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Maisch T, Scholz KJ, Forster EM, Wenzl V, Auer DL, Cieplik F, Hiller KA. Optimal effective concentration combinations (OPECCs) for binary application of membrane-targeting antiseptics and TMPyP-mediated antimicrobial photodynamic therapy. Photochem Photobiol Sci 2024; 23:189-196. [PMID: 38113026 DOI: 10.1007/s43630-023-00512-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 11/12/2023] [Indexed: 12/21/2023]
Abstract
The widespread occurrence of multi-resistant bacteria is a health problem of global dimension. Infections caused by multi-resistant pathogens are difficult to treat and often associated with high mortality. Therefore, new treatment strategies are of interest, such as the use of differently acting antibacterial concepts. One of these new concepts is the use of antiseptics in combination with the antibacterial photodynamic therapy (aPDT). Currently, no method has yet been established as a standard procedure for investigating combined effects and evaluating them in a generally valid and unambiguous manner. The focus of this study was on how cationic antiseptics benzalkonium chloride (BAC) and chlorhexidine digluconate (CHX) behave in a combined application with aPDT using the photosensitizer TMPyP. For this purpose, BAC and CHX were applied in combination with the aPDT using TMPyP in non-lethal concentrations to the three bacteria Escherichia coli, Staphylococcus aureus, and Enterococcus faecalis. The results of the combination experiments with sublethal concentrations of BAC or CHX with the aPDT showed that the binary application had a lethal effect. Irrespective of the bacteria, the reduction in concentrations in OPECC, compared to individual concentrations, was more than 50% for TMPyP, 23-40% for BAC, and 18-43% for CHX. Furthermore, the optimal effective concentration combinations (OPECCs) could be determined. The latter showed that the combined application allowed the reduction of both concentrations compared to the single application.
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Affiliation(s)
- Tim Maisch
- Department of Dermatology, University Hospital Regensburg, 93053, Regensburg, Germany.
| | - Konstantin J Scholz
- Department of Conservative Dentistry and Periodontology, University Hospital Regensburg, 93053, Regensburg, Germany
| | - Eva-Maria Forster
- Department of Dermatology, University Hospital Regensburg, 93053, Regensburg, Germany
- Department of Conservative Dentistry and Periodontology, University Hospital Regensburg, 93053, Regensburg, Germany
| | - Verena Wenzl
- Department of Dermatology, University Hospital Regensburg, 93053, Regensburg, Germany
- Department of Conservative Dentistry and Periodontology, University Hospital Regensburg, 93053, Regensburg, Germany
| | - David L Auer
- Department of Conservative Dentistry and Periodontology, University Hospital Regensburg, 93053, Regensburg, Germany
| | - Fabian Cieplik
- Department of Conservative Dentistry and Periodontology, University Hospital Regensburg, 93053, Regensburg, Germany
| | - Karl-Anton Hiller
- Department of Conservative Dentistry and Periodontology, University Hospital Regensburg, 93053, Regensburg, Germany
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Brookes Z, Teoh L, Cieplik F, Kumar P. Mouthwash Effects on the Oral Microbiome: Are They Good, Bad, or Balanced? Int Dent J 2023; 73 Suppl 2:S74-S81. [PMID: 37867065 PMCID: PMC10690560 DOI: 10.1016/j.identj.2023.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 08/21/2023] [Indexed: 10/24/2023] Open
Abstract
This narrative review describes the oral microbiome, and its role in oral health and disease, before considering the impact of commonly used over-the-counter (OTC) mouthwashes on oral bacteria, viruses, bacteriophages, and fungi that make up these microbial communities in different niches of the mouth. Whilst certain mouthwashes have proven antimicrobial actions and clinical effectiveness supported by robust evidence, this review reports more recent metagenomics evidence, suggesting that mouthwashes such as chlorhexidine may cause "dysbiosis," whereby certain species of bacteria are killed, leaving others, sometimes unwanted, to predominate. There is little known about the effects of mouthwashes on fungi and viruses in the context of the oral microbiome (virome) in vivo, despite evidence that they "kill" certain viral pathogens ex vivo. Evidence for mouthwashes, much like antibiotics, is also emerging with regards to antimicrobial resistance, and this should further be considered in the context of their widespread use by clinicians and patients. Therefore, considering the potential of currently available OTC mouthwashes to alter the oral microbiome, this article finally proposes that the ideal mouthwash, whilst combatting oral disease, should "balance" antimicrobial communities, especially those associated with health. Which antimicrobial mouthwash best fits this ideal remains uncertain.
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Affiliation(s)
- Zoë Brookes
- Peninsula Dental School, Plymouth University, Plymouth, UK.
| | - Leanne Teoh
- Melbourne Dental School, The University of Melbourne, Carlton, Victoria, Australia
| | - Fabian Cieplik
- Department of Conservative Dentistry and Periodontology, University Hospital Regensburg, Regensburg, Germany
| | - Purnima Kumar
- Department of Periodontics and Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor, USA
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Lin SY, Sun JS, Hung MC, Chang JZC. Effectiveness of mouth rinses against COVID-19: a systematic review and network meta-analysis. J Hosp Infect 2023; 139:175-191. [PMID: 37419189 DOI: 10.1016/j.jhin.2023.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/21/2023] [Accepted: 06/25/2023] [Indexed: 07/09/2023]
Abstract
OBJECTIVE This systematic review and network meta-analysis (NMA) comprehensively compared the effectiveness of different mouth rinses in reducing the viral load/infectivity of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) (Part I), alleviating clinical symptoms or severity of disease (Part II), and decreasing the incidence of SARS-CoV-2 infection (Part III). METHODS Randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) with restrictions were searched up to 3rd March 2023. Twenty-three studies (22 RCTs and one NRCT) met the inclusion criteria for this systematic review. RESULTS Five RCTs (454 patients and nine interventions) in Part I were eligible for NMA. The NMA results showed that, in comparison with no rinse, sodium chloride (NaCl) was the most effective mouth rinse for reducing the viral load, followed by povidone-iodine (PVP-I), ß-cyclodextrin + citrox (CDCM), hydrogen peroxide (HP), chlorhexidine gluconate (CHX), cetylpyridinium chloride (CPC), placebo and hypochlorous acid (HClO). However, these results were not significant. Based on surface under the cumulative ranking curve scores, PVP-I was likely to be the most efficacious mouth rinse for reducing SARS-CoV-2 viral load, followed by CDCM, HP, NaCl, CHX, CPC, placebo, no rinse and HClO. CONCLUSION Due to heterogeneity of the primary studies, the effectiveness of different mouth rinses to reduce viral infectivity, improve clinical symptoms or prevent SARS-CoV-2 infection remains inconclusive.
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Affiliation(s)
- S-Y Lin
- Department of Dentistry, MacKay Memorial Hospital, Taipei, Taiwan
| | - J-S Sun
- Department of Orthopaedic Surgery, College of Medicine, China Medical University, Taichung, Taiwan; Department of Orthopaedic Surgery, En Chu Kong Hospital, New Taipei City, Taiwan
| | - M-C Hung
- School of Dentistry, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - J Z-C Chang
- School of Dentistry, College of Medicine, National Taiwan University, Taipei, Taiwan.
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Weber J, Bonn EL, Auer DL, Kirschneck C, Buchalla W, Scholz KJ, Cieplik F. Preprocedural mouthwashes for infection control in dentistry-an update. Clin Oral Investig 2023:10.1007/s00784-023-04953-z. [PMID: 37079156 PMCID: PMC10116478 DOI: 10.1007/s00784-023-04953-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/17/2023] [Indexed: 04/21/2023]
Abstract
OBJECTIVES Aerosols and splatter are routinely generated in dental practice and can be contaminated by potentially harmful bacteria or viruses such as SARS-CoV-2. Therefore, preprocedural mouthwashes containing antiseptic agents have been proposed as a potential measure for infection control in dental practice. This review article aims to summarize the clinical (and, if insufficient, preclinical) evidence on preprocedural mouthwashes containing antiseptic agents and to draw conclusions for dental practitioners. METHODS Literature on preprocedural mouthwashes for reduction of bacterial or viral load in dental aerosols was searched and summarized. RESULTS Preprocedural mouthwashes, particularly those containing chlorhexidine digluconate (CHX), cetylpyridinium chloride (CPC), or essential oils (EO), can significantly reduce the bacterial load in dental aerosols. With respect to viruses such as HSV-1, there are too little clinical data to draw any clear recommendations. On the other hand, clinical data is consolidating that CPC-containing mouthwashes can temporarily reduce the intraoral viral load and infectivity in SARS-CoV-2 positive individuals. Nevertheless, potential risks and side effects due to regular antiseptic use such as ecological effects or adaptation of bacteria need to be considered. CONCLUSIONS The use of preprocedural mouthwashes containing antiseptics can be recommended according to currently available data, but further studies are needed, particularly on the effects on other viruses besides SARS-CoV-2. When selecting a specific antiseptic, the biggest data basis currently exists for CHX, CPC, EO, or combinations thereof. CLINICAL RELEVANCE Preprocedural mouthwashes containing antiseptics can serve as part of a bundle of measures for protection of dental personnel despite some remaining ambiguities and in view of potential risks and side effects.
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Affiliation(s)
- Johanna Weber
- Department of Conservative Dentistry and Periodontology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
- Department of Orthodontics, University Hospital Regensburg, Regensburg, Germany
| | - Eva L Bonn
- Department of Conservative Dentistry and Periodontology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - David L Auer
- Department of Conservative Dentistry and Periodontology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | | | - Wolfgang Buchalla
- Department of Conservative Dentistry and Periodontology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Konstantin J Scholz
- Department of Conservative Dentistry and Periodontology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Fabian Cieplik
- Department of Conservative Dentistry and Periodontology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.
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Bonn EL, Rohrhofer A, Audebert FX, Lang H, Auer DL, Scholz KJ, Schuster P, Wenzel JJ, Hiller KA, Buchalla W, Gottsauner JM, Vielsmeier V, Schmidt B, Cieplik F. Efficacy of a Mouthwash Containing CHX and CPC in SARS-CoV-2-Positive Patients: A Randomized Controlled Clinical Trial. J Dent Res 2023; 102:608-615. [PMID: 36942423 PMCID: PMC10030878 DOI: 10.1177/00220345231156415] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
Soon after the outbreak of the coronavirus disease 2019 (COVID-19) pandemic, preprocedural mouthwashes were recommended for temporarily reducing intraoral viral load and infectivity of individuals potentially infected with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in order to protect medical personnel. Particularly, the antiseptic cetylpyridinium chloride (CPC) has shown virucidal effects against SARS-CoV-2 in vitro. Therefore, the aim of this randomized controlled clinical trial was to investigate the efficacy of a commercially available mouthwash containing CPC and chlorhexidine digluconate (CHX) at 0.05% each in SARS-CoV-2-positive patients as compared to a placebo mouthwash. Sixty-one patients who tested positive for SARS-CoV-2 with onset of symptoms within the last 72 h were included in this study. Oropharyngeal specimens were taken at baseline, whereupon patients had to gargle mouth and throat with 20 mL test or placebo (0.9% NaCl) mouthwash for 60 s. After 30 min, further oropharyngeal specimens were collected. Viral load was analyzed by quantitative reverse transcriptase polymerase chain reaction, and infectivity of oropharyngeal specimens was analyzed by virus rescue in cell culture and quantified via determination of tissue culture infectious doses 50% (TCID50). Data were analyzed nonparametrically (α = 0.05). Viral load slightly but significantly decreased upon gargling in the test group (P = 0.0435) but not in the placebo group. Viral infectivity as measured by TCID50 also significantly decreased in the test group (P = 0.0313), whereas there was no significant effect but a trend in the placebo group. Furthermore, it was found that the specimens from patients with a vaccine booster exhibited significantly lower infectivity at baseline as compared to those without vaccine booster (P = 0.0231). This study indicates that a preprocedural mouthwash containing CPC and CHX could slightly but significantly reduce the viral load and infectivity in SARS-CoV-2-positive patients. Further studies are needed to corroborate these results and investigate whether the observed reductions in viral load and infectivity could translate into clinically useful effects in reducing COVID-19 transmission (German Clinical Trials Register DRKS00027812).
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Affiliation(s)
- E L Bonn
- Department of Conservative Dentistry and Periodontology, University Hospital Regensburg, Regensburg, Germany
- Institute of Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany
| | - A Rohrhofer
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - F X Audebert
- Praxiszentrum Alte Mälzerei, Regensburg, Germany
| | - H Lang
- Praxiszentrum Alte Mälzerei, Regensburg, Germany
| | - D L Auer
- Department of Conservative Dentistry and Periodontology, University Hospital Regensburg, Regensburg, Germany
| | - K J Scholz
- Department of Conservative Dentistry and Periodontology, University Hospital Regensburg, Regensburg, Germany
| | - P Schuster
- Institute of Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany
| | - J J Wenzel
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - K-A Hiller
- Department of Conservative Dentistry and Periodontology, University Hospital Regensburg, Regensburg, Germany
| | - W Buchalla
- Department of Conservative Dentistry and Periodontology, University Hospital Regensburg, Regensburg, Germany
| | - J M Gottsauner
- Department of Oral and Maxillofacial Surgery, University Hospital Regensburg, Regensburg, Germany
| | - V Vielsmeier
- Department of Otorhinolaryngology, University Hospital Regensburg, Regensburg, Germany
| | - B Schmidt
- Institute of Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - F Cieplik
- Department of Conservative Dentistry and Periodontology, University Hospital Regensburg, Regensburg, Germany
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Sánchez Barrueco A, Mateos-Moreno MV, Villacampa Aubá JM, Campos González A, Bogoya Castaño A, Rubio Yanguas R, Blanco Goñi A, Zapardiel Ferrero J, Cenjor Español C, Ausina Márquez V, García-Esteban S, Artacho A, López Labrador FX, Mira A, Ferrer MD. In vivo effect of mouthwashes on viable viral load of SARS-CoV-2 in saliva: a pilot study. J Oral Microbiol 2023; 15:2198432. [PMID: 37063978 PMCID: PMC10101681 DOI: 10.1080/20002297.2023.2198432] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023] Open
Abstract
Current data on the efficacy of antiseptic mouthwashes to reduce viral load are contradictory. Firstly, in vitro data indicate very strong virucidal effects that are not replicated in clinical studies. Secondly, most clinical studies identify a limited effect, do not include a control/placebo group, or do not evaluate viral viability in an infection model. In the current manuscript, we perform a double-blind, randomized clinical trial where salivary viral load was measured before and after the mouthwash, and where saliva samples were also cultured in an in vitro infection model of SARS-CoV-2 to evaluate the effect of mouthwashes on viral viability. Our data show a 90-99% reduction in SARS-CoV-2 salivary copies with one of the tested mouthwashes, although we show that the remaining viruses are mostly viable. In addition, our data suggest that the active ingredient concentration and the overall excipients' formulation can play an important role; and most importantly, they indicate that the effect is not immediate, being significant at 15 min and having maximum effectiveness after 1 h. Thus, we show that some oral mouthwashes can be useful in reducing viral transmission, although their efficacy must be improved through refined formulations or revised protocols.
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Affiliation(s)
- Alvaro Sánchez Barrueco
- ENT and Cervicofacial Surgery Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
- ENT and Cervicofacial Surgery Department, Villalba General University Hospital, Collado Villalba, Spain
| | | | | | - Alfonso Campos González
- ENT and Cervicofacial Surgery Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
- ENT and Cervicofacial Surgery Department, Villalba General University Hospital, Collado Villalba, Spain
| | - Abel Bogoya Castaño
- ENT and Cervicofacial Surgery Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Raúl Rubio Yanguas
- ENT and Cervicofacial Surgery Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Asier Blanco Goñi
- ENT and Cervicofacial Surgery Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Javier Zapardiel Ferrero
- Microbiology Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
- Microbiology Department, Villalba General University Hospital, Collado Villalba, Spain
| | - Carlos Cenjor Español
- ENT and Cervicofacial Surgery Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | | | | | - Alejandro Artacho
- Genomics & Health Department, FISABIO-Public Health Foundation, Valencia, Spain
| | - F. Xavier López Labrador
- Genomics & Health Department, FISABIO-Public Health Foundation, Valencia, Spain
- Department of Microbiology and Ecology, Medical School, University of Valencia, Valencia, Spain
- CIBER in Epidemiology and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
| | - Alex Mira
- Genomics & Health Department, FISABIO-Public Health Foundation, Valencia, Spain
- CIBER in Epidemiology and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
- CONTACT Alex Mira Genomics & Health Department, FISABIO-Public Health Foundation, Valencia, Spain
| | - María D. Ferrer
- Genomics & Health Department, FISABIO-Public Health Foundation, Valencia, Spain
- María D. Ferrer Genomics & Health Department, FISABIO-Public Health Foundation, Valencia, Spain
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