀ and T₄, and a logistic regression identified correlates of gingival bleeding (T₄). Among 100 subjects (2273 interdental sites), the median percentage of bleeding sites per participant at T₀ was 65%. The bleeding sites dramatically decreased in all groups between T₀ and T₄ (relative variations from −54% to −75%, p < 0.01 for all). Gingival bleeding did not significantly differ between the CPLE dentifrice and the SLS-free dentifrice +/− EO mouthwash groups (from p = 0.05 to p = 0.86), regardless of the baseline risk level. Among the CPLE dentifrice users, fewer bleeding sites were observed when toothpaste and mouthwash were combined compared to bleeding sites in those who used toothpaste alone (21% vs. 32%, p = 0.04). CPLE dentifrice/mouthwash provides an efficacious and natural alternative to SLS-free dentifrice +/−EO-containing mouthwash when used as an adjunct to mechanical oral care to reduce interdental gingival inflammation.

Will a chlorhexidine-fluoride mouthwash reduce plaque and gingivitis?

FOCUS QUESTION

What is the efficacy of a chlorhexidine (CHX) mouthwash (MW) containing sodium fluoride (NaF) compared to a CHX - MW alone on the parameters of plaque, gingivitis and discoloration?

MATERIAL AND METHODS

MEDLINE-PubMed, Cochrane-CENTRAL, and EMBASE were searched for papers from inception to December 2017. The inclusion criteria were (randomized) controlled clinical trials conducted in human subjects with good general health and without removable prosthesis. Papers evaluating the effect of a MW containing CHX + NaF compared to a CHX alone were included. From the eligible studies, data were extracted, a descriptive analysis was performed and a meta-analysis when feasible.

RESULTS

Independent screening of 412 unique papers resulted in 9 eligible publications presenting 10 clinical trials comparing the effect of CHX + NaF to CHX - MW and provided 13 comparisons. Five evaluated the MW as an adjunct to brushing and 8 were non-brushing comparisons of which 4 used an experimental gingivitis model. No significant difference was observed for plaque score reduction in the brushing studies the end scores (diffM; -0.04, P = .36; 95%CI: [-0.13, 0.05]) nor the differences (diffM; 0.11, P = .33; 95%CI: [-0.12, 0.24]). In the descriptive analysis, none of the experiments demonstrated a statistical significant difference regarding Gingival Index (GI), Bleeding Score and Discoloration Scores. For the GI, a meta-analysis of the difference of Means was not significant when included experimental gingivitis model studies end scores (0.01, P = .78; 95%CI: [-0.08, 0.11]) and the difference (0.01, P = .81; 9 5%CI: [-0.08, 0.10]) either for the end scores of brushing studies (diffM; -0.01, P = .82; 95%CI: [-0.10, 0.08]).

CONCLUSION

From this study, it can be concluded that NaF and CHX may be present in the same MW without reducing CHX efficacy with respect to plaque and gingivitis scores. Moreover, no difference in the development of tooth discoloration was observed.

Evaluation of the effect of hydrogen peroxide as a mouthwash in comparison with chlorhexidine in chronic periodontitis patients: A clinical study

Aims and Objective:

This study was conducted to evaluate the effect of hydrogen peroxide (H₂O₂) as a mouthwash in comparison with chlorhexidine (CHX) in chronic periodontitis patients.

Materials and Methods:

A total of 45 patients suffering from localized mild to moderate chronic periodontitis were chosen. The subjects were divided equally into three groups. Group A patients were treated only with scaling and root planning (SRP). Group B were treated with SRP in combination with 0.2% CHX gluconate mouthwash twice daily for 10 days. Group C were treated with SRP in combination with 1.5% H₂O₂ mouthwash twice daily for 10 days. Gingival index, plaque index, pocket depth, and clinical attachment level were recorded for patients of all groups on day 0 (Baseline), 15, 30, and 90, respectively. Statistical analysis was done using the Statistical Package for the Social Sciences version 22.0. Repeated measures analysis of variance was used to assess the differences in the abovementioned indices because of time and groups.

Results:

Both CHX gluconate and H₂O₂ mouthwashes significantly reduced the gingival index more than that observed in the control group, but similar to each other. There were no significant differences in the clinical attachment loss, plaque index, and pocket depth among the study groups, but improvement was seen within the CHX group participants. In participants with chronic periodontitis, SRP in combination with 0.2% CHX gluconate mouthwash was an effective treatment in reducing the gingival index and the pocket depth, as well as improving the clinical attachment level.

Conclusion:

The use of CHX gluconate was observed to be higher than H₂O₂ for the reduction in the gingival index and the pocket depth, as well as for the improvement of the clinical attachment level.

Comparison of a commercially available herbal and 0.2% chlorhexidine mouthrinse for prevention of oral malodor: A clinical trial

Objectives:

Despite the adverse effects of chlorhexidine (CHX) in the oral cavity, it is still the most commonly prescribed mouthrinse for halitosis control due to its excellent results. The purpose of this study was to compare the efficacy of a mouthrinse with herbal formulation for halitosis control with 0.2% CHX gluconate containing rinse and to simultaneously assess adverse effects caused by the herbal mouthrinse if any.

Materials and Methods:

Ninety-six systemically healthy subjects with chronic generalized gingivitis were recruited in the study and divided into three groups receiving 0.2% CHX gluconate mouthrinse, herbal mouthrinse, or negative control, respectively as Group A, B, and C. The halimeter scores and organoleptic scores were recorded for each subject at baseline and after scaling. Others parameters recorded were plaque index and gingival index. All scores were reassessed on the 7^th and 14^th day, respectively. Statistical analysis was performed using Kruskal–Wallis ANOVA, Mann–Whitney U-test, and Wilcoxon matched pairs test.

Results:

There was an overall reduction in the halimeter scores both in Group A and B subjects which were not statistically significant within the groups; this was in accordance with the decrease in the mean organoleptic scores. Reduction in Group C scores was the least and differed statistically from both Group A and B scores.

Conclusions:

The results indicate an equivalent reduction in breath odor by both the herbal mouthrinse and CHX. Furthermore, side effects were less, and patient compliance was more with the herbal mouthrinse, which can thus be prescribed more safely and with predictable outcomes for oral malodor.