The effect of chlorhexidine mouthrinses on the human oral flora

Efficacy of Tocopherol vs. Chlorhexidine in the Management of Oral Biopsy Site: A Randomized Clinical Trial

Background/Objectives: Chlorhexidine digluconate (CHX) is widely regarded as the gold standard for oral mucosa antiseptic treatments but has been associated with delayed healing, scar formation, microbiome alterations, and fibroblast toxicity. Tocopherol, with its ability to accelerate tissue healing and minimal side effects, has emerged as a potential alternative. This randomized clinical trial aimed to compare the efficacy of topical tocopherol acetate and 0.2% chlorhexidine in managing postoperative pain and wound healing following oral cavity biopsies. Methods: Seventy-seven patients undergoing oral biopsies were divided into two groups: the test group (tocopherol acetate) and the control group (0.2% chlorhexidine). Pain was assessed using VAS (Visual Analogue Scale) scores on days 1 and 6 postoperatively, and wound healing was evaluated through measurements of the biopsy site's height and width from standardized photographs analyzed with ImageJ. Painkiller use was also documented. The study followed CONSORT (Consolidated Standards of Reporting Trials) guidelines, with ethical approval from the Padua Ethics Committee and registration on ISRCTN. Results: No significant differences were found between the groups in VAS scores, wound dimensions, or painkiller use (p > 0.05). However, significant pain reduction within each group was observed (p < 0.0001). Conclusions: Tocopherol acetate showed comparable efficacy to chlorhexidine, suggesting it could be a viable alternative for postoperative care in oral surgery.

Supra and subgingival application of antiseptics or antibiotics during periodontal therapy

Periodontal diseases (gingivitis and periodontitis) are characterized by inflammatory processes which arise as a result of disruption of the balance in the oral ecosystem. According to the current S3 level clinical practice guidelines, therapy of patients with periodontitis involves a stepwise approach that includes the control of the patient's risk factors and the debridement of supra and subgingival biofilm. This debridement can be performed with or without the use of some adjuvant therapies, including physical or chemical agents, host modulating agents, subgingivally locally delivered antimicrobials, or systemic antimicrobials. Therefore, the main aim of this article is to review in a narrative manner the existing literature regarding the adjuvant application of local agents, either subgingivally delivered antibiotics and antiseptics or supragingivally applied rinses and dentifrices, during the different steps in periodontal therapy performed in Europe.

Preprocedural Viral Load Effects of Oral Antiseptics on SARS-CoV-2 in Patients with COVID-19: A Systematic Review

(1) There are limited clinical trials to support the effectiveness of mouth rinses when used as a preprocedural rinse against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This systematic review aims to evaluate the efficacy of antiseptic mouth rinses as a preprocedural rinse in reducing SARS-CoV-2 oral viral load in-vivo. (2) Methods: A literature search was conducted through November 2022 for the following databases: PubMed, Web of Science, Cochrane Library, and Google Scholar. The evaluated outcomes were quantitative changes in viral load and the statistical significance of that change after using antiseptic mouth rinses. (3) Results: 14 randomized controlled trials (RCT) were selected for risk of bias assessment and data extraction. (4) Conclusion: Within the limits of this systematic review, preprocedural mouth rinses may significantly reduce SARS-CoV-2 in the mouth, thus, reducing the viral particles available for airborne dispersion. Preprocedural mouth rinses may be an effective strategy for reducing airborne SARS-CoV-2 dispersion in the environment. Their use may be a preventive strategy to reduce the spread of COVID-19 in selected medical and healthcare facilities, including dental clinics. Potential preprocedural mouth rinses are identified for use as an integral part of safe practice for healthcare protocols. This systematic review was registered with the National Institute for Health Research, international prospective register of systematic reviews (PROSPERO): CRD42022315177.

Milk Reduces Enamel Staining Caused by Black Tea and Chlorhexidine Mouthwash

The aim of our study was to determine whether milk diminished the staining effects of Turkish and imported black tea with or without chlorhexidine. Human incisor teeth (n = 36) were incubated with 18 different preparations of steeped or infused black tea plus saliva with or without milk and/or chlorhexidine. Enamel staining was measured using a colorimeter before and after exposure. Independent of the type of tea, the inclusion of milk changed the tooth color toward blue on the yellow–blue spectrum (p < 0.001) and toward black on the black–white spectrum (p < 0.001). The inclusion of chlorhexidine changed the tooth color toward white on the black–white spectrum (p < 0.01) and toward yellow on the yellow–blue spectrum (p < 0.001). The inclusion of both milk and chlorhexidine caused a yellow color difference (Δb*= 0.244); this change was reduced with the addition of chlorhexidine only (Δb* = 0.8224). Tea plus chlorhexidine exerted a substantial color change. Milk reduces the staining caused by tea, and the color change induced by the addition of milk can be interpreted as optical white. Milk also neutralizes some of the yellow staining caused by chlorhexidine.

Effectiveness of acellular dermal matrix graft with a coronally advanced flap for the treatment of Miller Class I/II single gingival recession with thin gingival phenotype: study protocol for a split-mouth randomised controlled trial

INTRODUCTION

Gingival recession is one of the most common mucogingival deformities requiring surgical correction. The American Academy of Periodontology Regeneration Workshop recommended connective tissue graft (CTG) combined with coronally advanced flap (CAF) for the treatment of Miller Class I and II single-tooth gingival recession. The disadvantages of harvesting autogenous tissue include postoperative bleeding, pain and discomfort at the donor site, restricted tissue supply, increased morbidity and prolonged operative times. Acellular dermal matrix (ADM) contains undamaged collagen and elastin matrices that can be used as a substitute for CTG during root coverage procedures. However, the use of ADM is still controversial. The objective of this split-mouth; randomised, controlled, clinical study is to evaluate the long-term effects of ADM graft (ADMG) combined with CAF on root coverage, aesthetics and patient satisfaction for the treatment of single gingival recession with thin gingival phenotype.

METHODS AND ANALYSIS

Forty participants with bilateral Miller Class I/II gingival recession will be randomised to receive an ADMG on one side and CTG on the contralateral side, combined with CAF. Gingival recession depth, gingival recession width and keratinised tissue width will be measured at baseline, 2 weeks and 1, 3, 6, 12 and 24 months. Mean root coverage, complete root coverage, root coverage aesthetic score, colour change (∆E) and patient satisfaction will be assessed during follow-up visits.

ETHICS AND DISSEMINATION

The present study has received approval from the Ethics Committee of Peking University School and Hospital of Stomatology (PKUSSIRB-202054029). Data of this study will be registered with the International Clinical Trials Registry Platform. Additionally, we will disseminate the results through scientific journal.

TRIAL REGISTRATION NUMBER

ChiCTR2000033230.

Effect of Chlorhexidine Digluconate in Early Wound Healing of Human Gingival Tissues. A Histological, Immunohistochemical and Biomolecular Analysis

Chlorhexidine digluconate (CHX) is considered the gold standard for oral cavity antiseptic treatment. Nevertheless, several in vitro studies have reported detrimental effects in oral tissue repair. The aim of the present study was to evaluate the in vivo effect of post-surgical CHX mouth rinse on gingival tissue (G) 24 h after injury. G biopsies were obtained in three patients 24 h after surgery with the indication of post-surgical 0.12% CHX use and were compared with those obtained from the same patients without any antiseptic use. Changes in collagen production, cell proliferation, and apoptosis were examined by histological and Ki-67/P53 immunohistochemical analysis. Fibrotic markers (COL1A1, αSMA), proapoptotic protein (BAX) expression, and wound healing-related gene modulation (RAC1, SERPINE1, TIMP1) were analyzed by quantitative real-time PCR analysis. CHX was able to reduce cellular proliferation and increase collagen deposition, proapoptotic molecule and fibrotic marker expression, and myofibroblast differentiation, reduce expression of RAC1 and trigger expression of SERPINE1 and TIMP1, showing “scar wound healing response” pattern. This study assessed for the first time the in vivo effects of CHX on gingival tissue. The demonstration of a CHX-induced fibrotic transformation, leading to scar repair, supports the need for new post-surgical clinical protocols based on a strategic and personalized use of CHX.

Selective Antimicrobial Therapies for Periodontitis: Win the "Battle and the War"

Traditional antimicrobial therapies for periodontitis (PD) have long focused on non-selective and direct approaches. Professional cleaning of the subgingival biofilm by instrumentation of dental root surfaces, known as scaling and root planning (SRP), is the mainstay of periodontal therapy and is indisputably effective. Non-physical approaches used as adjuncts to SRP, such as chemical and biological agents, will be the focus of this review. In this regard, traditional agents such as oral antiseptics and antibiotics, delivered either locally or systemically, were briefly reviewed as a backdrop. While generally effective in winning the “battle” against PD in the short term, by reducing its signs and symptoms, patients receiving such therapies are more susceptible to recurrence of PD. Moreover, the long-term consequences of such therapies are still in question. In particular, concern about chronic use of systemic antibiotics and their influence on the oral and gut microbiota is warranted, considering antibiotic resistance plasmids, and potential transfer between oral and non-oral microbes. In the interest of winning the “battle and the war”, new more selective and targeted antimicrobials and biologics for PD are being studied. These are principally indirect, blocking pathways involved in bacterial colonization, nutrient acquisition, inflammation or cellular invasion without directly killing the pathogens. This review will focus on current and prospective antimicrobial therapies for PD, emphasizing therapies that act indirectly on the microbiota, with clearly defined cellular and molecular targets.

First insights into chlorhexidine retention in the oral cavity after application of different regimens

Objectives

This in situ study aimed to determine and compare the chlorhexidine (CHX) retention in the oral cavity after the application of different CHX pharmaceutical regimens.

Methods

Five volunteers used different CHX treatment regimens including mouth rinses, dental spray and toothpaste gel. After the application of the different CHX regimens, 2-μl samples were taken from saliva and buccal mucosa pellicle as well as the dental pellicle samples formed on standardized enamel surfaces. Sample collection was conducted at six time points within 12 h. Retention of CHX was measured using matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry.

Results

CHX retention values in the oral mucosa pellicle were significantly higher than those in saliva. CHX remained in the mucosal pellicle at microgrammes per millilitre levels for 12 h after mouth rinsing, 10 h after spray application and 2 h after using the toothpaste. CHX was detected in the dental pellicle for at least 12 h after application of mouth rinsing and spray. Retention of CHX after mouth rinsing or spray application was significantly higher than the retention after using toothpaste.

Conclusions

Oral mucosa was the favourable site for CHX retention. Higher mouth rinse concentration and longer rinsing time produced a slight increase in CHX retention. CHX spray provided considerable retention values, whereas toothpaste gel delivered the lowest retention after application. MALDI-TOF was a sensitive method with excellent limits of quantification for CHX detection.

A pilot study to evaluate the effectiveness of adjunctive use of two antimicrobial topical gels in chronic gingivitis

Background

Gingivitis is one of the most prevalent oral disease in humans. The most important etiological factor of gingivitis is dental plaque. Plaque control procedures comprises of several mechanical and chemical methods. Many studies have advocated that chemical plaque control methods can be used successfully as an adjunct to mechanical plaque control procedures. Thus, the aim of this pilot study is to evaluate the effectiveness of two topical antimicrobial gels as an adjunct to mechanical plaque control over a period of 2 weeks in treatment of chronic gingivitis patients.

Material and Methods

This is a single blind, two arm parallel design pilot clinical study including 60 systemically healthy patients with 1) chronic generalized gingivitis (MGI>1), 2) probing depth ≤ 3mm and 3) zero clinical attachment loss. The study participants were randomly assigned into two groups i.e., Group I- Chlorhexidine Gluconate (CHX) gel, Group II- combination gel of Chlorhexidine gluconate and Metronidazole (CHX-MTZ) gel. Clinical parameters viz. Gingival Index (GI) and Modified Sulcus bleeding index (MSBI) were recorded firstly at baseline after Scaling and Root Planing(SRP), and secondly at the end of the study period of two weeks. Intra and inter-group comparisons of clinical parameters were done using appropriate statistical tests.

Results

There was high significant reduction in GI and MSBI scores at the end of 2 weeks period in both the groups. Further, combination gel of Group II (CHX+MTZ) was found to be statistically more effective as compared to Group I (CHX) used alone.

Conclusions

Our study suggests that Chemotherapeutic agents like CHX and combination CHX-MTZ Gel are clinically effective as adjunct to Scaling and Root Planning(SRP) in treatment of Chronic Gingivitis. Further, post statistical comparative analysis has proved CHX-MTZ combination gel regime to be more clinically effective than CHX gel used alone in treatment of Chronic Gingivitis as adjunct to SRP.

Key words:Scaling and Root Planning (SRP), Chronic Gingivitis, Chlorhexidine Gluconate (CHX) gel, Combination (CHX+MTZ) Gel, Metronidazole (MTZ).

Biguanides: Species with versatile therapeutic applications

Biguanides are compounds in which two guanidine moieties are fused to form a highly conjugated system. Biguanides are highly basic and hence they are available as salts mostly hydrochloride salts, these cationic species have been found to exhibit many therapeutic properties. This review covers the research and development carried out on biguanides and accounts the various therapeutic applications of drugs containing biguanide group-such as antimalarial, antidiabetic, antiviral, anticancer, antibacterial, antifungal, anti-tubercular, antifilarial, anti-HIV, as well as other biological activities. The aim of this review is to compile all the medicinal chemistry applications of this class of compounds so as to pave way for the accelerated efforts in finding the drug action mechanisms associated with this class of compounds. Importance has been given to the organic chemistry of these biguanide derivatives also.

Evaluation of Anti-Biofilm Activity of Mouthrinses Containing Tannic Acid or Chitosan on Dentin In Situ

In contrast to enamel, dentin surfaces have been rarely used as substrates for studies evaluating the effects of experimental rinsing solutions on oral biofilm formation. The aim of the present in situ study was to investigate the effects of tannic acid and chitosan on 48-h biofilm formation on dentin surfaces. Biofilm was formed intraorally on dentin specimens, while six subjects rinsed with experimental solutions containing tannic acid, chitosan and water as negative or chlorhexidine as positive control. After 48 h of biofilm formation, specimens were evaluated for biofilm coverage and for viability of bacteria by fluorescence and scanning electron microscopy. In addition, saliva samples were collected after rinsing and analyzed by fluorescence (five subjects) and transmission electron microscopy (two subjects) in order to investigate the antibacterial effect on bacteria in a planktonic state and to visualize effects of the rinsing agents on salivary proteins. After rinsing with water, dentin specimens were covered by a multiple-layered biofilm with predominantly vital bacteria. In contrast, chlorhexidine led to dentin surfaces covered only by few and avital bacteria. By rinsing with tannic acid both strong anti-adherent and antibacterial effects were observed, but the effects declined in a time-dependent manner. Transmission electron micrographs of salivary samples indicated that aggregation of proteins and bacteria might explain the antiadhesion effects of tannic acid. Chitosan showed antibacterial effects on bacteria in saliva, while biofilm viability was only slightly reduced and no effects on bacterial adherence on dentin were observed, despite proteins being aggregated in saliva after rinsing with chitosan. Tannic acid is a promising anti-biofilm agent even on dentin surfaces, while rinsing with chitosan could not sufficiently prevent biofilm formation on dentin.

Antimicrobial Activity of EPA and DHA against Oral Pathogenic Bacteria Using an In Vitro Multi-Species Subgingival Biofilm Model

In search for natural products with antimicrobial properties for use in the prevention and treatment of periodontitis, the purpose of this investigation was to evaluate the antimicrobial activity of two omega-3 fatty acids, docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), using an in vitro multi-species subgingival biofilm model including Streptococcus oralis, Actinomyces naeslundii, Veillonella parvula, Fusobacterium nucleatum, Porphyromonas gingivalis, and Aggregatibacter actinomycetemcomitans. The antimicrobial activities of EPA and DHA extracts (100 µM) and the respective controls were assessed on 72 h biofilms by their submersion onto discs for 60 s. Antimicrobial activity was evaluated by quantitative polymerase chain reaction (qPCR), confocal laser scanning microscopy (CLSM) and scanning electron microscopy (SEM). ANOVA with Bonferroni correction was used to evaluate the antimicrobial activity of each of the fatty acids. Both DHA and EPA significantly reduced (p < 0.001 in all cases) the bacterial strains used in this biofilm model. The results with CLSM were consistent with those reported with qPCR. Structural damage was evidenced by SEM in some of the observed bacteria. It was concluded that both DHA and EPA have significant antimicrobial activity against the six bacterial species included in this biofilm model.

Effect of antiseptic gels in the microbiologic colonization of the suture threads after oral surgery

Three different bioadhesive gels were evaluated in a double-blind randomized clinical trial in which microbial growth in the suture thread was assessed following post-surgical application of the aforementioned gels. Also assessed in this trial were, the intensity of post-surgical pain as well as the degree of healing of the patients’ surgical wounds. A total of 21 patients (with 42 wisdom teeth) participated in this trial. Chlorhexidine gel, chlorhexidine-chitosan gel, and hyaluronic acid gel were evaluated, with a neutral water-based gel serving as the control agent. The aerobic and facultative anaerobic bacterial recovery on blood agar was lower in the placebo group than in the experimental groups. The most significant difference (p = 0.04) was observed in the chlorhexidine-chitosan group. in which the growth of Blood Agar and Mitis Salivarius Agar was significantly higher than in the placebo group. The intensity of post-surgical pain was very similar among all the groups. Significantly better healing rates were observed in the patients treated with chlorhexidine-chitosan gel when compared with those who used the placebo gel (p = 0.03), and in particular when compared with those patients who used hyaluronic acid gel (p = 0.01). Through our microbiological analyses, we were able to conclude that none of the bioadhesive gels tested resulted in beneficial reductions in the bacterial/fungal populations. However, the healing rates of patients who were treated with chlorhexidine-chitosan were better than those of the patients who used either the placebo gel or the hyaluronic acid gel.

Determination of chlorhexidine retention in different oral sites using matrix-assisted laser desorption/ionization-time of flight mass spectrometry

OBJECTIVE

The aim of this study was to determine chlorhexidine retention in different oral sites after a one-time 30 s mouth rinsing.

DESIGN

Five volunteers were asked to rinse their mouth with 10 ml of 0.2 % chlorhexidine digluconate for 30 s. After rinsing, samples were collected from the interdental area, buccal dental pellicle, anterior labial and posterior buccal mucosa, and saliva with a microbrush at five-time points within 24 h. Retention of chlorhexidine was measured using matrix-assisted laser desorption/ionization-time of flight mass spectrometry with a quantification limit of 15 ng/ml.

RESULTS

Chlorhexidine remained in the oral cavity at micrograms per milliliter levels for 11 h after mouth rinsing and was even detected 24 h after application. The results showed a distinct decline of intraoral chlorhexidine levels during the first 6 h after rinsing and it was then retained at low concentrations for at least 24 h.

CONCLUSIONS

The dental pellicle and oral mucosa were favorable sites for chlorhexidine retention. The novel method used for chlorhexidine determination offered excellent quantification limits and readily permitted quantification of chlorhexidine.

Bacterial Leakage at Implant-Abutment Interface With Different Intermediate Materials

A gap exists at the implant-abutment interface in two-piece implants and can serve as a reservoir of bacteria and compromise the health of peri-implant tissue. This study aimed to compare the effect of different intermediate materials on bacterial leakage at the implant-abutment interface. A total of 75 implants were divided into 5 groups (n = 15) based on the material applied at the implant-abutment connection: (1) Atridox, (2) chlorhexidine, (3) Gapseal silicone, (4) saliva, and (5) no material. All the implants were inoculated with 0.1 μL of Aggregatibacter actinomycetemcomitans (A. actinomycetemcomitans) suspension, and then the respective material was applied. The abutments were connected to the implants, and appropriate torque was applied as recommended by the manufacturer (Implantium, Dentium, Korea, Seoul). Bacterial leakage was determined by evaluating the turbidity of the broth. Bacterial contamination was found in all samples at different times; in groups 1, 2 and 3, contamination was noted after 7, 5, and 6 days, respectively, on average. Contamination occurred averagely after 4 days in groups 4 and 5. The present study showed that Atridox applied at the implant-abutment interface significantly delayed bacterial leakage.

Incidence and severity of postoperative complications following oral, periodontal, and implant surgeries: A retrospective study

BACKGROUND

Incidence and severity of postoperative complications are key elements in determining the risk-benefit relationship of any surgical procedure. The aim of this retrospective study was to assess and categorize the postoperative complications that occur following, and are associated with, oral, periodontal, and implant surgeries.

METHODS

A total of 3,900 patients who underwent surgical procedures including, but not limited to, sinus floor elevation, guided tissue regeneration, crown lengthening, implant placement, soft tissue graft, open flap debridement or surgical removal of impacted teeth were included. Postoperative complications were recorded and graded based on impedance to routine daily activity and favorable surgical outcomes. Regression models were generated to evaluate correlations between complication types, as well as between patient/surgical characteristics and the incidence of complications.

RESULTS

Surgical removal of impacted teeth and lateral sinus floor elevation had the highest incidence and severity of complications. Postoperative dentinal hypersensitivity (5.7%) was the most frequent complication, followed by excessive pain (4.1%), and moderate postoperative bleeding (3.5%). Based on the devised grading system described in this paper, the complications were 11.1% of Grade I, 3.3% of Grade II, 8.3% of Grade III, 0.1% of Grade IV, and no complications recorded under Grades V or VI.

CONCLUSIONS

Surgical removal of impacted teeth and lateral sinus floor elevation are more prone to more severe complications compared with other procedures. Additionally, complications that do not impede favorable surgical outcomes and/or routine daily activity are the most likely to occur. Smoking and diabetes are generally associated with postoperative complications.

Evaluation of wound healing and postoperative pain after oral mucosa laser biopsy with the aid of compound with chlorhexidine and sodium hyaluronate: a randomized double blind clinical trial

OBJECTIVES

The aim of this study is to evaluate secondary intention healing process and postoperative pain of oral soft tissues after laser surgery with the use of a compound containing chlorhexidine and sodium hyaluronate.

MATERIALS AND METHODS

This double-blind, randomized clinical study included 56 patients affected by benign oral lesions and subjected to excisional biopsy with diode laser and randomly divided into three groups. Study group (SG) received 0.2% chlorhexidine digluconate and 0.2% sodium hyaluronate treatment; control group (CG) received 0.2% chlorhexidine digluconate; and placebo group (PG) followed the same protocol, taking a neutral solution having the same organoleptic characteristics. Wound healing was evaluated using percentage healing index (PHI). Numeric rating scale (NRS) was used to evaluate postoperative pain.

RESULTS

PHI (T1 = 7 days) was 67.25% for SG, 58.67% for CG, and 54.55% for PG. PHI (T2 = 14 days) was 94.35% for SG, 77.79% for CG, and 78.98% for PG. A statistically significant difference was between the groups for PHI at T2 p = 0.001. No difference was detectable for pain index.

CONCLUSIONS

A solution containing sodium hyaluronate and chlorhexidine is a good support to increase wound healing by secondary intention after laser biopsy, but no differences were in postoperative perception of pain.

CLINICAL RELEVANCE

The use of the tested solution can be recommended after laser oral biopsies, to achieve a healing without suture. About the postoperative pain, the compound has not showed the same results and did not have measurable effects.

A randomized controlled clinical trial on the effectiveness of three different mouthrinses (chlorhexidine with or without alcohol and C31G), adjunct to periodontal surgery, in early wound healing

OBJECTIVES

The use of chlorhexidine (CHX) with or without alcohol has been recommended for a number of clinical applications. On the other hand, there is a plethora of widely subscribed antiseptics, such as agent C31G (alkyl dimethyl glycine/alkyl dimethyl amine oxide), which has not yet been evaluated postsurgically. The effectiveness of three different mouthrinses (CHX with and without alcohol, C31G) in plaque control and early wound healing was compared postoperatively.

MATERIALS AND METHODS

In this, randomized, double-blind, controlled clinical trial 42 patients were allocated to three groups assigned to 2 weeks rinsing after non-regenerative periodontal flap surgery with or without osseous surgery with C31G (group A), alcohol-free CHX 0.12% (group B) or alcohol-based CHX 0.12% (group C). At days 7 and 14, plaque and early wound healing indices were recorded. At day 14, total bacterial counts were estimated utilizing real-time quantitative polymerase chain reaction (qPCR). Statistics included linear and generalized linear mixed models.

RESULTS

At day 7, healing response was not significantly different among groups. At day 14, group A revealed the highest while group C demonstrated the lowest plaque index values (B vs A, odds ratio-OR = 0.18, p = 0.012; C vs A, OR = 0.01, p < 0.001; C vs B, OR = 0.06, p < 0.001). Group C demonstrated the lowest bacterial counts levels at day 14 (38.470 × 10⁶, 48.190 × 10⁶, and 3.020 × 10⁶ for groups A, B, and C, respectively). At day 14, healing was significantly better in group C compared to B (p = 0.007). Group A showed no significant differences compared to other groups.

CONCLUSIONS

(1) The presence of alcohol may increase the effectiveness of CHX in early wound healing, (2) C31G might be an alternative solution prescribed during early postoperative period after non-regenerative periodontal flap surgery.

CLINICAL RELEVANCE

The present study found that active agent C31G displayed no significant differences to CHX formulations regarding periodontal wound healing improvement and might be used alternatively after non-regenerative periodontal flap surgery. In addition, an alcohol based 0.12% CHX mouthwash was more effective than an alcohol-free 0.12% CHX and C31G mouthrinse on plaque control in the absence of mechanical oral hygiene.

The effect of metronidazole plus amoxicillin or metronidazole plus penicillin V on periodontal pathogens in an in vitro biofilm model

A combination of metronidazole (MET) and amoxicillin (AMX) is commonly used as adjunct to mechanical therapy of periodontal disease. The use of broad spectrum antibiotics such as AMX may contribute to development of antibiotic resistance. The aim was to evaluate the in vitro effect of replacing AMX with penicillin V (PV) in combination with MET on a biofilm model. A biofilm model consisting of Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, and Fusobacterium nucleatum was developed. The biofilms were exposed to AMX + MET and PV + MET in two different concentrations. Bacterial viability in biofilms following antibiotic exposure was assessed by viable counts and by confocal microscopy. No live colonies of P. gingivalis nor F. nucleatum were retrieved from biofilms exposed to AMX + MET or PV + MET. The amount of A. actinomycetemcomitans was 4-5 logs reduced following antibiotic treatment; no statistical significance was achieved between AMX + MET or PV + MET treated biofilms. Replacement of AMX with PV at the same concentration, in combination with MET, resulted in similar effect on bacterial viability in this in vitro model. The option of using PV + MET instead of AMX + MET deserves further investigation, as this may contribute to reduce the risk of antibiotic resistance development.

Determining the antibacterial substantivity of Triphala mouthwash and comparing it with 0.2% chlorhexidine gluconate after a single oral rinse: A crossover clinical trial

Context:

Triphala has been extensively used in dentistry as a mouthwash because of its antiplaque and antigingivitis properties.

Aim:

The present study is designed to determine the duration of its antibacterial substantivity after a single oral rinse and to compare it with the substantivity of 0.2% chlorhexidine gluconate (CHX).

Materials and Methods:

In this clinical crossover trial, unstimulated saliva from 30 individuals was collected 2 h after routine oral hygiene procedures but not rinsing (pre-sample) with randomly selected mouthwash, (10% Triphala mouthwash, 0.2% CHX, and normal saline) and 5 min after rinsing (postsample). A washout period of 1 week was kept between two rinses. The sampling was repeated after every 2 h for 12 h (post 1, post 2, post 3, post 4, post 5, and post 6) and was checked for microbial count.

Statistical Analysis Used:

Friedman test, Kruskal–Wallis test, and post hoc analysis were used to assess the effect of different mouthrinses on colony forming units at different times.

Results:

Ten percent Triphala showed statistically significant results when the antibacterial effect at post, post 1 and post 2 were compared to pre-assessment count (P < 0.05). After which the effect was at par with normal saline (P > 0.05). The results for CHX were statistically significant at all times when compared to pre-assessment count (P < 0.05) and it showed the maximum substantivity of 7 h.

Conclusion:

After a single rinse with no eating and drinking restrictions over the day, 10% Triphala mouthwash had an antibacterial effect for 3–4 h. It can be used three times daily for its maximum antibacterial effect.

In vitro chlorhexidine release from alginate based microbeads for periodontal therapy

Periodontitis is one of the most common infectious diseases globally that, if untreated, leads to destruction of the tooth supporting tissues and finally results in tooth loss. Evidence shows that standard procedures as mechanical root cleaning could be supported by further treatment options such as locally applied substances. Due to gingival crevicular fluid flow, substances are commonly washed out off the periodontal pockets. The evaluation of administration techniques and the development of local drug releasing devices is thus an important aspect in periodontal research. This study describes the development and examination of a new alginate based, biodegradable and easily applicable drug delivery system for chlorhexidine (CHX). Different micro beads were produced and loaded with CHX and the release profiles were investigated by high performance liquid chromatography (HPLC). The in vitro-demonstrated release of CHX from alginate based beads shows comparable releasing characteristics as clinically approved systems. Yet many characteristics of this new delivery system show to be favourable for periodontal therapy. Easy application by injection, low production costs and multifunctional adaptions to patient related specifics may improve the usage in routine care.

Inhibition of de novo plaque growth by a new 0.03 % chlorhexidine mouth rinse formulation applying a non-brushing model: a randomized, double blind clinical trial

OBJECTIVES

The aim of this study was to investigate the plaque inhibitory effect of a new 0.03 % chlorhexidine digluconate (CHX) and 0.05 % cetylpyridinium chloride (CPC) mouthrinse formulation and to explore patients' experience and side effects after its use.

MATERIALS AND METHODS

This short-term, randomized, double blind, parallel, clinical trial enrolled 150 periodontally healthy patients. These volunteers were randomly allocated to one of following mouthrinse groups (n = 50/group): 0.12 % CHX + 0.05 % CPC (Perio-Aid® Treatment alcohol-free), 0.03 % CHX + 0.05 % CPC new test formulation or to the placebo group. Clinical parameters (plaque, gingival, and stain indexes) and microbiological samples were taken at baseline, before supragingival cleaning, and after 4 days of undisturbed plaque growth, rinsing twice/day with one of the mouthrinses.

RESULTS

Plaque reduction was similar for the 0.12 % CHX (-0.52 ± 0.55) and 0.03 % CHX (-0.47 ± 0.49) groups. Both showed significant reductions in plaque accumulation compared to the placebo (p < 0.001). The new formulation had less of a negative impact on taste perception when compared to the 0.12 % CHX solution. The new CHX mouthrinse was also able to control bacterial loads and reduce some periodontopathogens.

CONCLUSIONS

This study indicated that the new 0.03 % CHX + 0.05 % CPC formulation exerted clinical efficacy similar to that achieved by an already-marketed 0.12 % CHX + 0.05 % CPC mouthrinse, but with slightly fewer side effects.

CLINICAL RELEVANCE

Lower CHX mouthrinse formulations could be effective in the inhibition of plaque regrowth with reduced unpleasant subjective side effects.

Iatrogenic Damage to the Periodontium by Chemicals and Dental Materials

The toxicity and tissue reactions to dental materials are receiving more attention as a wide variety of materials are used and as federal agencies demonstrate more concern in this area. A further indication of the importance of the interaction of materials and tissues is the development of recommended standard practices and tests for the biological interaction of materials.

The efficacy of 0.12% chlorhexidine versus 0.12% chlorhexidine plus hyaluronic acid mouthwash on healing of submerged single implant insertion areas: a short-term randomized controlled clinical trial

OBJECTIVES

The study was performed to evaluate the incidence of post-surgical adverse events at submerged implant sites as well as the antiplaque, antigingivitis and antistaining effects in the entire dentition of patients treated with two mouthwashes.

METHODS

The present randomized controlled clinical study considered 40 patients subjected to dental implant treatment. Two 0.12% chlorhexidine mouthwashes were compared for 15 days: one with 0.1% hyaluronic acid (CHX⊗HYL group) and one without it (CHX group). Surgical outcome variables, and plaque, gingival, and staining indexes were recorded.

RESULTS

Significant differences were found between the two rinses regarding the presence of oedema within 2 days after surgery (20% for the CHX⊗HYL group and 78% for the CHX group). No other significant differences were recorded between the two mouthwashes. No intergroup differences in plaque, staining and gingivitis indexes were registered. The intragroup analysis revealed that for the plaque and gingival indexes, the differences between the baseline values (before surgery) and those at 15 days were all found to be significant just for CHX⊗HYL rinse, with final values ranging from 0.18 to 0.23 for the plaque index and from 0.06 to 0.07 for the gingival index. The staining index increased for both mouthwash types with significant results (with final value of 0.19 and 0.31 for CHX⊗HYL and CHX groups, respectively).

CONCLUSIONS

In the sites of patients subjected to dental implant placement, an additional anti-oedematigenous effect in early healing seemed to be disclosed for 0.12% CHX⊗HYL mouthwash. Regarding antiplaque and antigingivitis activities, HYL seemed to be ineffective.

Ventilator-associated pneumonia, liver disease and oral chlorhexldine

As part of the ventilator care bundle, the Department of Health (DH) in the U.K. recommends the use of chlorhexidine (CHX) for oral care to prevent the occurrence of ventilator-associated pneumonia (VAP) in all mechanically ventilated patients. Due to the heterogenous nature of this population, however, it is important to consider whether such recommendations are also relevant to specific critical care patient population groups. This article reviews the available scientific evidence on the use of CHX in the prevention of VAP, with a focus on critically ill mechanically ventilated patients who have liver dysfunction. Findings will be discussed with reference to the wider research literature in order to make recommendations for future practice.

Chlorhexidine mouthwash reduces plaque and gingivitis

DATA SOURCES

Medline, Embase and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched along with the reference lists of all selected studies. Only English language studies were included.

STUDY SELECTION

Randomised controlled clinical trials comparing chlorhexidine (CHX) to placebo/control mouthrinses for oral hygiene in studies of at least four weeks duration were included.

DATA EXTRACTION AND SYNTHESIS

Screening, selection and data abstractions were conducted independently by two reviewers. Where possible meta-analysis of weighted mean differences was carried out using fixed or random effects models where appropriate.

RESULTS

Thirty studies were included, with 13 studies contributing to the meta-analysis. The meta-analysis found significant differences favouring CHX for a range of indices; the Plaque Index Silness & Löe, Plaque-Index Quigley & Hein (PIQH), the Gingival Index (GI), Papillary BIeeding Index, Bleeding on Marginal Probing and the Lobene Stain Index. Relative to control, the reduction with CHX for plaque was 33% and for gingivitis 26%. CHX rinsing groups demonstrated significantly more staining.

CONCLUSIONS

In gingivitis patients, CHX mouthrinses together with OH versus placebo, or control mouthrinse provide significant reductions in plaque and gingivitis scores, but a significant increase in staining score.

Allergic urticaria: a case report of rare skin allergy with a common mouthwash

Chlorhexidine is a widely used antiseptic and disinfectant in medical and non-medical environments. Compared to its ubiquitous use, allergic contact dermatitis from chlorhexidine has rarely been reported and so its sensitization rate seems to be low. Chlorhexidine has been used for more than 50 years but it was only in the last two decades, that reports of immediate- type reactions to chlorhexidine were seen. Reactions ranging from localized urticaria to anaphylactic shock and hypersensitivity reactions, including delayed hypersensitivity reactions such as contact dermatitis, fixed drug eruptions, and photosensitivity reactions, began to appear more frequently. However the prevalence of contact urticaria and anaphylaxis due to chlorhexidine remains to be unknown. In this case report we have reported a case of urticaria due to oral use of chlorhexidine. The adverse reaction was confirmed by a skin prick test.

In situ chlorhexidine substantivity on saliva and plaque-like biofilm: influence of circadian rhythm

BACKGROUND

The aim of the present study is to assess in situ substantivity of a single mouthrinse with 0.2% chlorhexidine (CHX) on saliva and on undisturbed de novo plaque-like biofilm (PL-biofilm), differentiating between two times of application: 1) CHX mouthrinse in the morning; and 2) CHX mouthrinse at night.

METHODS

The study participants were 10 healthy volunteers who wore an individualized splint with glass disks for 48 hours to boost the growth of PL-biofilm. Saliva samples were collected, and two disks were removed from each volunteer's splint at 8, 10, and 12 hours after performing a mouthrinse with 0.2% CHX at 7:00 am (M-0.2% CHX-diurnal) and 1:00 am (M-0.2% CHX-nocturnal). The saliva and plaque samples were analyzed by epifluorescence and confocal laser scanning microscopy, respectively, using a green fluorescent nucleic acid stain/propidium iodide staining.

RESULTS

With M-0.2% CHX-diurnal, the frequency of vital bacteria in saliva was significantly higher than in the PL-biofilm at 8, 10, and 12 hours after mouthrinse. After M-0.2% CHX-nocturnal, the frequency of vital bacteria in saliva was significantly lower than in the PL-biofilm at 8 hours and higher than in the PL-biofilm at 12 hours after mouthrinse.

CONCLUSION

These results support the more active physiologic dynamics of the salivary flora and the possible reservoir function associated with the structure of undisturbed de novo PL-biofilm.

Endodontic 'solutions' part 1: a literature review on the use of endodontic lubricants, irrigants and medicaments

Endodontic lubricants, irrigants and medicaments help prepare and disinfect root canal systems (RCS) but primary and secondary cases involve different microbes and therefore it is unlikely that one protocol will be effective for both case types. Each individual 'solution' or sequence of'solutions' could play a significant role in each case type, but there are no detailed published guidelines in existence. To help inform clinical practice it was decided to undertake a literature review followed by a UK and Republic of Ireland wide audit on current endodontic'solution' usage within dental schools. The literature review was undertaken under the following headings: pre-op oral rinse; file lubricants; root canal irrigants and intracanal medicaments and provides an evidence base for protocol development for both primary and retreatment cases.The audit project and the protocols developed from the findings of both the literature review and audit will be presented in Part 2.

Periodontal pharmacotherapy - an updated review

Periodontal disease is mainly associated with the activity of bacteria which adhere to the tooth surface and form specific structure of bacterial biofilm. Periodontal bacteria cause inflammation of the gums and aggressive immune response, affecting the periodontium. The first phase of initial therapy - mechanical removal of dental plaque and calculus - is necessary. If this non-surgical therapy has proved to be unsuccessful, an alternative treatment with antimicrobial agents is then considered. Pharmacotherapy is based on systemic or local antibiotics and/or antiseptics, which are applied according to the severity of the disease. A number of recent periodontal studies present some of the pharmacological agents, that are directed against bacteria or a host immune response, are often chosen as an adjunct treatment option, but none of these antimicrobials were established as 'a gold standard' in the periodontal treatment. This review provides some present recommendation of pharmacological strategies, with particular emphasis on systemic and local antimicrobial therapy of periodontal disease.

Comparative evaluation of efficacy of 0.2% Chlorhexidine, Listerine and Tulsi extract mouth rinses on salivary Streptococcus mutans count of high school children--RCT

OBJECTIVE

To assess and compare the effect of 0.2% Chlorhexidine mouth rinse, Listerine mouth rinse and 4% Tulsi extract mouth rinse on salivary Streptococcus mutans level.

METHODS

The present study is an experimental study of cross over type, employing Latin square design. 45 school children aged 14-15 years were divided into three groups/blocks. The baseline unstimulated saliva samples were obtained from each group and assessed for Streptococcus mutans counts. The study was divided in to three phases, each phase lasted for 8 days separated by a washout period of 15 days in between them. Groups A, B and C were treated with 0.2% Chlorhexidine, Listerine and 4% Tulsi extract mouth rinses respectively in the phase I. The study subjects were instructed to use the assigned mouth rinse twice daily for 1 min for 7 days. On day 8th the subjects were instructed to use the mouth rinse only once in the morning. The follow up unstimulated saliva samples were collected 1h after the use of the assigned mouth rinse and assessed for salivary Streptococcus mutans counts. After phase I, mouth rinses were crossed over as dictated by the Latin square design in phase II and III.

RESULTS

All the three mouth rinses have individually shown a statistically significant reduction in the salivary Streptococcus mutans counts. When the three mouth rinses were compared the difference did not reach statistical significance.

CONCLUSION

Tulsi has stood the test and is as effective as Chlorhexidine and Listerine in reducing the salivary S. mutans levels.

Effects of topically applied agents on intra-oral wound healing in a rat model: a clinical and histomorphometric study

OBJECTIVES

Topically applied chlorhexidine and hyaluronan have many studies supporting their use to enhance oral wound healing. Allantoin is widely used topically to promote epithelial proliferation and wound healing, with very little scientific evidence to support such uses. This study investigated and compared the influence of these agents on the healing of intra-oral excisional wounds with large epithelial and connective tissue defects.

METHODS

Excisional wounds, 3 mm in diameter, were made at the centre of the palate of 125 Wistar male albino rats. Five animals constituted the baseline group at time 0. The remaining animals were divided into four experimental and one control groups, in which chlorhexidine digluconate gel 0.2% (Perio.Kin®), hyaluronan gel (Gengigel®), allantoin 0.5% in vehicle gel, vehicle gel alone and nothing were applied daily to the wounds. The wound areas were measured photographically and the epithelialization rates were determined histologically at 0, 3, 7, 14 and 21 days post-surgery.

RESULTS

The mean wound area and mean distance between the epithelial margins decreased significantly with time in all experimental and control groups (P < 0.05). A significant rate of wound area reduction was observed following the use of Perio.Kin® and Gengigel® at 7 and 14 days. Perio.Kin® showed a significant rate of wound epithelialization at 7 days. Allantoin did not positively or negatively affect wound healing.

CONCLUSIONS

None of the tested agents had a negative effect on the rate of wound healing when applied on an excisional wound with epithelial and connective tissue defect. Positive results were achieved with Perio.Kin® and Gengigel®.

Essential oils compared to chlorhexidine with respect to plaque and parameters of gingival inflammation: a systematic review

BACKGROUND

The purpose of this review is to systematically evaluate the effects of an essential-oil mouthwash (EOMW) compared to a chlorhexidine mouthwash with respect to plaque and parameters of gingival inflammation.

METHODS

PubMed/MEDLINE and Cochrane CENTRAL databases were searched for studies up to and including September 2010 to identify appropriate articles. A comprehensive search was designed, and the articles were independently screened for eligibility by two reviewers. Articles that evaluated the effects of the EOMW compared to chlorhexidine mouthwash were included. Where appropriate, a meta-analysis was performed, and weighted mean differences (WMDs) were calculated.

RESULTS

A total of 390 unique articles were found, of which 19 articles met the eligibility criteria. A meta-analysis of long-term studies (duration ≥ 4 weeks) showed that the chlorhexidine mouthwash provided significantly better effects regarding plaque control than EOMW (WMD: 0.19; P = 0.0009). No significant difference with respect to reduction of gingival inflammation was found between EOMW and chlorhexidine mouthwash (WMD: 0.03; P = 0.58).

CONCLUSION

In long-term use, the standardized formulation of EOMW appeared to be a reliable alternative to chlorhexidine mouthwash with respect to parameters of gingival inflammation.

A direct comparison between extracted tooth and filter-membrane biofilm models of endodontic irrigation using Enterococcus faecalis

Endodontic restorations often fail due to inadequate disinfection of the root canal even though the antimicrobial irrigants used have been shown to be capable of killing the bacterium frequently implicated in this complication, Enterococcus faecalis (Ef). Extracted human teeth were root-prepared and filled with a liquid culture of Ef. Following incubation, the root canals were irrigated with 1% sodium hypochlorite (NaOCl), electrochemically activated water or saline control. Irrigation was modelled using an electronic pipette to deliver the solutions at a reproducible flow velocity. A series of parallel experiments employed a membrane biofilm model that was directly immersed into irrigant. Experimental conditions where contiguous between the extracted tooth model and biofilm model wherever possible. After 60 s of exposure, 1% NaOCl effectively sterilised the biofilm model, whereas log 3.36 viable Ef where recoverable from the analogous extracted tooth model, the other irrigants proved ineffective. Biofilms of Ef were susceptible to concentrations of irrigant that proved ineffective in the tooth model. NaOCl was the most effective biocide in either case. This suggests that the biofilm modality of bacterial growth may not be the most important factor for the recalcitrance of root canal infections during endodontic irrigation; it is more likely due to the inability of the irrigant to access the infection.

Clinical concepts of dry socket

Dry socket is one of the most studied complications in dentistry, and a great number of studies have searched for an effective and safe method for its prevention and treatment. One of the great clinical challenges since the first case was reported has been the inconsistency and differences in the various definitions of dry socket and the criteria used for diagnosis. The pathophysiology, etiology, prevention, and treatment of dry socket are very important in the practice of oral surgery. The aim of the present report was to review and discuss each aspect.

In vivo substantivity of 0.12% and 0.2% chlorhexidine mouthrinses on salivary bacteria

The in vivo antimicrobial activity of 0.12% and 0.2% chlorhexidine (CHX) on the salivary flora up to 7 h after its application, using epifluorescence microscopy with the SYTO 9/propidium iodide dual staining, was evaluated. Fifteen volunteers performed a single mouthrinse with sterile water (SM-water), a single mouthrinse with 0.12% CHX (0.12% SM-CHX) and a single and double mouthrinse with 0.2% CHX (0.2% SM-CHX and 0.2% DM-CHX). Samples of saliva were taken at 30 s, and 1, 3, 5, and 7 h after each application. In comparison with SM-water, 0.2% CHX (SM and DM) showed a significant antibacterial effect up to 7 h after the mouthrinse, whereas this effect only persisted up to 5 h after the 0.12% SM-CHX mouthrinse. On comparing the two concentrations of CHX, significantly higher percentages of bacterial vitality were observed in all the saliva samples after the use of 0.12% CHX than after 0.2% CHX. On comparison of the 0.2% SM-CHX and 0.2% DM-CHX, significantly higher percentages of live bacteria were observed in the saliva samples taken at 1, 3, 5, and 7 h after the single mouthrinse compared with the double mouthrinse. The 0.2% CHX mouthrinse had the greatest antimicrobial activity on the salivary flora up to 7 h after its application, with a progressive recovery in bacterial vitality. The differences observed with respect to the 0.12% CHX mouthrinse demonstrate the influence of the concentration on its immediate antimicrobial activity and substantivity.

Evaluation of chlorhexidine substantivity on salivary flora by epifluorescence microscopy

OBJECTIVE

To evaluate the in vivo antimicrobial activity of chlorhexidine (CHX) in saliva 7 h after its application using an epifluorescence microscopy technique.

SUBJECTS AND METHODS

Fifteen volunteers performed a single mouthrinse with sterile water (SM-water) and with 0.2% CHX (SM-0.2% CHX). Saliva samples were taken at 30 s and 1, 3, 5 and 7 h after each application. The bacterial suspension was mixed with the SYTO 9/propidium iodide staining and observed using an Olympus BX51 microscope. The mean percentage of viable bacteria was calculated for each sample.

RESULTS

In comparison with baseline values, the frequency of viable bacteria decreased significantly at 30 s after the SM-0.2% CHX (P < 0.001) and presented significant antibacterial activity up to 7 h after the mouthrinse (P < 0.001). In comparison with SM-water, the prevalence of viable bacteria was significantly lower at 30 s after the SM-0.2% CHX (P < 0.001) and showed a significant antibacterial effect up to 7 h after the mouthrinse (P < 0.001).

CONCLUSIONS

Epifluorescence microscopy permits evaluating the antimicrobial activity of CHX on the salivary flora in real-time. Fluorescence assays could be particularly useful to analyse simultaneously the effect of antimicrobials that alter the cytoplasmic membrane integrity on different oral ecosystems.