Potentials of mouthwashes in disinfecting cariogenic bacteria and biofilms leading to inhibition of caries

Effectiveness of Mouthwashes in Managing Oral Diseases and Conditions: Do They Have a Role?

Antimicrobial mouthwashes are considered to reduce dental plaque biofilm and thus the potential to prevent plaque-induced oral diseases, particularly periodontal diseases. The effectiveness of mouthwashes relates to this antiplaque role, as well as, their tooth-whitening potential and ability to mask/mange malodour (halitosis). There is also a growing interest in the use of mouthwashes as an adjunctive measure in post surgical and post-dental care, while the COVID-19 pandemic has given a new lease of life to mouthwashes as an oral antispetic that may be useful in reducing the oral viral load. The mode of action of mouthwashes varies, depending on their active ingredients, concentrations, and mode and frequency of use, as does their potential effectiveness. This article aims to provide a narrative overview of the evidence of the effectiveness of the most widely used mouthwashes in managing oral diseases, oral conditions, and adjunctive care roles.

Revisiting Oral Antiseptics, Microorganism Targets and Effectiveness

A good oral health status is mostly dependent on good oral hygiene habits, which knowingly impacts systemic health. Although controversial, chemical oral antiseptics can be useful in adjunct use to mechanical dental plaque control techniques in the prevention and management of local and overall health and well-being. This review aims to revisit, gather and update evidence-based clinical indications for the use of the most popular oral antiseptics, considering different types, microorganism targets and effectiveness in order to establish updated clinical recommendations.

Hydrogel-Encapsulated Biofilm Inhibitors Abrogate the Cariogenic Activity of Streptococcus mutans

We designed and synthesized analogues of a previously identified biofilm inhibitor IIIC5 to improve solubility, retain inhibitory activities, and to facilitate encapsulation into pH-responsive hydrogel microparticles. The optimized lead compound HA5 showed improved solubility of 120.09 μg/mL, inhibited Streptococcus mutans biofilm with an IC50 value of 6.42 μM, and did not affect the growth of oral commensal species up to a 15-fold higher concentration. The cocrystal structure of HA5 with GtfB catalytic domain determined at 2.35 Å resolution revealed its active site interactions. The ability of HA5 to inhibit S. mutans Gtfs and to reduce glucan production has been demonstrated. The hydrogel-encapsulated biofilm inhibitor (HEBI), generated by encapsulating HA5 in hydrogel, selectively inhibited S. mutans biofilms like HA5. Treatment of S. mutans-infected rats with HA5 or HEBI resulted in a significant reduction in buccal, sulcal, and proximal dental caries compared to untreated, infected rats.

Disinfectant Susceptibility of Third-Generation-Cephalosporin/Carbapenem-Resistant Gram-Negative Bacteria Isolated from the Oral Cavity of Residents of Long-Term-Care Facilities

We have recently reported the isolation of third-generation-cephalosporin-resistant Gram-negative bacteria from the oral cavity of residents of a long-term-care facility (LTCF). Since disinfectants are often used in the oral cavity, it is important to investigate the disinfectant susceptibility of oral bacteria. Here, we evaluated the susceptibilities of Gram-negative antimicrobial-resistant bacteria (GN-ARB), including Pseudomonas, Acinetobacter, and Enterobacteriaceae, obtained from the oral cavity of residents of LTCFs to povidone-iodine (PVPI), cetylpyridinium chloride (CPC), benzalkonium chloride (BZK), and chlorhexidine chloride (CHX). We also evaluated the susceptibilities of isolates from the rectum to the same agents to compare the susceptibility profiles of oral and rectal isolates. Next, we investigated the relationship between their susceptibility and disinfectant resistance genes delineated by whole-genome sequencing of the isolates. Additionally, we evaluated the correlation between disinfectant-resistant GN-ARB and clinical information. In oral GN-ARB, the MIC of PVPI showed almost identical values across isolates, while the MICs of CPC, BZK, and CHX showed a wide range of variation among species/strains. In particular, Pseudomonas aeruginosa exhibited high-level resistance to CPC and BZK. The disinfectant susceptibility of rectal GN-ARB showed a tendency similar to that of oral GN-ARB. The presence of qacEΔ1 was correlated with CPC/BZK resistance in P. aeruginosa, while other species exhibited no correlation between qacEΔ1 and resistance. Multiple analyses showed the correlation between the presence of CPC-resistant bacteria in the oral cavity and tube feeding. In conclusion, we found that some oral GN-ARB isolates showed resistance to not only antibiotics but also disinfectants. IMPORTANCE Antibiotic-resistant bacteria (ARB) are becoming a serious concern worldwide. We previously reported the isolation of third-generation-cephalosporin-resistant Gram-negative bacteria from the oral cavity of residents of a long-term-care facility (LTCF). To prevent infection with ARB in hospitals and eldercare facilities, we must pay more attention to the use of not only antibiotics but also disinfectants. However, the effect of disinfectants on ARB is unclear. In this study, we evaluated the susceptibility of Gram-negative ARB (GN-ARB) from the oral cavity of residents of LTCFs to some disinfectants that are often used for the oral cavity; we found that some isolates showed resistance to several disinfectants. This is the first comprehensive analysis of the disinfectant susceptibility of oral GN-ARB. These results provide some important information for infection control and suggest that disinfectants should be applied carefully.

Impact of benzalkonium chloride, benzethonium chloride and chloroxylenol on bacterial antimicrobial resistance

This review examined 3655 articles on benzalkonium chloride (BKC), benzethonium chloride (BZT) and chloroxylenol (CHO) aiming to understand their impact on antimicrobial resistance. Following the application of inclusion/exclusion criteria, only 230 articles were retained for analysis; 212 concerned BKC, with only 18 for CHO and BZT. Seventy-eight percent of studies used MIC to measure BKC efficacy. Very few studies defined the term 'resistance' and 85% of studies defined 'resistance' as <10-fold increase (40% as low as 2-fold) in MIC. Only a few in vitro studies reported on formulated products and when they did, products performed better. In vitro studies looking at the impact of BKC exposure on bacterial resistance used either a stepwise training protocol or exposure to constant BKC concentrations. In these, BKC exposure resulted in elevated MIC or/and MBC, often associated with efflux, and at time, a change in antibiotic susceptibility profile. The clinical relevance of these findings was, however, neither reported nor addressed. Of note, several studies reported that bacterial strains with an elevated MIC or MBC remained susceptible to the in-use BKC concentration. BKC exposure was shown to reduce bacterial diversity in complex microbial microcosms, although the clinical significance of such a change has not been established. The impact of BKC exposure on the dissemination of resistant genes (notably efflux) remains speculative, although it manifests that clinical, veterinary and food isolates with elevated BKC MIC carried multiple efflux pump genes. The correlation between BKC usage and gene carriage, maintenance and dissemination has also not been established. The lack of clinical interpretation and significance in these studies does not allow to establish with certainty the role of BKC on AMR in practice. The limited literature and BZT and CHO do not allow to conclude that these will impact negatively on emerging bacterial resistance in practice.

Anti-Inflammatory and Protective Effects of Juncus effusus L. Water Extract on Oral Keratinocytes

Periodontitis is a chronic inflammatory disease caused by periodontopathogenic bacteria that form biofilms in periodontal pockets. The gingival epithelium acts as the first physical barrier in fighting attacks by periodontopathogenic pathogens, such as the primary etiological agent Porphyromonas gingivalis, and various exogenous chemicals, as well as regulates the local innate immune responses. Therefore, the development of novel oral care products to inhibit inflammatory reactions caused by bacterial infection and protect the gingival epithelium is necessary. Juncus effusus L. has generally been used as an indigenous medicine, such as a diuretic, an antipyretic, and an analgesic, in ancient practice. In this study, we examined the effects of a water extract from J. effusus L. on the inhibition of the inflammatory reaction elicited by bacterial infection and protection of the oral epithelium by chemical irritation. Pretreatment of oral epithelial cells with the water extract from J. effusus L. significantly reduced P. gingivalis or its lipopolysaccharide- (LPS-) mediated production of chemokines (interleukin-8 and C-C-chemokine ligand20) in a concentration-dependent manner with comparable to or greater effects than epigallocatechin gallate and protected oral epithelial cells from injury by chemical irritants, cetylpyridinium chloride, and benzethonium chloride. Moreover, the water extract from J. effusus L. in the presence of antimicrobial agents or antifibrinolytics already used as ingredients in mouthwash could significantly reduce the production of chemokines from P. gingivalis LPS-stimulated oral epithelial cells in a concentration-dependent manner. These findings suggest that the water extract from J. effusus L. is potentially useful for oral care to prevent oral infections, such as periodontal infections, and maintain oral epithelial function.

Discovery of Potent Inhibitors of Streptococcus mutans Biofilm with Antivirulence Activity

Dental caries is a bacterial infectious disease characterized by demineralization of the tooth enamel. Treatment of this disease with conventional antibiotics is largely ineffective as the cariogenic bacteria form tenacious biofilms that are resistant to such treatments. The main etiological agent for dental caries is the bacterium Streptococcus mutans. S. mutans readily forms biofilms on the tooth surface and rapidly produces lactic acid from dietary sucrose. Glucosyl transferases (Gtfs) secreted by S. mutans are mainly responsible for the production of exopolysaccharides that are crucial for the biofilm architecture. Thus, inhibiting S. mutans' Gtfs is an effective approach to develop selective biofilm inhibitors that do not affect the growth of oral commensals. Herein, we report a library of 90 analogs of the previously identified lead compound, G43, and exploration of its structure activity relationships (SAR). All compounds were evaluated for the inhibition of S. mutans biofilms and bacterial growth. Selected compounds from this library were further evaluated for enzyme inhibition against Gtfs using a zymogram assay and for growth inhibition against oral commensal bacterial species such as Streptococcus gordonii and Streptococcus sanguinis. This study has led to the discovery of several new biofilm inhibitors with enhanced potency and selectivity. One of the leads, III _F1 , showed marked reduction in buccal, sulcal, and proximal caries scores in a rat model of dental caries.

Assessment of the antibacterial, antivirulence, and action mechanism of Copaifera pubiflora oleoresin and isolated compounds against oral bacteria

The microorganisms that constitute the oral microbiome can cause oral diseases, including dental caries and endodontic infections. The use of natural products could help to overcome bacterial resistance to the antimicrobials that are currently employed in clinical therapy. This study assessed the antimicrobial activity of the Copaifera pubiflora oleoresin and of the compounds isolated from this resin against oral bacteria. The minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) assays provided values ranging from 6.25 to > 400 μg/mL for the C. pubiflora oleoresin and its isolated compounds. The fractional inhibitory concentration index (FICI) assay showed that the oleoresin and chlorhexidine did not act synergistically. All the tested bacterial strains formed biofilms. MICB₅₀ determination revealed inhibitory action: values varied from 3.12-25 μg/mL for the oleoresin, and from 0.78 to 25 μg/mL for the ent-hardwickiic acid. Concerning biofilm eradication, the C. pubiflora oleoresin and hardwickiic acid eradicated 99.9 % of some bacterial biofilms. Acid resistance determination showed that S. mutans was resistant to acid in the presence of the oleoresin and ent-hardwickiic acid at pH 4.0, 4.5, and 5.0 at all the tested concentrations. Analysis of DNA/RNA and protein release by the cell membrane demonstrated that the oleoresin and hardwiickic acid damaged the bacterial membrane irreversibly, which affected membrane integrity. Therefore, the C. pubiflora oleoresin and ent-hardwickiic acid have potential antibacterial effect and can be used as new therapeutic alternatives to treat oral diseases such as dental caries and endodontic infections.

Effect of a mouthrinse containing Malva sylvestris on the viability and activity of microcosm biofilm and on enamel demineralization compared to known antimicrobials mouthrinses

The purpose of this study was to evaluate the antimicrobial (anti-biofilm) and anti-caries (enamel demineralization prevention) effects of Malva sylvestris (Malvatricin^® Plus) compared with known antimicrobial mouthrinses. Microcosm biofilm was produced on enamel, using inoculum from pooled human saliva mixed with McBain saliva (0.2% sucrose) for 14 days. The biofilm was treated with mouthrinses for 1 min day^-1. Oral-B^® Complete, Listerine^® Zero and Malvatricin^® Plus had the greatest effect on the reduction of biofilm viability (p < 0.0001). On the other hand, lactic acid production was reduced significantly with PerioGard^®, Noplak^® Max and Listerine^® Zero compared with the control (p < 0.0001). No significant differences were found among the mouthrinses with respect to the colony-forming unit counting (total microorganisms, total streptococci, mutans streptococci and lactobacilli) and extracellular polysaccharide production. Enamel demineralization was reduced significantly with PerioGard^®, Noplak^® Max and Malvatricin^® Plus compared with the control (p < 0.0001). Malva sylvestris has a comparable anti-caries effect to chlorhexidine mouthrinses.

Effects of sub-minimum inhibitory concentrations of lemon essential oil on the acid tolerance and biofilm formation of Streptococcus mutans

OBJECTIVES

Lemon essential oil (LEO) is a kind of secondary metabolite from lemon peels and has been found to inhibit cariogenic bacteria for decades. However, its effects on main cariogenic virulence factors are rarely reported. The present study aimed to investigate the effects of sub-minimum inhibitory concentrations (sub-MICs) of LEO on the acid tolerance and biofilm formation of Streptococcus mutans (S. mutans) and preliminarily reveal the possible underlying mechanisms.

DESIGNS

Effects of LEO on the acid tolerance and biofilm formation of S. mutans were investigated by the broth dilution method and crystal violet staining method respectively. The expression of luxS, srtA and spaP gene was also determined to explore the underlying mechanism. In addition, Tea polyphenols (TP), a major natural inhibitor of cariogenic virulence factors, and limonene (LIM), the major component of LEO, were selected as comparisons to evaluate the effects of LEO.

RESULTS

Sub-MICs of LEO, LIM and TP exhibited a dose-dependent inhibition of growth of S. mutans at pH ranging from 4.0 to 7.0. The formation of S. mutans biofilm was remarkably inhibited and the inhibitory rates of LEO, LIM and TP were 97.87%, 94.88% and 96.01% respectively at 1/2 MIC. Similarly, a down-regulation was observed in the expression of luxS, srtA and spaP gene at sub-MIC levels.

CONCLUSIONS

Effects of LEO were similar or slightly stronger than LIM and TP, suggesting that LEO might represent a novel, natural anticarious agent that inhibited the specific genes associated with bacterial acid tolerance and biofilm formation without necessarily affecting the growth of oral bacteria.

Efficacy of Miswak toothpaste and mouthwash on cariogenic bacteria

Objectives:

To evaluate the efficacy of Salvadora persica (Miswak) products on cariogenic bacteria in comparison with ordinary toothpaste.

Methods:

The study was conducted in Zakho city, Kurdistan region, Iraq during the period from October 2013 to January 2014. A randomized controlled clinical trial of 40 students randomly allocated into 4 groups. They were instructed to use Mismark toothpaste, Miswak mouthwash, and ordinary toothpaste with water or with normal saline. Salivary samples were collected at 3-time intervals: before, immediately after use, and after 2 weeks of use. The effect of each method on Streptococcus mutans and Lactobacilli was evaluated by using caries risk test.

Results:

One-way repeated measure analysis of variance (ANOVA), one-way ANOVA, and least significant difference tests were used. Miswak wash has a significant reduction effect on both bacteria immediately and after 2 weeks of use. Miswak paste has a similar effect on Lactobacilli, while Streptococcus mutans showed a significant decrease only after 2 weeks of use. Ordinary paste showed a non significant effect on both bacteria at both time intervals; while the addition of normal saline showed a significant effect on both bacteria only after 2 weeks of use.

Conclusion:

Miswak products, especially mouth wash, were more effective in reducing the growth of cariogenic bacteria than ordinary toothpaste.

Antibiofilm and Anti-Inflammatory Activities of Houttuynia cordata Decoction for Oral Care

Dental biofilms that form in the oral cavity play a critical role in the pathogenesis of several infectious oral diseases, including dental caries, periodontal disease, and oral candidiasis. Houttuynia cordata (HC, Saururaceae) is a widely used traditional medicine, for both internal and external application. A decoction of dried HC leaves (dHC) has long been consumed as a health-promoting herbal tea in Japan. We have recently reported that a water solution of HC poultice ethanol extract (wHCP) exerts antimicrobial and antibiofilm effects against several important oral pathogens. It also exhibits anti-inflammatory effects on human keratinocytes. In our current study, we examined the effects of dHC on infectious oral pathogens and inflammation. Our results demonstrated that dHC exerts moderate antimicrobial effects against methicillin-resistant Staphylococcus aureus (MRSA) and other oral microorganisms. dHC also exhibited antibiofilm effects against MRSA, Fusobacterium nucleatum (involved in dental plaque formation), and Candida albicans and inhibitory effects on interleukin-8, CCL20, IP-10, and GROα productions by human oral keratinocytes stimulated by Porphyromonas gingivalis lipopolysaccharide (a cause of periodontal disease), without cytotoxic effects. This suggests that dHC exhibits multiple activities in microorganisms and host cells. dHC can be easily prepared and may be effective in preventing infectious oral diseases.

In Vitro Anti-Cariogenic Plaque Effects of Essential Oils Extracted from Culinary Herbs

Introduction

Cariogenic bacteria including mutans streptococci and lactobacilli are partly but significantly involved in dental caries development. An effective prevention strategy against dental caries is to decrease the accumulation of this microbiota either in planktonic or in biofilm form.

Aim

To examine the antimicrobial and anti-plaque effects of some culinary herbs (spices), so the herbs are plausibly used as alternative and effective herbal plaque control supplements to promote good oral health.

Materials and Methods

Essential oils extracted from sweet basil (Ocimum basilicum), cinnamon bark (Cinnamomum zeylanicum), sweet fennel (Foeniculum vulgare), kaffir lime (Citrus hystrix), black pepper (Piper nigrum), peppermint (Mentha piperita), and spearmint (Mentha spicata) were primarily examined for their antimicrobial activities against the cariogenic bacteria (Streptococcus mutans KPSK2 and Lactobacillus casei) using the agar disk diffusion and broth microdilution methods, respectively. These essential oils were then analysed for anti-plaque effects (retardation of S. mutans biofilm formation and reduction of the in vitro established biofilm). This experimental study was performed at the Department of Oral Microbiology, Faculty of Dentistry, Mahidol University during June 2015 till August 2016.

Results

All selected essential oils showed different degrees of antimicrobial activity against the planktonic form of both cariogenic bacteria. Cinnamon bark essential oil expressed the strongest inhibitory effect against S. mutans {MIC of 0.08% (v/v)} and L. casei {MIC of 0.16% (v/v)}, whereas the weakest effect was found in kaffir lime essential oil {MIC values of 2.5% and 5.0% (v/v) for S. mutans and L. casei, respectively}. Up to 80% of S. mutans biofilm was retarded to form on the substratum primed with these spice essential oils, especially cinnamon oil. The preventive effect of these oils was in dose- and exposure time-dependent manners. For reductive effect against the 24-hour pre-established S. mutans biofilm, at least 50% of the biofilm mass was reduced when the biofilm was treated with each essential oil at the MIC for an hour. The reductive effect against the in vitro established S. mutans biofilm of these culinary herb essential oils only depended on the exposure time.

Conclusion

Cinnamon and sweet basil essential oils with impressive in vitro anti-cariogenic bacteria and anti-plaque effects may be proposed as alternative and effective supplements to promote oral health status.

Comparison of the antimicrobial efficacy of chlorhexidine, sodium fluoride, fluoride with essential oils, alum, green tea, and garlic with lime mouth rinses on cariogenic microbes

BACKGROUND

A number of natural mouth rinse formulations are being proposed as an alternative to the widely used chemical mouth rinses.

OBJECTIVE

To evaluate and compare the antimicrobial efficacy of chlorhexidine (0.2%), sodium fluoride (0.05%), fluoride with essential oils (0.05%), alum (0.02 M), green tea, and garlic with lime mouth rinses against Streptococcus mutans, lactobacilli, and Candida albicans.

MATERIALS AND METHODS

The three microbes were isolated from the saliva samples collected from children with severe early childhood caries. The zone of minimum inhibition was assessed using agar diffusion method. The data were statistically analyzed using SPSS software.

RESULTS

Against S. mutans and lactobacilli, chlorhexidine mouth rinse was found to be the most effective as compared to sodium fluoride (P < 0.001, P < 0.001), fluoride with essential oils (P < 0.001, P < 0.001), alum (P < 0.001, P < 0.001), green tea (P < 0.001, P < 0.001), and garlic with lime (P < 0.001, P < 0.001) mouth rinses, respectively. But against C. albicans, garlic with lime mouth rinse was found to be the most effective as compared to chlorhexidine (P < 0.001), sodium fluoride (P < 0.001), fluoride with essential oils (P < 0.001), alum (P < 0.001), and green tea (P < 0.001) mouth rinses. Against S. mutans and lactobacilli, after chlorhexidine mouth rinse, garlic with lime mouth rinse was found to be significantly more effective than sodium fluoride (P = 0.053, P = 0.001), fluoride with essential oils (P < 0.001, P < 0.001), alum (P < 0.001, P < 0.001), and green tea (P < 0.001, P < 0.001) mouth rinses.

CONCLUSION

As a natural mouth rinse, garlic with lime mouth rinse was found to be the most promising. However, further studies are needed in this field.

Antimicrobial Activity of the Essential Oil of Plectranthus neochilus against Cariogenic Bacteria

This work used the broth microdilution method to investigate the antimicrobial activity of the essential oil obtained from the leaves of Plectranthus neochilus (PN-EO) against a representative panel of oral pathogens. We assessed the antimicrobial activity of this oil in terms of the minimum inhibitory concentration (MIC). PN-EO displayed moderate activity against Enterococcus faecalis (MIC = 250 μg/mL) and Streptococcus salivarus (MIC = 250 μg/mL), significant activity against Streptococcus sobrinus (MIC = 62.5 μg/mL), Streptococcus sanguinis (MIC = 62.5 μg/mL), Streptococcus mitis (MIC = 31.25 μg/mL), and Lactobacillus casei (MIC = 31.25 μg/mL), and interesting activity against Streptococcus mutans (MIC = 3.9 μg/mL). GC-FID and GC-MS helped to identify thirty-one compounds in PN-EO; α-pinene (1, 14.1%), β-pinene (2, 7.1%), trans-caryophyllene (3, 29.8%), and caryophyllene oxide (4, 12.8%) were the major chemical constituents of this essential oil. When tested alone, compounds 1, 2, 3, and 4 were inactive (MIC > 4000 μg/mL) against all the microorganisms. These results suggested that the essential oil extracted from the leaves of Plectranthus neochilus displays promising activity against most of the evaluated cariogenic bacteria, especially S. mutans.

Cariostatic effect of green tea in comparison with common anticariogenic agents: an in vitro study

Background and aims. Anticariogenic effects of different mouthrinses have been shown previously. In this in vitro study the anticariogenic effects of polyphenol extract of green tea with 0.05% fluoride, 0.2% chlorhexidine and fluoride-chlorhexidine were compared. Materials and methods. This in vitro study was performed on 50 maxillary premolars in 5 groups: 1) normal saline; 2) a 10% solution of green tea polyphenol extract; 3) 0.05% fluoride; 4) 0.2% chlorhexidine; and 5) fluoride-chlorhexidine. Each tooth was placed in a tube which contained a cariogenic solution. Every day the teeth were washed (depending on the experimental groups) with 5 mL of mouthrinse solution. The depth of the caries was measured under a polarized light microscope. Data were analyzed using SPSS 13.0 with Kolmogorov-Smirnov, one-way ANOVA and Tukey tests. Results. The mean and standard deviation (in µm) of caries depth were 194±16.43, 175±17.94, 142±9.34, 155±13.27, and 144±8.57 in groups 1 to 5, respectively, with significant differences between the groups (P<0.001). Tukey test showed that although there was no significant difference in the depth of caries in groups 1 and 2 (P>0.001), they were significantlyless than those in groups 3 to 5 (P<0.001). There was no significant difference between decay depth of groups 3, 4 and 5 (P>0.001). Conclusion. The anticariogenic effect of fluoride-chlorhexidine was the highest among the groups. Although green tea showed higher cariostatic effects than normal saline, in comparison with other mouthrinses, it is less effective. More re-search is strongly recommended for clinical use of green tea as an anticariogenic agent.