A randomized, double-blind clinical study to assess the antimicrobial effects of a cetylpyridinium chloride mouth rinse on dental plaque bacteria

Reduction of SARS-CoV-2 viral load in saliva after rinsing with mouthwashes containing cetylpyridinium chloride: a randomized clinical study

Background

Symptomatic patients with COVID-19 typically have a high SARS-CoV-2 viral load in their saliva. Procedures to reduce the viral load in their oral cavity are important for mitigating the viral transmission.

Methods

This randomized clinical trial investigated the impact of two mouthwashes (0.075% cetylpyridinium chloride plus 0.28% zinc lactate (CPC+Zn) (n = 32), and 0.075% cetylpyridinium chloride (CPC) (n = 31)) on the viral load of SARS-CoV-2 in saliva when compared to the distilled water negative control (n = 32). Saliva was collected before (T0) and after (5 min, T1; 30 min, T2; and 60 min, T3) the intervention. Viral load in saliva was measured by qRT-PCR assays. The data in both groups was normalized for T0 and Negative Control, resulting in fold change values.

Results

CPC+Zn oral solution reduced the viral load in saliva by 6.34-fold at T1, 3.6-fold at T2 and 1.9-fold at T3. Rinsing with the CPC mouthwash reduced the viral load in saliva by 2.5-fold at T1, 1.9-fold at T2 and 2.0-fold at T3.

Conclusion

CPC+Zn mouthwash or with the CPC mouthwash reduced the viral load in saliva of COVID-19 patients immediately after rinsing. These reductions extended up to 60 min.

Effects of antimicrobial mouthwashes on the human oral microbiome: Systematic review of controlled clinical trials

OBJECTIVES

This review aimed to assess the impact of mouthwashes on the composition of the human oral microbiome.

METHOD

An electronic search algorithm was adapted to MEDLINE-PubMed, Scopus, Embase and ISI Web of Science, and reference lists of relevant sources were manually searched. Inclusion criteria were controlled clinical trials published in English whose population were adult individuals who rinse with antimicrobial mouthwashes and that analysed changes in the oral microbiome by metataxonomy, metagenomics or phylogenetic microarray. Identified studies were screened and assessed following the PRISMA guidelines, and results were compiled into qualitative synthesis of the evidence.

RESULTS

Five controlled clinical studies were included. These studies found associations between the daily use of mouthwashes and changes in the oral microbiome, but the nature of the effect varied according to the mouthwash. Chlorhexidine (CHX) rinses lowered microbial diversity. While 7-day use of CHX led to increases in the abundance of Neisseria, Streptococcus and Granulicatella and a decrease in the abundance of Actinomyces, its prolonged use led to widespread reductions in several genera and species. Cetylpyridinium chloride-containing mouthwashes specifically lowered the abundance of gingivitis-associated genera. In contrast, N-acetyl cysteine-based mouthwashes did not promote changes in the oral microbiome.

CONCLUSIONS

Despite substantial heterogeneity, we found evidence to support the hypothesis that CHX and CPC mouthwashes promote changes in oral microbial structure and/or reductions in community diversity that favour the resolution of dysbiosis. However, future large population-based studies of adequate duration are needed to fully understand the extent to which antimicrobial mouthwashes modulate the microbiome.

Efficacy of 0.05% cetylpyridinium chloride mouthwash as an adjunct to toothbrushing compared with 0.12% chlorhexidine gluconate mouthwash in reducing dental plaque and gingival inflammation: A randomized control trial

OBJECTIVES

This study determined the efficacy of alcohol-free 0.05% cetylpyridinium chloride (CPC) mouthwash as an adjunct to twice-daily toothbrushing in comparison with 0.12% chlorhexidine gluconate (CHX) mouthwash and a placebo in reducing plaque accumulation and gingival inflammation. The side effects of the mouthwashes were also determined.

MATERIALS AND METHODS

A double-blind, parallel, randomized control trial was conducted with 219 university students who were divided into three trial groups using block randomization: CPC, CHX and placebo groups. Clinical oral examinations to assess dental plaque accumulation (modified Quigley-Hein Plaque Index), gingival health (Löe and Silness Gingival Index) and tooth staining (modified Lobene Stain Index) were performed at baseline and at 6 weeks.

RESULTS

Plaque and gingivitis scores were not significantly different among participants at baseline. After 6 weeks, plaque and gingivitis scores between the CPC and placebo groups and between the CHX and placebo groups were found to be significantly different. However, there was no significant difference between the CPC and CHX groups. The staining scores of participants in the CPC group were lower than those in the CHX group, but the difference was not significant. Taste alteration and numbness were more common among participants in the CHX group than in the CPC group. No significant difference in the perception of a burning sensation was observed.

CONCLUSIONS

The 0.05% CPC mouthwash was as efficient as 0.12% CHX mouthwash in reducing dental plaque accumulation and gingival inflammation with fewer side effects, supporting its use as an adjunct to toothbrushing.

Classic vs. Novel Antibacterial Approaches for Eradicating Dental Biofilm as Adjunct to Periodontal Debridement: An Evidence-Based Overview

Periodontitis is a multifactorial chronic inflammatory disease that affects tooth-supporting soft/hard tissues of the dentition. The dental plaque biofilm is considered as a primary etiological factor in susceptible patients; however, other factors contribute to progression, such as diabetes and smoking. Current management utilizes mechanical biofilm removal as the gold standard of treatment. Antibacterial agents might be indicated in certain conditions as an adjunct to this mechanical approach. However, in view of the growing concern about bacterial resistance, alternative approaches have been investigated. Currently, a range of antimicrobial agents and protocols have been used in clinical management, but these remain largely non-validated. This review aimed to evaluate the efficacy of adjunctive antibiotic use in periodontal management and to compare them to recently suggested alternatives. Evidence from in vitro, observational and clinical trial studies suggests efficacy in the use of adjunctive antimicrobials in patients with grade C periodontitis of young age or where the associated risk factors are inconsistent with the amount of bone loss present. Meanwhile, alternative approaches such as photodynamic therapy, bacteriophage therapy and probiotics showed limited supportive evidence, and more studies are warranted to validate their efficiency.

Salivary SARS-CoV-2 load reduction with mouthwash use: A randomized pilot clinical trial

The saliva of patients with COVID-19 has a high SARS-CoV-2 viral load. The risk of spreading the virus is high, and procedures for viral load reduction in the oral cavity are important. Little research to date has been performed on the effect of mouthwashes on the salivary SARS-CoV-2 viral load. This pilot randomized single-center clinical trial investigated whether three types of mouthwash with solutions containing either 0.075% cetylpyridinium chloride plus 0.28% zinc lactate (CPC + Zn), 1.5% hydrogen peroxide (HP), or 0.12% chlorhexidine gluconate (CHX) reduce the SARS-CoV-2 viral load in saliva at different time points. Sixty SARS-CoV-2-positive patients were recruited and randomly partitioned into a placebo (oral rinsing with distilled water) group and other groups according to the type of mouthwash. Saliva samples were collected from the participants before rinsing (T0), immediately after rinsing (T1), 30 min after rinsing (T2), and 60 min after rinsing (T3). The salivary SARS-CoV-2 viral load was measured by qRT-PCR assays. Rinsing with HP and CPC + Zn resulted in better reductions in viral load, with 15.8 ± 0.08- and 20.4 ± 3.7-fold reductions at T1, respectively. Although the CPC + Zn group maintained a 2.6 ± 0.1-fold reduction at T3, this trend was not observed for HP. HP mouthwash resulted in a significant reduction in the SARS-CoV-2 viral load up to 30 min after rinsing (6.5 ± 3.4). The CHX mouthwash significantly reduced the viral load at T1, T2, and T3 (2.1 ± 1.5-, 6.2 ± 3.8-, and 4.2 ± 2.4-fold reductions, respectively). In conclusion, mouthwash with CPC + Zinc and CHX resulted in significant reductions of the SARS-CoV-2 viral load in saliva up to 60 mins after rinsing, while HP mouthwash resulted in a significant reduction up to 30 mins after rinsing. Despite this transitory effect, these results encourage further studies and suggest that these products could be considered as risk-mitigation strategies for patients infected with SARS-CoV-2.

Adherence to and acceptability of three alcohol-free, antiseptic oral rinses: A community-based pilot randomized controlled trial among pregnant women in rural Nepal

OBJECTIVES

Antiseptic oral rinses have been evaluated as interventions to reduce the risk of adverse pregnancy outcomes associated with periodontal disease in pregnant women. Oral rinse use is not common in Nepal or other countries in South Asia, where the prevalence of adverse pregnancy outcomes is high. Understanding whether pregnant women in rural communities in this region would incorporate rinse use into their daily teeth cleaning routine is an important prerequisite to future research on this topic in South Asia.

METHODS

We conducted a community-based pilot randomized controlled trial of three alcohol-free, antiseptic oral rinses among pregnant women <22 weeks pregnant in rural Nepal with the aim of assessing rinse acceptability, adherence, and effect on clinical periodontal measures. At baseline, participants underwent a clinical periodontal examination, and then were classified as healthy or having at least mild gingivitis (≥1 site with probing depth (PD) 3 mm and bleeding on probing (BOP) or ≥4 mm (PD)). Participants were stratified by periodontal status and randomized within each exposure category to chlorhexidine (CHX) (0.12%), cetylpyridinium chloride (CPC) (0.05%), salt and water (NaCl), or control (no rinse). Rinse participants were followed weekly for 12 weeks, and all participants underwent a second periodontal examination and answered a questionnaire.

RESULTS

Pregnant women in the rural Terai region of Nepal showed high adherence to (mean weekly rinse use: 185 mL (standard deviation: 66 mL)) a recommended 210 mL and acceptability of all three rinses. Participants reported greater frequency of tooth brushing with toothpaste and improvements in other recommended oral hygiene behaviours. CHX significantly reduced rates of gingivitis (defined as a participant with BOP ≥ 10% of sites) and the extent of BOP (gingivitis at the end of follow-up for CHX vs control: RR 0.37, 95% CI: 0.16, 0.84). CPC and NaCl rinse groups had rates of gingivitis and extent of BOP similar to the control group (gingivitis at the end of follow-up for CPC: RR 0.81, 95% CI: 0.47, 1.38; NaCl: RR 0.92, 95% CI: 0.55, 1.56).

CONCLUSIONS

Adherence to and acceptability of three alcohol-free, antiseptic oral rinses were high among pregnant women in rural Nepal. Among participants with mild gingivitis at baseline, CHX rinse was most effective at reducing signs of disease compared to the control group. Oral rinse should be considered as a supplement to current oral self-care routines for pregnant women in settings where rinse use is uncommon and access to oral health services is limited.

Oral rinses in growth inhibition and treatment of Helicobacter pylori infection

BACKGROUND

Helicobacter pylori (H. pylori) is well-known for its role in chronic gastritis and gastric cancer. Eradication of these carcinogenic bacteria from the gut is one of the challenges for clinicians. The complexity of treatment mainly owes to antibiotic resistance and relapse due to an additional reservoir in the oral cavity. Our study emphases the isolation of H. pylori from distinct habitats of the gut microenvironment (gastric biopsy and gastric juice) and its subsequent characterization. We have also evaluated the effect of various oral rinses on isolated H. pylori from different anatomical locations of included subjects.

RESULTS

The possible strains isolated from two different habitats of the same subject shows a striking difference in their growth pattern. Promisingly, some of the included oral rinses are efficient in growth inhibition as per recommended 30 s treatment. The subsequent evaluation shows that oral rinse B (among A-E) is most effective and down-regulates the expression of one of the potent H. pylori gene, CagA, in the infected gastric adenocarcinoma (AGS) cells.

CONCLUSION

Our study, for the first time, revealed that H. pylori, isolated from the different habitat of the same subject, show a different growth pattern. The expression of H. pylori pathogenic gene (CagA) was down-regulated by the use of oral rinses. Hence, oral rinses will reduce the H. pylori in the oral cavity and help to control its migration from oral to the gastric compartment and may be used as an adjuvant treatment option for its re-infection.

Synthesis and Antibacterial Activity of Ionic Liquids and Organic Salts Based on Penicillin G and Amoxicillin hydrolysate Derivatives against Resistant Bacteria

The preparation and characterization of ionic liquids and organic salts (OSILs) that contain anionic penicillin G [secoPen] and amoxicillin [seco-Amx] hydrolysate derivatives and their in vitro antibacterial activity against sensitive and resistant Escherichia coli and Staphylococcus aureus strains is reported. Eleven hydrolyzed β-lactam-OSILs were obtained after precipitation in moderate-to-high yields via the neutralization of the basic ammonia buffer of antibiotics with different cation hydroxide salts. The obtained minimum inhibitory concentration (MIC) data of the prepared compounds showed a relative decrease of the inhibitory concentrations (RDIC) in the order of 100 in the case of [C₂OHMIM][seco-Pen] against sensitive S. aureus ATCC25923 and, most strikingly, higher than 1000 with [C₁₆Pyr][seco-Amx] against methicillin-resistant Staphylococcus aureus (MRSA) ATCC 43300. These outstanding in vitro results showcase that a straightforward transformation of standard antibiotics into hydrolyzed organic salts can dramatically change the pharmaceutical activity of a drug, including giving rise to potent formulations of antibiotics against deadly bacteria strains.

Adverse events associated with home use of mouthrinses: a systematic review

Background

Poor oral hygiene is strongly associated with oral and systemic diseases. Alongside mechanical tooth cleaning, the adjunctive use of mouthrinses has been widely advocated. Although research on the efficacy of various mouthrinse formulations is very active, there are a lack of conclusive data regarding their adverse effects.

Methods

We undertook a systematic review in accordance wih PRISMA guidelines of electronic databases of clinical trials of any duration with daily home use of mouthwashes, presenting clinical and subjective side effects (PROSPERO registration: CRD42016054037).

Results

After evaluating 614 titles and abstracts, 154 studies were selected for full-text analysis; 85 final papers were included. Based on the active ingredient in the test product, nine categories were created: cetyl pyridinium chloride, essential oils, chlorhexidine, triclosan, natural products, diclofenac, fluorides, delmopinol, and miscellaneous active substances. Most of the studies were of short duration (less than 6 months) with a defective 'methods' description; the reporting of adverse events often being overlooked. Both local morphological (oral mucosa and dental-crown staining, mucosal lesions) and functional (taste modifications, abnormal oral sensation) alterations were reported. Tooth staining was the most commonly listed adverse event, but it was quantitatively assessed only in a very small number of papers; most studies relied on patient reports. Staining was time associated; the longer the study, the higher its reported incidence and severity.

Conclusions

The reduced report of side effects may partly be due to a lack of an objective measure and lack of general guidelines that demand studies report their adverse events. The most frequently reported adverse effect was teeth staining. As in most studies, the effect was associated with trial duration; clinical trials should be of sufficient duration. New investigations meeting the suggested criteria of a minimal duration of 6 months should be planned.

N-acetyl cysteine versus chlorhexidine mouthwashes in prevention and treatment of experimental gingivitis: a randomized, triple-blind, placebo-controlled clinical trial

OBJECTIVES

To compare the efficacy of N-acetyl cysteine (NAC) mouthwash with chlorhexidine (CHX) in prevention and treatment of experimental gingivitis MATERIALS AND METHODS: Sixty subjects were assigned randomly and blindly into one of three equal groups: NAC, CHX, or placebo group. The study was conducted in two stages: preventive and treatment substudies. Professional prophylaxis was performed ahead of starting the preventive substudy. Then, the subjects were instructed to stop oral hygiene practices and begin rinsing twice/day with 15 ml of the assigned mouthwash (1.25% NAC, 0.2% CHX, or inert base). Plaque index (PI), gingival index (GI), and papillary bleeding index (PBI) were measured at baseline, 7, 14, and 21 days. The treatment substudy started on day 21 in which the subjects in the placebo group (now with established experimental gingivitis) were assigned to NAC (n = 10) or CHX (n = 10); the abovementioned indices were measured at 28 and 35 days. Efficacy of these interventions was compared.

RESULTS

All groups accumulated plaque and developed some degree of gingivitis: full-blown in the placebo group and remarkably mild in the CHX group. NAC had slight preventive properties at days 14 and 21. In the treatment substudy, CHX was associated with remarkable reduction in plaque and gingivitis while NAC resulted in insignificant reductions.

CONCLUSIONS

1.25% NAC is marginally effective in prevention and treatment of experimental gingivitis.

CLINICAL RELEVANCE

When compared with the placebo, NAC showed promising preventive and treatment effects of gingivitis that deserve further development and studies.

TRIAL REGISTRATION

ISRCTN31352091.

Hybrid surfactants decorated with copper ions: aggregation behavior, antimicrobial activity and anti-proliferative effect

In the present study, the emphasis is laid on the self aggregation behavior and biological activity of copper based inorganic–organic hybrids in aqueous media.

Antibacterial and anti-biofilm activity of mouthrinses containing cetylpyridinium chloride and sodium fluoride

Background

Cetylpyridinium chloride (CPC) and sodium fluoride augment oral hygiene by inactivating bacteria and inhibiting enamel demineralisation, respectively. However, there are few reports in the literature documenting the antibacterial efficacy of their combined use in mouthrinses. We have used six experimental systems to compare the antibacterial effects of mouthrinses containing 0.075 % CPC (test rinse, TR) or 0.075 % CPC with sodium fluoride (test fluoride rinse, TFR).

Results

Effects against planktonic bacteria were determined using viable counting (for Streptococcus mutans and salivary bacteria), a redox dye (for Actinomyces viscosus and salivary bacteria) and viable counting (for ex vivo oral rinses). Effects against saliva-derived biofilms were quantified using confocal microscopy and differential viable counting. Inhibition of biofilm formation was evaluated by pre-treating hydroxyapatite coupons with mouthrinses prior to inoculation. Otherwise-identical controls without CPC (control rinse and control fluoride rinse, CR and CFR, respectively), were included throughout. Compared to the controls, TFR and TR demonstrated significant antimicrobial effects in the redox assays, by viable counts (>3 log reductions) and in oral rinse samples (>1.25 log reductions, p < 0.05). TFR and TR also significantly reduced the viability of oral biofilms. Pre-treatment of hydroxyapatite with TFR and TR significantly inhibited biofilm formation (>3 log difference, p < 0.05). Overall, there were no consistent differences in the activities of TR and TFR.

Conclusions

Sodium fluoride did not influence the antibacterial and anti-biofilm potency of CPC-containing formulations, supporting the combined use of CPC and sodium fluoride in mouthrinses to control oral bacteria and protect tooth enamel.

Impact of three different mouthwashes on the incidence of gingival overgrowth induced by cyclosporine-A: a randomized controlled experimental animal study

OBJECTIVE

This study aimed to evaluate the effects of three different mouthwashes on the incidence of cyclosporine-A-induced gingival overgrowth.

STUDY DESIGN

One hundred albino rats were divided into five equal groups. Group I rats received no treatment. Group II rats were administered cyclosporine-A. Group III, IV, and V rats were handled as group II and concomitantly treated with chlorhexidine gluconate, cetylpyridinium chloride, and essential oil mouthwashes, respectively. Ten rats from each group were euthanized after the first week of treatment, and the remaining rats were euthanized after the second week of treatment. The obtained specimens were stained with hematoxylin and eosin, Masson's trichrome, and tumor growth factor beta (TGF-β), matrix metalloproteinase 1 (MMP-1), and interleukin 6 (IL-6) immunohistochemical stains.

RESULTS

The histologic findings at the end of the first and second weeks revealed marked increases in gingival overgrowth for groups II and IV in comparison with groups III and V. Increased epithelial thickness and collagen accumulation were prominent in groups II and IV compared with the other groups. Groups II and IV revealed the highest immunoreactivities for TGF-β and for IL-6. Groups I, III, and V revealed the highest level of MMP-1 expression.

CONCLUSIONS

Essential oils and chlorhexidine gluconate mouthwashes significantly reduced the incidence of gingival overgrowth compared with cetylpyridinium chloride.