Chlorhexidine: is it still the gold standard?

Effects of three approaches to standardized oral hygiene to reduce bacterial colonization and ventilator associated pneumonia in mechanically ventilated patients: a randomised control trial

BACKGROUND

Ventilator associated pneumonia remains an important concern in the intensive care unit (ICU). An increasing body of evidence shows that mortality and morbidity can be reduced by implementing a range of preventive strategies, including optimizing oral hygiene.

AIM

The aim of this feasibility study was to test two oral hygiene strategies on the effects of microbial colonization of dental plaque with respiratory pathogens (primary outcome) and incidence of ventilator associated pneumonia (secondary outcome).

METHODS

A single blind randomised comparative study was conducted in a 20-bed adult intensive care unit in a university hospital. Patients with an expected duration of mechanical ventilation more than 48 h were eligible. Patients were randomised to one of three study regimens (Group A control, second hourly oral rinse with sterile water, Group B sodium bicarbonate mouth wash second hourly, and Group C twice daily irrigations with chlorhexidine 0.2% aqueous oral rinse and second hourly irrigations with sterile water). All study options included cleaning with a toothbrush and non foaming toothpaste.

RESULTS

Data from a total of 109 patients were analyzed. Group A 43, Group B 33 and Group C 33 (mean age: 58 ± 17 years, simplified acute physiology score II: 44 ± 14 points). On admission no significant differences were found between groups for all clinical data. While Group B showed a greater trend to reduction in bacterial colonization no significant differences could be demonstrated at Day 4 of admission (p=0.302). The incidence of ventilator associated pneumonia was evenly spread between Groups B and C (5%) while Group A was only 1%.

CONCLUSIONS

While a number of studies have advocated the use of various mouth rinses in reducing colonization of dental plaque a standardized oral hygiene protocol which includes the use of mechanical cleaning with a toothbrush may be a factor in the reduction of colonization of dental plaque with respiratory pathogens. This feasibility study provides data to inform future adequately powered studies.

Efficacy of concurrent application of chlorhexidine gluconate and povidone iodine against six nosocomial pathogens

BACKGROUND

Chlorhexidine gluconate (CHG) and povidone iodine (PI) are rarely used concurrently despite a lack of evidence regarding functional incompatibility of these agents.

METHODS

CHG and PI, alone and combined, were evaluated against Staphylococcus aureus (methicillin-susceptible S aureus [MSSA] and methicillin-resistant S aureus [MRSA]), Staphylococcus epidermidis (MRSE), Acinetobacter baumannii, Pseudomonas aeruginosa, and Escherichia coli using checkerboard microbroth dilution techniques. Minimum bactericidal concentration (MBC) was the concentration (percent wt/vol) that reduced bacterial burden ≥ 5-log(10) colony-forming units/mL at 2 hours when compared with bacterial densities in growth controls. Fractional bactericidal concentration indexes (FBCIs) were calculated to determine CHG and PI compatibility. Additionally, tissue plugs from freshly excised porcine vaginal mucosa were infected with S aureus (MSSA), treated for 2 hours with CHG 3%, PI 5%, or CHG 3% and PI 5% combined and then viable bacteria on the tissue plugs enumerated.

RESULTS

In broth, CHG demonstrated dose-dependent bactericidal activity, whereas PI activity was all-or-none. All isolates studied were similarly susceptible to CHG (MBCs: 0.0078% ± 0.0019%, 0.0069% ± 0.0026%, 0.0024% ± 0.0005%, 0.0024% ± 0.0005%, 0.0059% ± 0.0%, and 0.0029% ± 0.0%, respectively). The MBCs of PI were identical (0.625%) for all isolates. Overall, FBCI calculations showed indifference. Treatment of MSSA-infected porcine tissue for 2 hours demonstrated that the CHG-PI combination was superior to either antiseptic alone.

CONCLUSION

FBCIs, determined in broth culture, indicate that combining CHG and PI had no negative impact on antisepsis. Moreover, data from an ex vivo porcine mucosal infection model suggest a potential benefit when combining the 2 antiseptic agents.

Clinical and microbiological evaluation of the use of toothpaste containing 1% chlorhexidine and the influence of motivation on oral hygiene in patients with motor deficiency

Patients with motor deficiency have variable difficulties with mechanical plaque control, and as a consequence, the incidence of dental caries and periodontal disease can be higher in these patients. The objective of this study was to evaluate the clinical and microbiological efficacy of a toothpaste containing 1% chlorhexidine, which was used by patients with motor deficiency for 14 days. The reduction in plaque and gingival index and the impact on salivary microorganisms was evaluated. We conclude that the motivation of caregivers to carry out oral hygiene for patients with mental and motor deficiency is of great importance and is effective in reducing the formation of plaque as long as it is continuously reinforced. The use of chlorhexidine-containing toothpaste significantly reduced the plaque index and microorganism count between days 0 and 14. A reduction was also observed in the group that used a dentifrice without the chlorhexidine, but this difference was not significant.

Comparing the effects of chlorhexidine and persica on alveolar bone healing following tooth extraction in rats, a randomised controlled trial

Chlorhexidine is broadly prescribed by clinicians for treating extraction socket wounds; however, studies have reported adverse effects for chlorhexidine. Persica, a herbal antibacterial agent, could be an alternative for chlorhexidine. The aim of this randomised controlled trial was to investigate the effects of persica and chlorhexidine on alveolar bone healing following tooth extraction in rats. Eighteen Wistar rats were randomly allocated to three study groups: 0.2% chlorhexidine, 10% persica and controls (tap water). The rats were mouth-rinsed for 14 days. On day 8, the mandibular right first molars of all the rats were extracted. On day 21, the rats were euthanized and histological slides of their extraction sockets were prepared. The amount of new bone formation and the number of inflammatory cells in the extraction socket for each rat were recorded. Data were analysed using linear regression and Mann-Whitney tests. There was no significant difference between the control group and the intervention groups in terms of new bone formation and inflammatory cell count. The mean new bone formation was significantly higher in the persica group than in the chlorhexidine group. There was a significant association between new bone formation and inflammatory cell count in the entire sample. In conclusion, there were no significant differences between rinsing with tap water and rinsing with 0.2% chlorhexidine and 10% persica in enhancing extraction socket wound healing in rats. Extraction socket wound healing in rats was better enhanced with 10% persica than 0.2% chlorhexidine.

Clinical evaluation of polyvinylpyrrolidone sodium hyaluronate gel and 0.2% chlorhexidine gel for pain after oral mucosa biopsy: a preliminary study

PURPOSE

To study the symptoms of patients during the 7 days after incisional biopsy of the oral mucosa and the application of polyvinylpyrrolidone-sodium hyaluronate (Aloclair) gel or 0.2% chlorhexidine digluconate gel.

MATERIALS AND METHODS

A total of 90 consecutive patients with lesions requiring histopathologic analysis were studied. These patients were divided randomly into 3 groups. Group I (control group) received no topical treatment. For group II, the site of surgical intervention was treated topically with polyvinylpyrrolidone sodium hyaluronate (Aloclair; Sinclair Pharma, Surrey, United Kingdom) gel 3 times daily for 1 week. Group III was treated the same as group II but with 0.2% chorhexidine digluconate gel. Using a visual analog scale, we determined the interval at which the postoperative pain was maximal, and which parts of the mouth experienced the most postoperative complications.

RESULTS

The most intense peaks of maximal pain were recorded in the control group, with the maximal pain occurring 2 hours (median 2.2, range 0 to 8.5) after surgery, after which it tended to diminish gradually during the week of the study period. The maximal level of pain was significantly lower in groups II and III than in the control group (P = .048 and P = .054, respectively). The lip was the site most likely to experience maximal pain.

CONCLUSION

Topical application of polyvinylpyrrolidone sodium hyaluronate and chlorhexidine digluconate decreases the symptoms of oral mucosa biopsy.

[Mouthwash solutions containing microencapsuled natural extracts: In vitro evaluation of antioxidant properties (dental plaque and gingivitis)]

INTRODUCTION

New mouthwash solutions containing microencapsulated natural extracts were developed to provide both antiseptic activity and in depth treatment of oral tissues, due to their antioxidant and immunoregulatory properties. The objective of this study was to quantify the antioxidant action of the GingiNat solution (LoB5 Foundation, Paris, France) in an in vitro cell model.

MATERIALS AND METHODS

Diluted GingNat solutions (0.12%, 0.06% and 0.012%) were put in contact with Jurkat type human lymphoid cells in basal radical state (cells at rest) and in provoked oxidative stress conditions (after an UVA+UVB irradiation). The lipid peroxidation was quantified by flow cytometry using a fluorescent probe.

RESULTS

The diluted GingNat solutions at 0.12%, 0.06%, and 0.012% showed a significant antioxidant effect with respectively 122.9%, 117.8% and 119.3% on average. The difference was statistically significant compared to controls for the three concentrations without any significant difference among them. This antioxidant effect was even more significant when cells were in oxidative stress with respectively 155.3%, 139.3%, and 132.5% on average. There was a significant difference between the tested concentrations (p<0.01).

DISCUSSION

These first in vitro results confirmed the antioxidant properties of the GingiNat solution. These antioxidant properties are significantly higher at stronger concentrations. Further studies are required to analyze the influence of microencapsulation on these results. Clinical trials are needed to confirm these antioxidant properties.

Prospective clinical study evaluating the long-time adjunctive use of chlorhexidine after one-stage full-mouth SRP

OBJECTIVES

Scaling and root planing are the causal procedure in the treatment of periodontitis. Many attempts have been made to improve the outcome. The aim of this study was to verify the influence of the extended use of chlorhexidine after one-stage full-mouth (FM) SRP in patients with chronic periodontitis on the clinical outcome after 3 months.

METHODS

Eighty-one patients with pockets > or =5 mm were treated by FM. All patients rinsed additionally with 0.2% chlorhexidine (CHX) twice daily over 3 months. Plaque index, bleeding on probing, probing depth (PD) and clinical attachment level (CAL) were recorded at baseline and after 1 and 3 months.

RESULTS

In the test group, all variables were significantly improved after 1 and 3 months. Mean reduction of PD and CAL gain was 2.25 +/- 1.08 and 1.67 +/- 1.08 after 1 and 2.99 +/- 1.11 and 2.33 +/- 1.31 after 3 months respectively.

CONCLUSIONS

Over 3 months of extended use of CHX mouth rinse after SRP showed slightly but statistically significant better results.

Periodontal management of a patient with severe aplastic anemia: a case report

This article describes the periodontal management of a patient with severe aplastic anemia. A 51-year-old female patient was hospitalized with aplastic anemia and was referred for the management of her cyclosporine-induced gingival enlargement and bleeding from her gums. She also complained of pain in the palatal area and the mandibular anterior region. The patient was managed successfully with supra- and subgingival instrumentation, local drug delivery (LDD), electrosurgery, repeated oral hygiene instruction, and constant supervision. The treatment resulted in dramatic improvement in the patient's oral health and quality of life. This report highlights the importance of nonsurgical therapy followed by electrosurgery for the management of residual gingival enlargement.

Taste coding after selective inhibition by chlorhexidine

Coding of the complex tastes of ionic stimuli in humans was studied by combining taste confusion matrix (TCM) methodology and treatment with chlorhexidine gluconate. The TCM evaluates discrimination of multiple stimuli simultaneously. Chlorhexidine, a bis-biguanide antiseptic, reversibly inhibits salty taste and tastes of a subset of bitter stimuli, including quinine hydrochloride. Identifications of salty (NaCl, "salt"), bitter (quinine.HCl, "quinine"), sweet (sucrose, "sugar"), and sour (citric acid, "acid") prototypes, alone and as components of binary mixtures, were measured under 4 conditions. One was a water-rinse control and the others had the salt and quinine tastes progressively reduced by treatment with 1 mM chlorhexidine, 3 mM chlorhexidine, and ultimately to zero by elimination of NaCl and quinine.HCl. Treatment with chlorhexidine perturbed identification of salt more than quinine; both were thereafter more often confused with "water" and unidentified when mixed with sucrose or citric acid. All pairwise discriminations that depended on the tastes of NaCl and quinine.HCl deteriorated, and although H(2)O was mistakenly identified as quinine after chlorhexidine, this may have been a decisional bias. Other confusions reflected "unprompted mixture analysis" and an obscuring of salt taste by a less-inhibited stronger quinine or sugar or acid tastes in mixtures. Partial inhibition of the tastes of NaCl and quinine.HCl by chlorhexidine was considered in the context of multiple receptors for the 2 compounds. Discrimination among prototypic stimuli with varying strengths was consistent with a gustatory system that evaluates a small number of independent tastes.

Activity of panduratin A isolated from Kaempferia pandurata Roxb. against multi-species oral biofilms in vitro

The formation of dental biofilm caused by oral bacteria on tooth surfaces is the primary step leading to oral diseases. This study was performed to investigate the preventive and reducing effects of panduratin A, isolated from Kaempferia pandurata Roxb., against multi-species oral biofilms consisting of Streptococcus mutans, Streptococcus sanguis and Actinomyces viscosus. Minimum inhibitory concentration (MIC) of panduratin A was determined by the Clinical and Laboratory Standards Institute (CLSI) broth microdilution assay. Prevention of biofilm formation was performed on 96-well microtiter plates by coating panduratin A in mucin at 0.5-40 microg/ml, followed by biofilm formation at 37 degrees C for 24 h. The reducing effect on the preformed biofilm was tested by forming the biofilm at 37 degrees C for 24 h, followed by treatment with panduratin A at 0.2-10 microg/ml for up to 60 min. Panduratin A showed a MIC of 1 microg/ml for multi-species strains. Panduratin A at 2 x MIC for 8 h exhibited bactericidal activity against multi-species planktonic cells for 8 h. At 8 x MIC, panduratin A was able to prevent biofilm formation by > 50%. Biofilm mass was reduced by > 50% after exposure to panduratin A at 10 microg/ml for 15 min. Panduratin A showed a dose-dependent effect in preventing and reducing the biofilm. These results suggest that panduratin A is applicable as a natural anti-biofilm agent to eliminate oral bacterial colonization during early dental plaque formation.

Bacteriostatic effect of Piper betle and Psidium guajava extracts on dental plaque bacteria

In this study, the bacteriostatic effect of Piper betle and Psidium guajava extracts on selected early dental plaque bacteria was investigated based on changes in the doubling time (g) and specific growth rates (micro). Streptococcus sanguinis, Streptococcus mitis and Actinomyces sp. were cultured in Brain Heart Infusion (BHI) in the presence and absence of the extracts. The growth of bacteria was monitored periodically every 15 min over a period of 9 h to allow for a complete growth cycle. Growth profiles of the bacteria in the presence of the extracts were compared to those in the absence and deviation in the g and micro were determined and analyzed. It was found that the g and mu were affected by both extracts. At 4 mg mL(-1) of P. betle the g-values for S. sanguinis and S. mitis were increased by 12.0- and 10.4-fold, respectively (p < 0.05). At similar concentration P. guajava increased the g-value by 1.8- and 2.6 -fold, respectively (p < 0.05). The effect on Actinomyces sp. was observed at a much lower magnitude. It appears that P. betle and P. guajava extracts have bacteriostatic effect on the plaque bacteria by creating a stressed environment that had suppressed the growth and propagation of the cells. Within the context of the dental plaque, this would ensure the attainment of thin and healthy plaque. Thus, decoctions of these plants would be suitable if used in the control of dental plaque.

Sodium fluoride and chlorhexidine effect in the inhibition of mutans streptococci in children with dental caries: a randomized, double-blind clinical trial

OBJECTIVE

We aimed to compare the effect of sodium fluoride and chlorhexidine on salivary levels of mutans streptococci (MS), in a double-blind, randomized clinical trial.

METHODS

Thirty-five healthy volunteers, aged 4-8 years, with at least one active carious lesion and no previous history of allergies were selected to participate in the study. A gel formulation containing either 1.23% sodium fluoride or 1% chlorhexidine was topically administered to the dentition every 24 h for 6 consecutive days. Salivary MS levels were measured at baseline (D1) and on the 6th (D6), 15th (D15), and 30th (D30) days. For microbiological analysis, Mitis Salivarius-Bacitracin agar medium was used.

RESULTS

Difference between treatments was only verified on D6. On the last day of treatment 1% chlorhexidine gel was significantly more effective than fluoride (P = 0.0000). The use of sodium fluoride did not cause a statistically significant variation in salivary MS levels throughout the duration of the study. Following treatment, a subsequent increase in MS counts between D6 and D15 (P = 0.0001) was observed with chlorhexidine.

CONCLUSION

A 6-day treatment with a 1% chlorhexidine gel was effective in reducing salivary MS; there was a significant MS increase once treatment was suspended. The use of 1.23% sodium fluoride under the same regimen was not able to reduce salivary MS levels. Our results suggest repeated treatment with 1% chlorhexidine as a means for maintaining low salivary MS levels in children with dental caries.

Chlorine dioxide and chlorhexidine mouthrinses compared in a 3-day plaque accumulation model

BACKGROUND

The aim of this study was to investigate the inhibiting effect of a chlorine dioxide mouthrinse as opposed to a mouthrinse containing chlorhexidine (0.20%) during 3 days of plaque accumulation.

METHODS

At baseline, all participants (N=77) received a professional prophylaxis and were randomly assigned to the test (chlorine dioxide) or (positive) control (chlorhexidine) group. On the following 3 days, both groups rinsed twice daily for 1 minute with 10 ml test or control solution. At the end of the experimental period, plaque was assessed, and the panelists filled out a questionnaire.

RESULTS

Chlorhexidine inhibited plaque growth significantly more than the mouthrinse containing chlorine dioxide (plaque index=1.39 versus 1.96, respectively; P<0.001). The results of the questionnaire showed that the panelists found chlorhexidine easier to use and more effective. However, they preferred the taste of the chlorine dioxide mouthrinse and experienced less taste alterations.

CONCLUSION

Chlorine dioxide mouthrinse seems to be a less potent plaque inhibitor than chlorhexidine.

The effects of an essential oil and an amine fluoride/stannous fluoride mouthrinse on supragingival plaque regrowth

BACKGROUND

The side effects of chlorhexidine (CHX) have stimulated the search for alternative antiplaque agents such as amine fluoride/stannous fluoride (ASF) and essential oils (EO). The aim of the study was to investigate the plaque-inhibiting effects of two commercially available mouthrinses containing ASF and EO, respectively.

METHODS

The study was an observer-masked, randomized, 5 x 5 Latin square cross-over design, balanced for carryover effects, involving 15 volunteers in a 4-day plaque regrowth model. A 0.12% CHX rinse and a saline solution served as positive and negative controls, respectively. On day 1, subjects received professional prophylaxis, suspended oral hygiene measures, and commenced rinsing with their allocated rinses. On day 5, subjects were scored for disclosed plaque. The ASF rinse was tested at two dosages: 10 and 20 ml (ASF-10 and ASF-20, respectively).

RESULTS

The ASF and EO rinses showed a significant inhibition of plaque regrowth compared to saline (P <0.0001), but the lowest plaque indices were obtained with the CHX product (P <0.01). There were no significant differences among products containing ASF-10, ASF-20, and EO (P >0.05). There was no correlation between the occurrence of side effects and the use of a particular rinse product (P >0.2).

CONCLUSIONS

ASF and EO mouthrinses exerted effective and similar plaque inhibition. The two dosages tested for ASF did not differ in plaque reduction. These findings, together with those from long-term trials, suggest that ASF and EO rinses may represent effective alternatives to CHX rinse as adjuncts to oral hygiene.

Chlorhexidine with an anti discoloration system after periodontal flap surgery: a cross-over, randomized, triple-blind clinical trial

The use of chlorhexidine (CHX) has been recommended for a number of clinical applications including plaque control in the post-operative period. However, the use of CHX is burdened by some side effects that could affect the compliance of the patient. The aim of this clinical trial was to evaluate the side effects, the staining in particular, the patient acceptance, and the efficacy of a 0.2% CHX mouthwash containing an anti discoloration system (ADS) compared with a 0.2% CHX alone, after periodontal flap surgery.

MATERIAL AND METHODS

This single-centre, cross-over, triple-blind randomized clinical trial was carried out on 48 consecutive patients. After periodontal flap surgery, the patients were prescribed to rinse two times per day for 1 min for 1 week with 10 ml of test or control CHX, contained in anonymous bottles coded K or M and assigned randomly. No brushing and interdental cleaning of the surgical area was allowed. At week 1, after suture removal, patients received full-mouth prophylaxis and were given a second anonymous bottle, reversing the products, with the same instructions as at baseline. Patients resumed tooth-brushing but not interdental cleaning. At the end of week 2, prophylaxis was repeated, mouth rinsing was discontinued and patients resumed normal oral hygiene. At weeks 1 and 2, the following variables were recorded: presence of pigmentation, gingival parameters at the surgically treated sites (gingival inflammation, tissue inflammation around the sutures, gingival swelling and presence of granulation tissue), patient perception and acceptance of the 2 mouthwashes.

RESULTS

Forty-seven patients completed the study. The difference between treatments related to gingival variables was not statistically significant. The test CHX caused consistently less pigmentations than the control CHX in all the evaluated areas of the dental surfaces (odds ratio (OR)=0.083 p<0.0001 in the incisal area, OR=0.036 p<0.0001 in the approximal area and OR=0.065 p<0.0001 in the gingival area). The CHX ADS was found to be more tolerated by patients than the control mouthwash and to cause less food alteration, less alterations to the perception of salt and to be less irritant for the oral tissues.

CONCLUSIONS

(1) CHX ADS caused less pigmentation, was burdened by less side effects and was more agreeable than the control CHX; (2) CHX ADS was as effective as CHX without ADS in reducing gingival signs of inflammation in the post-surgical early healing phase; (3) the use of CHX ADS could be of value in treatment protocols in which the patient compliance with a CHX mouthwash prescription is relevant.

A review of the current literature on management of halitosis

Halitosis is an unpleasant or offensive odour, emanating from the oral cavity. In approximately 80% of all cases, halitosis is caused by microbial degradation of oral organic substrates. Major degradation products are volatile sulphur-containing compounds. In this review, the available management methods of halitosis and their effectiveness and significance are presented and discussed. Undoubtedly, the basic management is mechanically reducing the amount of micro-organisms and substrates in the oral cavity. Masking products are not, and antimicrobial ingredients in oral healthcare products are only temporary effective in reducing micro-organisms or their substrates. Good short-term results were reported with chlorhexidine. Triclosan seems less effective, essential oils and cetylpyridinium chloride are only effective up to 2 or 3 h. Metal ions and oxidizing agents, such as hydrogen peroxide, chlorine dioxide and iminium are active in neutralizing volatile sulphur-containing compounds. Zinc seems to be an effective safe metal at concentrations of at least 1%. The effectiveness of active ingredients in oral healthcare products is dependent on their concentration and above a certain concentration the ingredients can have unpleasant side effects. Tonsillectomy might be indicated if (i) all other causes of halitosis are managed properly; (ii) halitosis still persists and (iii) crypts in tonsils are found to contain malodorous substrates.

Effect of food preservatives on in situ biofilm formation

The aim of this double-blind, controlled crossover study was to evaluate the influence of food preservatives on in situ dental biofilm growth. Twenty-four volunteers wore appliances with six specimens each of bovine enamel to build up intra-oral biofilms. During three test cycles, the subjects had to put one half of the appliance twice a day in one of the assigned active solutions (0.1% benzoate, BA; 0.1% sorbate, SA or 0.2% chlorhexidine, CHX) and the other into NaCl. After 5 days, the developed biofilms were stained with two fluorescent dyes to visualise vital (green) and dead bacteria (red). Biofilms were scanned by confocal laser scanning microscopy and biofilm thickness (BT) and bacterial vitality (BV%) were calculated. After a washout period of 7 days, a new test cycle was started. The use of SA, BA and CHX resulted in a significantly reduced BT and BV compared to NaCl (p<0.001). Differences between SA and BA were not significant (p>0.05) for both parameters, while CHX showed significantly lower values. Both preservatives showed antibacterial and plaque-inhibiting properties, but not to the extent of CHX. The biofilm model enabled the examination of undisturbed oral biofilm formation influenced by antibacterial components under clinical conditions.

Efficacy of two alcohol-free cetylpyridinium chloride mouthwashes - a randomized double-blind crossover study

AIM

(1) To determine the plaque inhibition properties of two formulations of alcohol-free mouthwash [0.1% w/w cetylpyridinium chloride (CPC) (B) and 0.05% w/w CPC (A)] versus a placebo mouthwash (C). (2) To compare the plaque-inhibiting activity between these two new CPC mouthwashes.

MATERIAL AND METHODS

A double-blind, crossover study with three 1-week periods was used. Subjects were randomly assigned to one of the following groups. Group 1 (n=10) received the mouthwashes A, C and B in the periods 1, 2 and 3, respectively, group 2 (n=11) received the mouthwashes in the order B, A, C, while group 3 (n=11) received the mouthwashes in the order C, B, A. Mean plaque areas and Quigley & Hein plaque index scores were analysed using anova (analysis of variance). Measurements were made at the start of each period (baseline) and at 16, 24 and 40 h.

RESULTS

Mean plaque scores were similar across the groups at baseline. At all time points thereafter, volunteers using mouthwash A or B had significantly lower plaque areas and plaque index scores than those using mouthwash C (p<0.05), but there were no significant differences between the test formulations. At 16 h, the reduction in plaque area relative to mouthwash C was 22% for mouthwash A and 18% for mouthwash B; at 24 h, 11% for mouthwash A and 15% for mouthwash B; and at 40 h, 15% for mouthwash A and 16% for mouthwash B.

CONCLUSIONS

The use of both CPC mouthwashes resulted in less plaque accumulation compared with the control. There was no statistically significant difference in plaque accumulation between the two CPC mouthwashes.

Systematic Literature Review of Oral Hygiene Practices for Intensive Care Patients Receiving Mechanical Ventilation

Background Oropharyngeal colonization with pathogenic organisms contributes to the development of ventilator-associated pneumonia in intensive care units. Although considered basic and potentially nonessential nursing care, oral hygiene has been proposed as a key intervention for reducing ventilator-associated pneumonia. Nevertheless, evidence from randomized controlled trials that could inform best practice is limited.

Objective To appraise the peer-reviewed literature to determine the best available evidence for providing oral care to intensive care patients receiving mechanical ventilation and to document a research agenda for this important activity in optimizing patients’ outcomes.

Methods Articles published from 1985 to 2006 in English and indexed in the CINAHL, MEDLINE, Joanna Briggs Institute, Cochrane Library, EMBASE, and DARE databases were searched by using the key terms oral hygiene, oral hygiene practices, oral care, mouth care, mouth hygiene, intubated, mechanically ventilated, intensive care, and critical care. Reference lists of retrieved journal articles were searched for publications missed during the primary search. Finally, the Google search engine was used to do a comprehensive search of the World Wide Web to ensure completeness of the search. The search strategy was verified by a health librarian.

Results The search yielded 55 articles: 11 prospective controlled trials, 20 observational studies, and 24 descriptive reports. Methodological issues and the heterogeneity of samples precluded meta-analysis.

Conclusions Despite the importance of providing oral hygiene to intensive care patients receiving mechanical ventilation, high-level evidence from rigorous randomized controlled trials or high-quality systematic reviews that could inform clinical practice is scarce.

The long-term effect of a mouthrinse containing essential oils on dental plaque and gingivitis: a systematic review

BACKGROUND

The purpose of this study was to review the literature on the effects of a mouthrinse containing essential oils (EO) on plaque and parameters of gingival inflammation.

METHODS

The MEDLINE and Cochrane Central Register of Controlled Trials were searched up to and including December 2006 to identify appropriate studies. The primary outcome measure was gingivitis. Secondary parameters were plaque and, when reported, staining.

RESULTS

Independent screening of titles and abstracts of 566 papers resulted in 11 publications that met the criteria of eligibility. In all studies, EO was used as an adjunct to regular daily toothbrushing. A statistically significant reduction in overall gingivitis was noted compared to the control (weighted mean difference [WMD]: -0.32, 95% confidence interval [CI]: -0.46 to -0.19, P <0.00001; test for heterogeneity: P <0.00001, I(2) = 96.7%). For interproximal sites the use of the test mouthrinse resulted in significantly more gingivitis reduction compared to control mouthrinse (WMD: -0.29, 95% CI: -0.48 to -0.11, P = 0.002; test for heterogeneity: P <0.00001, I(2) = 95.18%), whereas no differences were observed compared to dental floss. With respect to plaque scores, EO produced significant overall reductions in plaque (WMD: -0.83, 95% CI: -1.13 to -0.53, P <0.00001; test for heterogeneity: P <0.00001, I(2) = 96.1%). Separate analysis for interproximal areas revealed that EO resulted in more pronounced plaque drops compared to the control mouthrinse (WMD: -1.02, 95% CI: -1.44 to -0.60, P <0.00001; test for heterogeneity: P <0.00001, I(2) = 96.1%) or the use of floss (WMD: -0.75, 95% CI: -1.15 to -0.363, P <0.0002; test for heterogeneity: P <0.0002, I(2) = 93.0%). Most studies agreed that EO did not produce more staining than the control products.

CONCLUSION

When used as an adjunct to unsupervised oral hygiene, EO provides an additional benefit with regard to plaque and gingivitis reduction as compared to a placebo or control.

Hop bract polyphenols reduced three-day dental plaque regrowth

Previous research has shown the inhibitory effects of hop bract polyphenols (HBP) on cariogenic streptococci in vitro, but their effects in humans have not been investigated. This double-blind, crossover clinical study tested the hypothesis that HBP delivered in a mouthrinse suppresses plaque regrowth in humans. Twenty-nine healthy male volunteers had all plaque removed, and refrained from all oral hygiene for 3 days, except for rinsing with a mouthrinse containing 0.1% HBP or a placebo. The results showed that the mean amount of plaque assessed by the Patient Hygiene Performance score after the volunteers used the HBP mouthrinse was significantly less than that after they used the placebo (p < 0.001). The number of mutans streptococci in the plaque samples after volunteers used the HBP mouthrinse was significantly lower than that after they used the placebo (p < 0.05). These findings suggested that HBP, delivered in a mouthrinse, successfully reduced dental plaque regrowth in humans.

The clinical efficacy of triclosan/copolymer and other common therapeutic approaches to periodontal health

The maintenance of an effective level of oral hygiene is the cornerstone of all attempts to prevent and control periodontal disease, and yet the widespread prevalence of the disease indicates the inability of most people to maintain a level of plaque control commensurate with periodontal health. The inclusion of antibacterial agents, such as chlorhexidine and triclosan, in oral care products has provided a means to improve oral health. Randomised, controlled clinical trials have demonstrated that the unsupervised use of a dentifrice (toothpaste) containing triclosan/copolymer significantly improves gingival health, prevents the onset of periodontitis and reduces further progression of tissue destruction. The delivery of such benefits has positive implications for the oral health of individuals and populations.

Risks and complications of orthodontic miniscrews

The risks associated with miniscrew placement should be clearly understood by both the clinician and the patient. Complications can arise during miniscrew placement and after orthodontic loading that affect stability and patient safety. A thorough understanding of proper placement technique, bone density and landscape, peri-implant soft-tissue, regional anatomic structures, and patient home care are imperative for optimal patient safety and miniscrew success. The purpose of this article was to review the potential risks and complications of orthodontic miniscrews in regard to insertion, orthodontic loading, peri-implant soft-tissue health, and removal.

Biofilm formation on surface characterized micro-implants for skeletal anchorage in orthodontics

Micro-implants are increasingly popular in clinical orthodontics to effect skeletal anchorage. However, biofilm formation on their surfaces and subsequent infection of peri-implant tissues can result in either exfoliation or surgical removal of these devices. The present study aimed to assess biofilm formation on five commercially available, surface characterized micro-implant systems in vitro. The elemental surface compositions of as-received and autoclave-sterilized micro-implants were characterized by X-ray photoelectron spectroscopy. High carbon contamination was detected on the oxide surfaces, along with traces of inorganic elements (Ca, Cu, Cr, Pb, Zn, and P) which disappeared after Ar(+) ion sputtering. The mean surface roughnesses (R(a)) were around 182nm for titanium micro-implants, and 69nm for stainless steel micro-implants, as measured by atomic force microscopy. Scanning electron microscopy revealed different surface topographies between manufacturers, varying from typical machined grooves to structural defects like pores and pits. Overnight biofilms were grown on micro-implant surfaces by immersion in pooled human whole saliva. Biofilms on micro-implants treated with chlorhexidine and fluoride mouthrinses contained comparable numbers of viable organisms, but significantly less than did untreated micro-implants. Comparison of different implant systems using multiple linear regression analysis indicated that biofilm formation was governed by roughness of the implant surface and the prevalence of carbon- and oxygen-rich components.

Effect of local antimicrobial agents on excisional palatal wound healing: a clinical and histomorphometric study in rats

AIM

To assess the effect of topically applied antimicrobial agents on palatal excisional wound in rats.

MATERIALS AND METHODS

Excisional wounds, 5 mm in diameter, were made in the centre of the palate of 125 Wistar male rats. In four experimental groups, chlorhexidine digluconate (CHX) 0.12% solution, 1% CHX gel, phenolic compounds solution (Listerine), amine/stannous fluoride solution (Meridol) and saline solution as a control group were applied daily for 1 min. The wound area was measured photographically and the epithelialization rate was determined histologically at 3, 7, 14 and 21 days post-surgery.

RESULTS

The mean wound area and mean distance between the epithelial margins decreased significantly with time (p<0.001) in experimental and control groups, with the greatest wound area reduction and rate of epithelialization on day 14. A significantly superior rate of wound epithelialization (p=0.03) was presented following use of 1% CHX gel and Listerine and a comparatively inferior one when the Meridol solution was applied.

CONCLUSIONS

Each tested antimicrobial agent when applied on an excisional wound with epithelial and connective tissue deficiency did not have a negative effect on the rate of wound closure. The best results were achieved with 1%CHX gel and Listerine.

The use of temporary anchorage devices for molar intrusion

BACKGROUND

This article reviews the use of temporary anchorage devices (TADs) for maxillary molar intrusion.

TYPES OF STUDIES REVIEWED

The authors reviewed clinical, radiographic and histologic studies and case reports. The studies provided information regarding the application, placement and biological response of orthodontic TADs.

RESULTS

TAD-supported molar intrusion is controlled and timely and may be accomplished without the need for full-arch brackets and wires. Supraerupted maxillary first molars can be intruded 3 to 8 millimeters in 7.5 months (approximately 0.5-1.0 mm per month), without loss of tooth vitality, adverse periodontal response or radiographically evident root resorption.

CLINICAL IMPLICATIONS

True molar intrusion can be achieved successfully with orthodontic TADs, re-establishing a functional posterior occlusion and reducing the need for prosthetic crown reduction.

The effect of 0.12% chlorhexidine dentifrice gel on plaque accumulation: a 3-day non-brushing model

BACKGROUND

Maintaining an adequate low level of plaque through daily tooth brushing is often not feasible. Effective chemotherapeutic agents as an adjunct to mechanical plaque control would therefore be valuable. Chlorhexidine (CHX) mouthwash has proved to be an effective inhibitor of plaque accumulation.

AIM

The purpose of the present study was to assess the effect of application of 0.12% CHX dentifrice gel on de novo plaque accumulation.

MATERIAL AND METHODS

The study was designed as a single blind, randomized three-arm parallel clinical trial. At the beginning of the test period all volunteers received a thorough professional oral prophylaxis. Subjects were randomly assigned to one of three regimens. During a 3-day non-brushing period, subjects abstained from all forms of mechanical oral hygiene. One regimen (test group) used 0.12% chlorhexidine dentifrice gel (CHX-DGel, Perio.Aid) applied in a fluoride gel tray, the benchmark control group used a regular dentifrice applied in a fluoride gel tray (RegD, Everclean HEMA). The positive control group rinsed with a 0.12% chlorhexidine mouthwash (CHX-MW, Perio.Aid). The Quigley and Hein plaque index (PI) from all subjects was assessed after 3 days of de novo plaque accumulation. Subsequently, all subjects received a questionnaire to evaluate their attitude, appreciation and perception towards the products used employing a Visual Analogue Scale scores. After the experimental period, habitual oral hygiene procedures were resumed.

RESULTS

Ninety-six systemically healthy subjects completed the study. After 3 days, the full-mouth PI for the CHX-DGel regimen was 1.87 compared with 1.93 for the RegD regimen and 1.55 for the CHX-MW regimen. The two dentifrices (CHX-DGel and RegD) were significantly less effective as the CHX-MW (P=0.0006). No significant difference between scores of the dentifrices was found.

CONCLUSION

Within the limitations of the present 3-day non-brushing study design, it can be concluded that application of 0.12% CHX dentifrice gel is not significantly different from application of regular dentifrice on plaque accumulation. Use of a 0.12% CHX mouthwash is significantly more effective. CHX-DGel appears a poor alternative for a dentifrice. It is not an effective inhibitor of plaque growth and does not possess fluoride.

Effect of coating the wells of a polystyrene microtiter plate with xanthorrhizol on the biofilm formation of Streptococcus mutans

Colonization on the surface of tooth by Streptococcus mutans is an important step in the initiation of dental plaque. Polystyrene microtiter plates have been employed to study bacterial colonization and biofilm formation of periodontal bacteria. The objective of this work was to evaluate the effect of coating the wells of a polystyrene microtiter plate with xanthorrhizol isolated from java turmeric (Curcuma xanthorrhiza Roxb.) on Strep. mutans biofilm formation. Our studies demonstrated that coating of a polystyrene microtiter plate with 5 microg/ml of xanthorrhizol resulted in significant (up to 60%) reduction of adherent cells compared to that of cells in uncoated wells. This result suggests that xanthorrhizol displays potent activity in preventing Strep. mutans biofilm formation.