Periodontal effects of 0.25% sodium hypochlorite twice-weekly oral rinse. A pilot study

Three-Dimensional Planimetry Assessment of Dental Plaque-Covered Area Reduction after Rinsing with 0.2% Sodium Hypochlorite Solution as Part of a Guided Biofilm Therapy® Protocol-Pilot Longitudinal Study

Background/Objectives: Less often employed as a rinsing solution for controlling oral biofilms, NaOCL was used in oral rinses at various concentrations in steps 1 and 4 of periodontal therapy. The aim of this study was to quantitatively evaluate the biofilm-disruptive properties of a 0.2% NaOCl solution in standardized oral rinses using dedicated plaque-disclosing agents and 3D scanning methods in patients undergoing the regular Guided Biofilm Therapy® protocol. Methods: Eight patients with at least 20 teeth present evenly distributed between the two arches were included. After 24 h of refraining from oral hygiene, dental arches were stained with a disclosing agent, the subjects rinsed for 20 s, clinical photographs and 3D scans were performed, subjects rinsed again for 20 s, photographs and 3D scans were performed again, and then the GBT® protocol was resumed as usual. Data representing areas covered with dental plaque were acquired using the "Medit Scan for Clinics" software and then underwent a post-processing and rendering process. The outcome variable was the percent reduction in the plaque-covered areas. Results: For the upper jaw, the estimated mean percent reduction in the biofilm-covered area was 39.65%, while for the mandible, it was 38.26%. The analysis of individual photographs revealed changes in the plaque-covered areas and reductions in the color intensity of the residual plaque-covered areas under identical lighting conditions. Conclusions: When analyzed using 3D intraoral scanning, the 0.2% NaOCl rinsing solution seems to be a clinically efficient disruptor/dissolvent of the oral biofilm, both when integrated into modern protocols of periodontal therapy like GBT® and for home self-care.

A Low-Cost Protocol Using the Adjunctive Action of Povidone-Iodine Irrigations and Sodium Hypochlorite Rinsing Solution in Step 2 of Periodontal Therapy for Patients with Stage III-IV Periodontitis: A Single-Blind, Randomized Controlled Trial

In severe stages of periodontitis, conventional periodontal therapy and maintenance care are usually insufficient due to the viral and bacterial etiology; thus, a mechanical approach alone may not be sufficient to eliminate a substantial portion of subgingival pathogens, especially in deep periodontal sites. Background and Objectives: This single-blind, randomized clinical trial aimed to compare the clinical and microbiological efficacy of a low-cost protocol using povidone-iodine and sodium hypochlorite formulations as adjuncts to non-surgical therapy for patients with stage IV periodontitis when compared with chlorhexidine, the most commonly employed substance to date for antimicrobial regimens in periodontal therapy. Materials and Methods: Forty-five patients were randomly divided into two groups: control (subgingival instrumentation, chlorhexidine-assisted) and test (antiviral medication, subgingival instrumentation with povidone-iodine, sodium hypochlorite rinsing solution, and antibiotics). Clinical measurements and microbiological analyses were performed at baseline and after three months. Results: After three months, notable differences were found in the bacterial detection scores for Porphyromonas gingivalis (a significant reduction in detection frequency was observed in the test compared to the control (p = 0.021)), and there were significant reductions in detection in the test group for Tannerella forsythia and Treponema denticola, showing undetectable levels (p < 0.0001 for both). In the test group, the pocket probing depth median value was reduced significantly (p = 0.0005); similarly, bleeding on probing showed a marked decrease (p < 0.0001). However, changes in clinical attachment loss and full-mouth plaque score were not statistically significant. Conclusions: Using the proposed protocol, substantial improvements in clinical and microbiological parameters were obtained when compared with the current antimicrobial recommendations.

Effect of sodium hypochlorite gel on bacteria associated with periodontal disease

OBJECTIVES

An adjunct in non-surgical periodontal therapy might be sodium hypochlorite (NaOCl)-based agents. The purpose of the present in vitro study was to get deeper knowledge on the influence of different parameters as time after mixing, pH, and chemical composition of an amino acid 0.475% NaOCl (AA-NaOCl) gel consisting of two components on its anti-biofilm activity.

MATERIALS AND METHODS

Six-species biofilms were cultured for 5 days, before AA-NaOCl gel was applied. In the different series, the influence of the time after mixing of the two components before application, of the concentration of NaOCl in the gel mixture, of the pH of the gel mixture, and of an exchange of the amino acid component by hyaluronic acid (HA), was analyzed.

RESULTS

Mixing time point experiments showed that the AA-NaOCl gel is capable of statistically significantly reducing colony-forming unit (cfu) counts up to 30 min after mixing, but only up to 20 min after mixing the reduction was more than 2 log10 cfu. The pH experiments indicate that a reduced pH results in a reduced activity of the NaOCl formulation. NaOCl concentrations in the formulation in the range from 0.475 to 0.2% provide adequate activity on biofilms. A HA/NaOCl gel was equally active against the biofilm as the AA-NaOCl gel.

CONCLUSION

Mixing of the components should be made in a timeframe of 20 min before applications. An optimization of the composition of the NaOCl formulation might be possible and should be a topic in further in vitro studies.

CLINICAL RELEVANCE

The AA-NaOCl gel formulation can be mixed up to 20 min before application. Further, the study indicates that the composition of the NaOCl gel formulation can be optimized.

Electrolyzed Saline Targets Biofilm Periodontal Pathogens In Vitro

Preventing the development and recurrence of periodontal diseases often includes antimicrobial mouthrinses to control the growth of the periodontal pathogens. Most antimicrobials are nonselective, targeting the symbiotic oral species as well as the dysbiosis-inducing ones. This affects the overall microbial composition and metabolic activity and consequently the host-microbe interactions, which can be detrimental (associated with inflammation) or beneficial (health-associated). Consequently, guiding the antimicrobial effect for modulating the microbial composition to a health-associated one should be considered. For such an approach, this study investigated electrolyzed saline as a novel rinse. Electrolyzed saline was prepared from sterile saline using a portable electrolysis device. Multispecies oral homeostatic and dysbiotic biofilms were grown on hydroxyapatite discs and rinsed daily with electrolyzed saline (EOS). Corresponding positive (NaOCl) and negative (phosphate-buffered saline) controls were included. After 3 rinses, biofilms were analyzed with viability quantitative polymerase chain reaction and scanning electron microscopy. Supernatants of rinsed biofilms were used for metabolic activity analysis (high-performance liquid chromatography) through measuring organic acid content. In addition, human oral keratinocytes (HOKs) were exposed to EOS to test biocompatibility (cytotoxicity and inflammation induction) and also to rinsed biofilms to assess their immunogenicity after rinsing. Rinsing the dysbiotic biofilms with EOS could reduce the counts of the pathobionts (>3 log10 Geq/mm2 reduction) and avert biofilm dysbiosis (≤1% pathobiont abundance), leading to the dominance of commensal species (≥99%), which altered both biofilm metabolism and interleukin 8 (IL-8) induction in HOKs. EOS had no harmful effects on homeostatic biofilms. The scanning electron micrographs confirmed the same. In addition, tested concentrations of EOS did not have any cytotoxic effects and did not induce IL-8 production in HOKs. EOS showed promising results for diverting dysbiosis in in vitro rinsed biofilms and controlling key periopathogens, with no toxic effects on commensal species or human cells. This novel rinsing should be considered for clinical applications.

Herpesvirus-Bacteria pathogenic interaction in juvenile (aggressive) periodontitis. A novel etiologic concept of the disease

Localized juvenile (aggressive) periodontitis starts at puberty in otherwise healthy individuals and involves the proximal surfaces of permanent incisors and first molars. The disease destroys a sizeable amount of periodontal bone within a few months despite minimal dental plaque and gingival tissue inflammation. Cytomegalovirus and Epstein-Barr virus, as well as the two main periodontopathic bacteria Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis, are linked to juvenile periodontitis. Juvenile periodontitis-affected teeth show cementum hypoplasia. We hypothesize that an active herpesvirus infection, at the time of root formation, hampers cementum formation and, at puberty, herpesvirus reactivation triggers an upgrowth of bacterial pathogens which produce rapid periodontal destruction on teeth with a defective periodontium. A pathogenic interaction between active herpesviruses and bacterial pathogens can potentially explain the etiology and incisor-first molar destructive pattern of juvenile periodontitis. Effective treatment of juvenile periodontitis may target the herpesvirus-bacteria co-infection.

Antimicrobial efficacy of chlorine agents against selected oral pathogens

OBJECTIVES

Method-dependent comparison of antimicrobial agents' efficacy against oral pathogens.

MATERIALS AND METHODS

Several sodium hypochlorite solutions (NaOCl)-Perisolv®, Carisolv® and Dakin's solution-were equated with chlorhexidine (CHX) and hydrogen peroxide (H2O2) against ten oral micro-organisms related to caries and periodontitis using different minimum inhibitory concentration (MIC) and the minimum bactericidal concentration (MBC) techniques. Agents were adjusted to the final 70 mmol/L concentration of active chlorine molecule.

RESULTS

Apart from H2O2 and the amino acids of Perisolv®, all the agents revealed an antimicrobial effect. Agar diffusion test ranked CHX (p < 0.05) as the most effective against all ten specimens, followed by the NaOCl of Perisolv® and Dakin's solution. Correspondingly, in broth microdilution on agar, CHX was the most effective in eradicating micro-organisms at 0.03 mmol/L compared with 2.2 mmol/L of Dakin's solution. In contrast, the bactericidal concentration of Dakin's solution was the most effective at 0.2 mmol/L, (p < 0.001), followed by Perisolv® (2.14 mmol/L), CHX (2.38 mmol/L) and Carisolv® (3.33 mmol/L) after 5 and 10 min in broth dilution test. In live/dead analysis, 60-min exposure to a 2-fold concentration of agents resulted in two-log Aggregatibacter actinomycetemcomitans inhibition by CHX (35 mmol/L) whilst Streptococcus mutans was more susceptible, in 0.8 and 8.8 mmol/L, after 10 min to CHX and Dakin's respectively.

CONCLUSION

Replacement of CHX with tested hypochlorite agents showed evident potential and promoted rapid antimicrobial effect.

CLINICAL RELEVANCE

Effective antimicrobial agents are crucial in controlling pathogen-induced oral infections increasing clinical possibilities to combat oral biofilms. Additionally, CHX substitution with hypochlorite agents could eliminate CHX's adverse effects.

Antimicrobial Chemotherapy for Recalcitrant Severe Human Periodontitis

This study evaluated a combined systemic and topical anti-infective periodontal treatment of 35 adults who had experienced ongoing periodontal breakdown following conventional surgical periodontics. The prescribed anti-infective therapy, based on microbiological testing, consisted of a single course of metronidazole plus ciprofloxacin (23 patients), metronidazole plus amoxicillin/clavulanic acid (10 patients), and metronidazole plus ciprofloxacin followed by metronidazole plus amoxicillin/clavulanic acid (2 patients). In addition, the study patients received 0.1% povidone-iodine subgingival disinfection during non-surgical root debridement and daily patient administered oral irrigation with 0.1% sodium hypochlorite. At 1 and 5 years post-treatment, all study patients showed gains in clinical periodontal attachment with no further attachment loss, and significant decreases in pocket probing depth, bleeding on probing, and subgingival temperature. The greatest disease resolution occurred in patients who at baseline harbored predominantly major periodontal pathogens which post-antibiotics became non-detectable and substituted by non-periodontopathic viridans streptococci. The personalized and minimally invasive anti-infective treatment regimen described here controlled periodontitis disease activity and markedly improved the clinical and microbiological status of the refractory periodontitis patients.

Molecular Iodine Mouthrinse Antimicrobial Activity Against Periodontopathic Bacteria

AIM

This study compared two molecular iodine mouthrinses for their in vitro bactericidal effects against subgingival biofilm bacteria from severe periodontitis patients.

MATERIALS AND METHODS

In a subgingival biofilm eradication assay, dilution aliquots of subgingival microbial specimens from 32 adults with severe periodontitis were mixed in vitro with either a mouthrinse containing 100 parts per million (ppm) molecular iodine (Iorinse®) or one containing 150 ppm molecular iodine (iClean®), followed by mouthrinse neutralization after 60 seconds with 3% sodium thiosulfate. The mixtures, along with unexposed subgingival biofilm aliquots, were inoculated onto enriched Brucella blood agar and incubated anaerobically for 7 days to quantitate total viable bacterial counts and selected red/orange complex periodontal pathogens (Porphyromonas gingivalis, Tannerella forsythia, Prevotella intermedia/nigrescens, Parvimonas micra, Campylobacter rectus, and Fusobacterium nucleatum).

RESULTS

Both molecular iodine mouthrinses significantly reduced total viable bacterial counts in the subgingival biofilm samples, with iClean® providing significantly greater in vitro suppression than Iorinse®. Both molecular iodine mouthrinses also significantly reduced total red/orange complex periodontal pathogens, with significantly greater suppression also exhibited by iClean®.

CONCLUSION

The molecular iodine mouthrinses exerted marked bactericidal activity in vitro against human subgingival biofilm microbial species, including red/orange complex periodontal pathogens associated with severe periodontitis, with iClean® providing significantly better antimicrobial activity than Iorinse®.

CLINICAL SIGNIFICANCE

These findings suggest potential value of molecular iodine mouthrinses in the treatment and prevention of periodontal diseases.

Efficacy of the Adjunct Use of Povidone-Iodine or Sodium Hypochlorite with Non-Surgical Management of Periodontitis: A Systematic Review and Meta-Analysis

This systematic review sought to assess the efficacy of combining either sodium hypochlorite or povidone-iodine as disinfection solutions with non-surgical treatment of periodontitis. An electronic search was conducted through PubMed, Scopus, Web of Science, CENTRAL, and Google Scholar from inception until 10 September 2022. Outcomes included clinical outcomes (probing pocket depth, plaque index, clinical attachment level, relative-horizontal attachment level, bleeding on probing, gingival recession, the position of gingival margin) and biochemical (BAPNA level) properties. A subgroup analysis was conducted according to the assessment timepoint. Ten studies reporting the use of povidone-iodine and five studies reporting the use of sodium hypochlorite were included in this review. Overall, in the meta-analysis of povidone-iodine, no significant changes were noted in any of the assessed outcomes; however, minor changes were noted in probing pocket depth and clinical attachment level at a specific timepoint. Regarding sodium hypochlorite, a significant reduction in all clinical outcomes, except for bleeding on probing, was noted. In conclusion, the use of povidone-iodine does not result in an improvement in clinical outcomes, whereas sodium hypochlorite has promising properties that result in significant improvement in probing pocket depth and clinical attachment level. However, more studies are needed to confirm these observations.

Concise evaluation and therapeutic guidelines for severe periodontitis: A public health perspective

The main goal of periodontology is to prevent and arrest gingivitis and periodontitis to avoid tooth loss and focal infection of periodontal origin. Periodontal scaling or flap surgery of moderate-to-severe periodontitis have shortcomings, most likely because removal of herpesviruses and bacterial pathogens in deep periodontal lesions and the adjacent inflamed gingiva requires systemic antimicrobial treatment (or gingivectomy). Valacyclovir (1000 mg twice daily on day 1, and 500 mg twice daily on day 2 and on day 3) is a potent anti-herpesvirus agent. Antibiotic combinations against bacterial pathogens include amoxicillin-metronidazole (250 mg of each, thrice daily for 4 days; for systemically healthy adults) and ciprofloxacin-metronidazole (500 mg of each, twice daily for 4 days; for immunosuppressed individuals and patients exposed to contaminated water and poor sanitation). Supportive antiseptic treatment may consist of 0.1%-0.2% sodium hypochlorite (regular household bleach) as cooling spray in ultrasonic scalers, flosser fluid in oral irrigators, and mouthrinse in patient self-care. The anti-infective treatment described here helps control cases of severe periodontitis and constitutes an exceedingly inexpensive alternative to conventional (mechanical) periodontal therapy.

Effects of stabilized hypochlorous acid on oral biofilm bacteria

Background

Caries and periodontitis are amongst the most prevalent diseases worldwide, leading to pain and loss of oral function for those affected. Prevention relies heavily on mechanical removal of dental plaque biofilms but for populations where this is not achievable, alternative plaque control methods are required. With concerns over undesirable side-effects and potential bacterial resistance due to the use of chlorhexidine gluconate (CHX), new antimicrobial substances for oral use are greatly needed. Here we have investigated the antimicrobial effect of hypochlorous acid (HOCl), stabilized with acetic acid (HAc), on oral biofilms and compared it to that of CHX. Possible adverse effects of stabilized HOCl on hydroxyapatite surfaces were also examined.

Methods

Single- and mixed-species biofilms of six common oral bacteria (Streptococcus mutans, Streptococcus gordonii, Actinomyces odontolyticus, Veillonella parvula, Parvimonas micra and Porphyromonas gingivalis) within a flow-cell model were exposed to HOCl stabilized with 0.14% or 2% HAc, pH 4.6, as well as HOCl or HAc alone. Biofilm viability was assessed in situ using confocal laser scanning microscopy following LIVE/DEAD® BacLight™ staining. In-situ quartz crystal microbalance with dissipation (QCM-D) was used to study erosion of hydroxyapatite (HA) surfaces by stabilized HOCl.

Results

Low concentrations of HOCl (5 ppm), stabilized with 0.14% or 2% HAc, significantly reduced viability in multi-species biofilms representing supra- and sub-gingival oral communities, after 5 min, without causing erosion of HA surfaces. No equivalent antimicrobial effect was seen for CHX. Gram-positive and Gram-negative bacteria showed no significant differential suceptibility to stabilized HOCl.

Conclusions

At low concentrations and with exposure times which could be achieved through oral rinsing, HOCl stabilized with HAc had a robust antimicrobial activity on oral biofilms, without causing erosion of HA surfaces or affecting viability of oral keratinocytes. This substance thus appears to offer potential for prevention and/or treatment of oral biofilm-mediated diseases.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02453-2.

Oral Health: Opportunities for Lifestyle Medicine Highlighted by the SARS-CoV-2 Pandemic

A significant amount of illness has origins in oral microorganisms. The current SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) pandemic has reduced the general population's access to and use of routine and nonemergency dental care. This creates a dangerous situation in which oral bacteria, fungi, and viruses may remain unchecked and allowed to flourish, which in turn increases risks for several systemic diseases as well as negative outcomes for pregnancies and surgical patients. This situation presents opportunities for health maintenance and disease prevention by individuals as well as for dental health professionals to use anti-infective treatments and procedures. Lifestyle medicine professionals have a chance to encourage behaviors that individuals can undertake to promote good oral health outside of the dentist's office as well as shaping public perceptions about and reinforcing the importance of resuming dental visits as governmental restrictions allow.

Virus transmission by ultrasonic scaler and its prevention by antiviral agent: an in vitro study

Background

It is well recognized that dental procedures represent a potential way of infection transmission. With the COVID‐19 pandemic, the focus of dental procedure associated transmission has rapidly changed from bacteria to viruses. The aim was to develop an experimental setup for testing the spread of viruses by ultrasonic scaler (USS) generated dental spray and evaluate its mitigation by antiviral coolants.

Methods

In a virus transmission tunnel, the dental spray was generated by USS with saline coolant and suspension of Equine Arteritis Virus (EAV) delivered to the USS tip. Virus transmission by settled droplets was evaluated with adherent RK13 cell lines culture monolayer. The suspended droplets were collected by a cyclone aero‐sampler. Antiviral activity of 0.25% NaOCl and electrolyzed oxidizing water (EOW) was tested using a suspension test. Antiviral agents' transmission prevention ability was evaluated by using them as a coolant.

Results

In the suspension test with 0.25% NaOCl or EOW, the TCID50/mL was below the detection limit after 5 seconds. With saline coolant, the EAV‐induced cytopathic effect on RK13 cells was found up to the distance of 45 cm, with the number of infected cells decreasing with distance. By aero‐sampler, viral particles were detected in concentration ≤4.2 TCID50/mL. With both antiviral agents used as coolants, no EAV‐associated RK‐13 cell infection was found.

Conclusion

We managed to predictably demonstrate EAV spread by droplets because of USS action. More importantly, we managed to mitigate the spread by a simple substitution of the USS coolant with NaOCl or EOW.

Changes in clinical parameters following adjunctive local sodium hypochlorite gel in minimally invasive nonsurgical therapy (MINST) of periodontal pockets: a 6-month randomized controlled clinical trial

BACKGROUND

The mechanical disruption and removal of the subgingival biofilm represent the most important step in the treatment of periodontitis. However, in deep periodontal pockets, mechanical removal of the subgingival biofilm is difficult and frequently incomplete. Preliminary findings indicate that the use of amino acid buffered sodium hypochlorite (NaOCl) gel may chemically destroy the bacterial biofilm and facilitate its mechanical removal.

OBJECTIVES

To clinically evaluate the efficacy of minimally invasive nonsurgical therapy (MINST) of periodontal pockets with or without local application of an amino acid buffered sodium hypochlorite (NaOCl) gel.

MATERIALS AND METHODS

Forty untreated patients diagnosed with severe/advanced periodontitis (i.e. stage III/IV) with a slow/moderate rate of progression (i.e. grade A/B) were randomly allocated in two treatment groups. In the test group, the periodontal pockets were treated by means of MINST and NaOCl gel application, while in the control group, treatment consisted of MINST alone. Full-mouth plaque scores (FMPS), full-mouth bleeding scores (FMBS), probing depths (PD), clinical attachment levels (CAL) and gingival recessions (GR) were assessed at baseline and at 6 months following therapy. The primary outcome variable was PD reduction at sites with PD ≥ 5 mm at baseline.

RESULTS

At 6 months, statistically significant differences between the two groups were found (p = 0.001) in terms of PD and CAL change. No statistically significant differences were found in terms of GR (p = 0.81). The number of sites with PD ≥ 5 mm and BOP (+) decreased statistically significantly (p = 0.001), i.e. from 85.3 to 2.2% in the test group and from 81.6 to 7.3% in the control group, respectively. Statistically significant differences between test and control groups were recorded at 6 months (p = 0.001). MINST + NaOCl compared to MINST alone decreased statistically significantly (p = 0.001) the probability of residual PDs ≥ 5 mm with BOP- (14.5% vs 18.3%) and BOP+ (2.2% vs. 7.2%).

CONCLUSIONS

Within their limits, the present results indicate that (a) the use of MINST may represent a clinically valuable approach for nonsurgical therapy and (b) the application of NaOCl gel in conjunction with MINST may additionally improve the clinical outcomes compared to the use of MINST alone.

CLINICAL RELEVANCE

In patients with untreated periodontitis, treatment of deep pockets by means of MINST in conjunction with a NaOCl gel may represent a valuable approach to additionally improve the clinical outcomes obtained with MINST alone.

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.

Effect of a sodium hypochlorite mouthwash on plaque and clinical parameters of periodontal disease-a systematic review

OBJECTIVE

The present study aimed to establish the efficacy of sodium hypochlorite mouthwash (NaOCl-MW) compared with a control mouthwash on plaque and clinical parameters of periodontal disease.

METHODS

MEDLINE-PubMed, Embase and Cochrane-CENTRAL databases were searched for clinical trials on patients with gingivitis or periodontitis that assessed the effect of NaOCl-MW in comparison with a negative or positive control on plaque index (PI), gingival index (GI), and bleeding index (BI) scores and probing pocket depth (PPD). Data were extracted from the eligible studies.

RESULTS

Seven eligible papers were retrieved, which together represented six clinical trials. The studies showed considerable heterogeneity regarding methodological and clinical aspects that did not permit a meta-analysis. Two of the three studies in which NaOCl-MW was compared with a negative control showed that NaOCl-MW significantly reduced PI, GI and BI, and no effect was found on PPD. In three studies, NaOCl-MW was assessed using chlorhexidine mouthwash (CHX-MW) as a positive control; no difference was found for GI and BI. One of the three comparisons showed a statistically significant PI score favouring NaOCl-MW. One study measured PPD and found it to be significant in favour of NaOCl-MW.

CONCLUSIONS

Studies with a negative control group provided very weak quality evidence for a very small beneficial effect of NaOCl-MW on PI, GI and BI scores. Studies with a positive control group provided very weak quality evidence that NaOCl-MW had a similar effect as CHX-MW on PI, GI and BI scores. The outcome for PPD was inconclusive.

Professionally Delivered Local Antimicrobials in the Treatment of Patients with Periodontitis-A Narrative Review

This review sheds light on the recent published scientific evidence relating to the use of professionally delivered local antimicrobial agents (LA’s). The review also analyses drug delivery systems available to date and provides an update on the latest scientific evidence about the benefits, limitations, and clinical results obtained by use of local drugs in the treatment of periodontal disease. The search strategy revealed randomized controlled trials (RCTs) that compared the efficacy of adjunctive LA’s to mechanical therapy alone. Based on the available evidence gathered from this review, we can infer that the use of local antimicrobial agents in conjunction to scaling and root debridement (SRD) delivers significant benefits in periodontal therapy and it is a useful aid, avoiding many of the side effects that systemic antibiotic therapy may involve. Local drug delivery (LDD) is an efficient and effective means of delivering drugs based on the evidence presented in the review. The authors of this review would suggest the use of local antimicrobials in cases of localized periodontitis or individual areas that do not respond to the usual mechanical therapy alone. This review summarizes the current use of local drug delivery in periodontal management ensuring that the general practitioners are able to choose an appropriate local antimicrobial.

Is oral hygiene as important as hand hygiene during COVID-19 pandemic?

Oral hygiene is an integral part of personal hygiene practices and should not be neglected. Similar to hand hygiene, oral hygiene is essential in reducing infection from the oral cavity, and thus, its transfer to the upper and lower respiratory tract. Although there is no randomized clinical trial, oral hygiene may imply to reduce the morbidity and mortality related to coronavirus disease pandemic potentially. At present, standard oral hygiene measures consist of thorough cleaning of all surfaces of teeth, interdental areas, and tongue daily. Oral health-care providers should emphasize its importance. Thorough toothbrushing for “Two Times For Two Minutes” in a day is an easy key to remember.

Periodontal herpesvirus morbidity and treatment

Four billion individuals worldwide have a history of periodontitis, with the poorest people in society most affected. Periodontitis can lead to unsightly drifting of teeth and tooth loss that may interfere with the wellbeing of daily living and has also been linked to at least 57 medical diseases and disabilities. The etiology of severe periodontitis includes active herpesviruses, specific bacterial pathogens, and destructive immune responses, but herpesviruses seem to be the major pathogenic determinant. Periodontal herpesviruses that disseminate via the systemic circulation to nonoral sites may represent a major link between periodontitis and systemic diseases. Current treatment of periodontitis focuses almost exclusively on bacterial biofilm and will require revision. Periodontal therapy that targets both herpesviruses and bacterial pathogens can provide long-term clinical improvement and potentially reduces the risk of systemic diseases. Molecular diagnostic tests for periodontal pathogens may enable early microbial identification and preemptive therapy. This review details an efficient and reliable anti-infective treatment of severe periodontitis that can be carried out in minimal time with minimal cost.

Focal infection of periodontal origin

Periodontology has evolved from a predominantly mechanical to a sophisticated infectious disease-based discipline. Research has paved the way for a greater understanding of the periodontal microbiome, improvement in periodontal diagnostics and therapies, and the recognition of periodontitis being associated with more than 50 systemic diseases. The etiopathology of progressive periodontitis includes active herpesviruses, specific bacterial pathogens, and proinflammatory immune responses. This article points to a role of periodontal herpesviruses in the development of systemic diseases and proposes treatment of severe periodontitis not only to avoid tooth loss, but also to reduce the risk for systemic diseases. An efficient, safe, and reliable anti-infective treatment of severe periodontitis is presented, which targets both herpesviruses and bacterial pathogens and which can be carried out in minimal time with minimal cost.

Influence of the acidity of electrolyzed water on the microhardness of inner layer dentin

Background/purpose

Electrolyzed water has been identified as an effective disinfectant that could represent as an alternative to sodium hypochlorite. Unfortunately, it remains unclear whether the texture or physical properties of dentin are affected by the application of electrolyzed water of different acidities. This study was aimed to assess the influence of electrolyzed waters with differing pHs on the demineralizing of inner dentin.

Materials and methods

The coronal superficial dentin of 20 human molars was exposed and further bisected into two pieces perpendicular to the dentin surface. The samples were immersed in strongly acidic electrolyzed water (AW group), neutral electrolyzed water (NW group), 5% sodium hypochlorite (positive control, NL group), or deionized water (negative control, DW group). Microhardness of the inner layer dentin was measured at a depth of 25 and 50 μm beneath the superficial surface layer every 5 up to 60 min.

Results

At a depth of 25 μm, microhardness decreased with increasing immersion time in all but the DW group. The AW group exhibited a decreasing trend from the first 5 min that became significant after 35 min of immersion and was the most rapid decrease in the four groups. The rate of decline in the NW group was low and similar to that of the NL group. Both NW and NL groups exhibited significantly less demineralization than the AW group after 15 min of immersion. No significant microhardness change was found at a depth of 50 μm in any of the samples.

Conclusion

AW produces a more pronounced softening of dentin than NW at a depth of 25 μm.

Local drug delivery systems in the management of periodontitis: A scientific review

Periodontitis (PD) is a microbial disease of tooth supporting tissues that results in progressive destruction of surrounding soft and hard tissues with eventual tooth mobility and exfoliation. Perioceutics, which includes the delivery of therapeutic agents via systemic and local means as an adjunct to mechanical therapy has revolutionized the arena of periodontal therapy. Selection of a right antimicrobial agent with appropriate route of drug administration is the key to successful periodontal therapy. Irrigating systems, fibers, gels, strips, films, microparticles, nanoparticles and low dose antimicrobial agents are some of the local drug delivery systems (LDDS) available in the field, which aims to deliver antimicrobial agents to sub-gingival diseased sites with minimal or no side-effects on other body sites. The present review aim to summarize the current state-of-the-art technology on LDDS in periodontal therapy ensuring the the practitioners are able to choose LDD agents which are custom made for a specific clinical condition.

Comparative evaluation of efficacy of 0.2% sodium hypochlorite (Hi Wash) mouthwash with 0.2% chlorhexidine mouthwash on plaque-induced gingivitis: A clinical trial

Background:

Bleeding gums are one of the common complaints to visit a dentist. Mechanical removal of plaque alone is not sufficient for the reduction of gingival inflammation associated with plaque. Mouthwashes are supplemented to it as a homecare product. The objective of this study is to evaluate the efficacy of 0.2% sodium hypochlorite mouthwash on plaque and gingival inflammation and to assess the clinical parameters of gingivitis patients from baseline to 21 days with the use of 0.2% sodium hypochlorite and 0.2% chlorhexidine mouthwashes.

Materials and Methods:

This clinical trial study included 60 patients with gingival inflammation evaluated using clinical parameters such as bleeding on probing index, plaque index, and gingival index at baseline and 21 days. Group A patients were given Hi Wash mouthwash and Group B 0.2% chlorhexidine mouthwash with 30 patients in each group.

Results:

The scores for clinical parameters were significantly reduced after 21 days in Group A and Group B patients, and there was a reduction in plaque-associated gingival inflammation without scaling and root planning.

Conclusions:

0.2% sodium hypochlorite mouthwash is as effective as 0.2% chlorhexidine for the treatment of gingivitis as it is an adjunct to mechanical plaque removal in terms of safety, less side effects, less staining and can be used as a routine mouthwash.

Discovery of a Novel Periodontal Disease-Associated Bacterium

One of the world's most common infectious disease, periodontitis (PD), derives from largely uncharacterized communities of oral bacteria growing as biofilms (a.k.a. plaque) on teeth and gum surfaces in periodontal pockets. Bacteria associated with periodontal disease trigger inflammatory responses in immune cells, which in later stages of the disease cause loss of both soft and hard tissue structures supporting teeth. Thus far, only a handful of bacteria have been characterized as infectious agents of PD. Although deep sequencing technologies, such as whole community shotgun sequencing have the potential to capture a detailed picture of highly complex bacterial communities in any given environment, we still lack major reference genomes for the oral microbiome associated with PD and other diseases. In recent work, by using a combination of supervised machine learning and genome assembly, we identified a genome from a novel member of the Bacteroidetes phylum in periodontal samples. Here, by applying a comparative metagenomics read-classification approach, including 272 metagenomes from various human body sites, and our previously assembled draft genome of the uncultivated Candidatus Bacteroides periocalifornicus (CBP) bacterium, we show CBP's ubiquitous distribution in dental plaque, as well as its strong association with the well-known pathogenic "red complex" that resides in deep periodontal pockets.

Periodontitis: facts, fallacies and the future

This volume of Periodontology 2000 represents the 25th anniversary of the Journal, and uses the occasion to assess important advancements in periodontology over the past quarter-century as well as the hurdles that remain. Periodontitis is defined by pathologic loss of the periodontal ligament and alveolar bone. The disease involves complex dynamic interactions among active herpesviruses, specific bacterial pathogens and destructive immune responses. Periodontal diagnostics is currently based on clinical rather than etiologic criteria, and provides limited therapeutic guidance. Periodontal causative treatment consists of scaling, antiseptic rinses and occasionally systemic antibiotics, and surgical intervention has been de-emphasized, except perhaps for the most advanced types of periodontitis. Plastic surgical therapy includes soft-tissue grafting to cover exposed root surfaces and bone grafting to provide support for implants. Dental implants are used to replace severely diseased or missing teeth, but implant overuse is of concern. The utility of laser treatment for periodontitis remains unresolved. Host modulation and risk-factor modification therapies may benefit select patient groups. Patient self-care is a critical part of periodontal health care, and twice-weekly oral rinsing with 0.10-0.25% sodium hypochlorite constitutes a valuable adjunct to conventional anti-plaque and anti-gingivitis treatments. A link between periodontal herpesviruses and systemic diseases is a strong biological plausibility. In summary, research during the past 25 years has significantly changed our concepts of periodontitis pathobiology and has produced more-effective and less-costly therapeutic options.

Multi-omics Analysis of Periodontal Pocket Microbial Communities Pre- and Posttreatment

Periodontal disease affects the majority of adults worldwide and has been linked to numerous systemic diseases. Despite decades of research, the reasons for the substantial differences among periodontitis patients in disease incidence, progressivity, and response to treatment remain poorly understood. While deep sequencing of oral bacterial communities has greatly expanded our comprehension of the microbial diversity of periodontal disease and identified associations with healthy and disease states, predicting treatment outcomes remains elusive. Our results suggest that combining multiple omics approaches enhances the ability to differentiate among disease states and determine differential effects of treatment, particularly with the addition of metabolomic information. Furthermore, multi-omics analysis of biofilm community instability indicated that these approaches provide new tools for investigating the ecological dynamics underlying the progressive periodontal disease process.

Periodontitis is a polymicrobial infectious disease that causes breakdown of the periodontal ligament and alveolar bone. We employed a meta-omics approach that included microbial 16S rRNA amplicon sequencing, shotgun metagenomics, and tandem mass spectrometry to analyze sub- and supragingival biofilms in adults with chronic periodontitis pre- and posttreatment with 0.25% sodium hypochlorite. Microbial samples were collected with periodontal curettes from 3- to 12-mm-deep periodontal pockets at the baseline and at 2 weeks and 3 months. All data types showed high interpersonal variability, and there was a significant correlation between phylogenetic diversity and pocket depth at the baseline and a strong correlation (rho = 0.21; P = 0.008) between metabolite diversity and maximum pocket depth (MPD). Analysis of subgingival baseline samples (16S rRNA and shotgun metagenomics) found positive correlations between abundances of particular bacterial genera and MPD, including Porphyromonas, Treponema, Tannerella, and Desulfovibrio species and unknown taxon SHD-231. At 2 weeks posttreatment, we observed an almost complete turnover in the bacterial genera (16S rRNA) and species (shotgun metagenomics) correlated with MPD. Among the metabolites detected, the medians of the 20 most abundant metabolites were significantly correlated with MPD pre- and posttreatment. Finally, tests of periodontal biofilm community instability found markedly higher taxonomic instability in patients who did not improve posttreatment than in patients who did improve (UniFrac distances; t = −3.59; P = 0.002). Interestingly, the opposite pattern occurred in the metabolic profiles (Bray-Curtis; t = 2.42; P = 0.02). Our results suggested that multi-omics approaches, and metabolomics analysis in particular, could enhance treatment prediction and reveal patients most likely to improve posttreatment.

IMPORTANCE Periodontal disease affects the majority of adults worldwide and has been linked to numerous systemic diseases. Despite decades of research, the reasons for the substantial differences among periodontitis patients in disease incidence, progressivity, and response to treatment remain poorly understood. While deep sequencing of oral bacterial communities has greatly expanded our comprehension of the microbial diversity of periodontal disease and identified associations with healthy and disease states, predicting treatment outcomes remains elusive. Our results suggest that combining multiple omics approaches enhances the ability to differentiate among disease states and determine differential effects of treatment, particularly with the addition of metabolomic information. Furthermore, multi-omics analysis of biofilm community instability indicated that these approaches provide new tools for investigating the ecological dynamics underlying the progressive periodontal disease process.

Lack of adjunctive effect of 0.1% sodium hypochlorite mouthwash combined to full-mouth ultrasonic debridement on supragingival plaque, gingival inflammation, and subgingival microbiota: A randomized placebo-controlled 6-month trial

To test the adjunctive effect of 0.1% sodium hypochlorite (NaOCl) mouthwash combined to full‐mouth ultrasonic debridement (FMUD) on reducing supragingival plaque, gingival inflammation, and microbial pathogens. In this 6‐month double‐blinded randomized clinical trial, individuals with gingivitis were assigned to test (n = 16) or placebo group (n = 16) and received FMUD followed by rinsing with 0.1% NaOCl (test) or distilled water (placebo), respectively, twice a day for 1 month. Full‐mouth periodontal examination was performed at baseline, 1, 3, and 6 months posttherapy, and subgingival plaque samples were obtained at the same time points and analysed for their composition by checkerboard. Differences between groups over time were examined by Student t test, Mann–Whitney, generalized linear model, and Friedman and chi‐square tests. Both therapeutic protocols resulted in significant clinical improvement in periodontal parameters over time, except for probing depth and attachment level, which had a slight mean increase of 0.2 mm (p < .01). No significant differences between groups were observed for any clinical parameter (p > .05). Most species (>65%) decreased similarly in levels in both groups over time. Significant reductions in the microbial complexes were seen mainly at 1 and 3 months, but they returned to baseline levels in both groups, except for the red and yellow complexes, and other oral species, which were kept in low levels at 6 months (p < .05). A 0.1% NaOCl mouthwash did not provide additional benefits to FMUD in reducing supragingival plaque, gingivitis, and/or microbial pathogens.

Local disinfection with sodium hypochlorite as adjunct to basic periodontal therapy: a randomized controlled trial

AIM

To investigate the clinical and microbiological effects of local disinfection with 0.5% sodium hypochlorite (NaOCl) with or without systemic antimicrobials (amoxicillin and metronidazole, AM) during basic periodontal therapy (BPT).

MATERIAL AND METHODS

In a randomized clinical trial (four groups), 110 chronic periodontitis patients received BPT plus local irrigation with saline (BPT + S), local disinfection with NaOCl (BPT + DIS), BPT + DIS + AM or BPT + S + AM. The outcome was analysed at baseline, 3, 6 and 12 months.

RESULTS

There was no difference in clinical attachment level gain at 12 months between the four groups. BPT + DIS showed no additional improvement compared to BPT + S; BPT + DIS + AM showed fewer sites with probing pocket depth (PPD) ≥7 mm versus BPT + S only up to 6 months (p = 0.037). In factorial analyses, additional clinical reduction for PPD (p = 0.023) and number of sites with PPD ≥5 (p = 0.007), ≥6 (p = 0.002) and ≥7 mm (p < 0.001) were found when AM was added to BPT, but not when DIS was applied. In all groups, a comparable decrease in targeted bacteria was found. AM caused adverse events in 22% of the patients.

CONCLUSION

Local disinfection with NaOCl, also in combination with AM, showed, after 1-year follow-up, no additional clinical and microbiological effects compared to BPT alone.

Towards microbiome transplant as a therapy for periodontitis: an exploratory study of periodontitis microbial signature contrasted by oral health, caries and edentulism

BACKGROUND

Conventional periodontal therapy aims at controlling supra- and subgingival biofilms. Although periodontal therapy was shown to improve periodontal health, it does not completely arrest the disease. Almost all subjects compliant with periodontal maintenance continue to experience progressive clinical attachment loss and a fraction of them loses teeth. An oral microbial transplant may be a new alternative for treating periodontitis (inspired by fecal transplant). First, it must be established that microbiomes of oral health and periodontitis are distinct. In that case, the health-associated microbiome could be introduced into the oral cavity of periodontitis patients. This relates to the goals of our study: (i) to assess if microbial communities of the entire oral cavity of subjects with periodontitis were different from or oral health contrasted by microbiotas of caries and edentulism patients; (ii) to test in vitro if safe concentration of sodium hypochlorite could be used for initial eradication of the original oral microbiota followed by a safe neutralization of the hypochlorite prior transplantation.

METHODS

Sixteen systemically healthy white adults with clinical signs of one of the following oral conditions were enrolled: periodontitis, established caries, edentulism, and oral health. Oral biofilm samples were collected from sub- and supra-gingival sites, and oral mucosae. DNA was extracted and 16S rRNA genes were amplified. Amplicons from the same patient were pooled, sequenced and quantified. Volunteer's oral plaque was treated with saline, 16 mM NaOCl and NaOCl neutralized by ascorbate buffer followed by plating on blood agar.

RESULTS

Ordination plots of rRNA gene abundances revealed distinct groupings for the oral microbiomes of subjects with periodontitis, edentulism, or oral health. The oral microbiome in subjects with periodontitis showed the greatest diversity harboring 29 bacterial species at significantly higher abundance compared to subjects with the other assessed conditions. Healthy subjects had significantly higher abundance in 10 microbial species compared to the other conditions. NaOCl showed strong antimicrobial properties; nontoxic ascorbate was capable of neutralizing the hypochlorite.

CONCLUSIONS

Distinct oral microbial signatures were found in subjects with periodontitis, edentulism, or oral health. This finding opens up a potential for a new therapy, whereby a health-related entire oral microbial community would be transplanted to the diseased patient.