Topical povidone iodine inhibits bacterial growth in the oral cavity of patients on mechanical ventilation: a randomized controlled study

Comparison of the inhibitory effects of tooth brushing and povidone-iodine mouthwash on salivary bacterial counts in patients undergoing surgery for malignant solid tumors other than head and neck cancers

Background/purpose

Infectious complications after invasive surgeries may originate from oral sources through either hematogenous infection or direct exposure to salivary bacteria. Perioperative oral management aims to remove oral foci of infection. However, the type of oral care that can reduce the salivary bacterial load remains unclear. This study aimed to identify factors influencing salivary bacterial counts during the perioperative period in patients with malignant tumors and to evaluate the effectiveness of tooth brushing and povidone-iodine mouthwash in reducing oral bacterial counts.

Materials and methods

Patients aged ≥18 years who underwent surgery under general anesthesia for malignant solid tumors other than head and neck cancer were included. Participants were randomly assigned to the brushing or povidone-iodine mouthwash groups. Factors such as sex, age, primary disease, preoperative blood-test results, oral functional metrics, and salivary bacterial counts were analyzed. Saliva samples were collected before and on the day after surgery, both before and after oral-care interventions. The total bacterial and streptococcal counts were determined using real-time polymerase chain reaction (PCR), and delayed real-time PCR was used to determine the viable bacterial count.

Results

Postoperatively, the salivary bacterial counts increased slightly. Significant factors affecting postoperative bacterial counts included high preoperative counts and postoperative fasting status. Brushing increased salivary bacterial counts, whereas the povidone-iodine mouthwash decreased them.

Conclusion

Poor preoperative oral hygiene and postoperative fasting were significantly associated with increased salivary bacterial counts. The povidone-iodine mouthwash reduced postoperative bacterial counts, indicating its effectiveness as a perioperative oral-care method.

Oral care medications for the prevention and treatment of ventilator-associated pneumonia in intensive care unit

This study aims to ameliorate the management of VAP in clinical practice and deliver more precise care in the ICU. Study selection using the appropriate critical appraisal tools was undertaken by three authors. This review provides an overview of empirical antibiotics, chlorhexidine, and povidone-iodine, which are currently commonly used in critical care. It also discusses oral medications and preparations that may be used to prevent and treat ICU ventilator-associated pneumonia, including new antibiotics, hydrogen peroxide solutions, sodium bicarbonate, octenidine, and oral herbal medicines. It also discusses ongoing research and potential applications, such as the antimicrobial effects of these agents in ICU oral hygiene. Pharmaceuticals and formulations used in oral hygiene are effective or have huge application potential in the prevention and treatment of VAP, but further research is needed to standardize oral health assessment and care practices to develop evidence-based personalized oral hygiene for critically ill patients.

Effects of enrofloxacin and povidone-iodine on immunity, the intestinal microbiome and transcriptome of juvenile grass carp (Ctenopharyngodon idella)

Gut microbiota stability is crucial for maintaining fish health. In aquaculture, antibiotics and disinfectants are frequently used to manipulate the host gut microbiota, but the combined effects on asymptomatic fish remain unclear. We investigated the effects of single and combined treatments with antibiotics and disinfectants on grass carp (Ctenopharyngodon idella) gut health, immune response, microbiome dynamics and transcriptome profile. In a 2-week trial, grass carp were exposed to enrofloxacin (10 mg/kg) in the basal diet or povidone-iodine (0.05 mg/L) in fresh water. A 14-day treatment led to significant oxidative stress, as indicated by reduced catalase and total superoxide dismutase activities. Digestive enzyme activities, including amylase and lipase, were also significantly suppressed. Gut microbiota diversity decreased, with notable shifts in dominant bacterial phyla, including reduced abundances of Firmicutes and Bacteroidetes and increased Proteobacteria and Fusobacteria. Transcriptomic analysis revealed downregulation of immune-related pathways, including those linked to IgA production, and suppression of key immune-related genes, such as major histocompatibility complex 2 (MHC2) and tumour necrosis factor alpha (TNF-α). Histopathological analysis showed damaged intestinal villi, increased goblet cell numbers and significant apoptosis in intestinal epithelial cells, as confirmed by terminal deoxynucleotidyl transferase (TdT) dUTP Nick-End Labeling (TUNEL) staining and upregulation of caspase-3, caspase-8 and caspase-9. These findings demonstrate that enrofloxacin and povidone-iodine disrupt gut microbiota balance, impair mucosal immunity and induce apoptosis in grass carp.

Potential effect of topical antibiotics administration in the oral cavity on the reduced number of bacteria entering the lower respiratory tract after oral cancer surgery

Background/purpose

One of the causes of ventilator-associated pneumonia (VAP) is aspiration of oropharyngeal fluid containing pathogenic microorganisms into the lower respiratory tract. In this study, we aimed to investigate whether antibiotic ointment applied to the oral cavity can reduce the number of bacteria in the fluid on the cuff of a tracheal cannula.

Materials and methods

Tetracycline ointment was applied intraorally once to a patient under endotracheal intubation by postoperative tracheostomy for oral cancer. The tetracycline concentrations in the oropharyngeal fluid and fluid on the cuff of tracheal cannula were determined by bioassay, and the total viable bacterial count was determined by delayed real-time polymerase chain reaction developed by the authors from before to 6 h after application.

Results

A total of seven patients were enrolled. Very high antibiotic concentrations were maintained, ranging from 481 μg/ml to 2060 μg/ml in oropharyngeal fluid and from 267 μg/ml to 858 μg/ml in fluid on the cuff from 1 h to 6 h after application. Compared to the pre-application results, the inhibition rates of viable bacteria were 80.0-97.7% for oropharyngeal fluid and 47.6%-91.9% for fluid on the cuff at 1-6 h after application, indicating that antibiotic ointment can inhibit bacteria entering the lower respiratory tract for a long period of time in intubated patients.

Conclusion

Oral application of antibiotic ointment reduced the number of bacteria entering the lower respiratory tract, suggesting that it may be useful in the prevention or treatment of VAP.

The effect of honey in oral care intervention against chemotherapy-induced mucositis in pediatric cancer patients: a pilot study

OBJECTIVE

Mucositis is one of the common side effects of chemotherapy. This study aimed to identify the effects of honey on oral care interventions to reduce mucositis scores among children undergoing chemotherapy.

METHODS

This pilot study was quasi-experimental with pre-post intervention with the control group. The study employed consecutive sampling, with 24 patients in the control and 24 in the intervention group. The intervention group received an oral care protocol using honey, whereas the control group received regular oral care. The data were collected using demographic information form and the Oral Assessment Guide (OAG) to assess mucositis. The intervention group received oral care intervention using honey (35 ml of honey applied topically in the oral cavity and 15 ml of honey used as a mouthwash and for lip care), which was given thrice daily for five days. The data were analyzed using percentage distributions, means, chi-square tests, dependent and independent t-tests, and multivariate analysis using analysis of covariance (ANCOVA).

RESULTS

The findings of this study showed that the intervention group experienced a significant reduction (-0.51 ± 0.66) in the average mucositis score after the intervention, whereas the control group experienced an increase in the mucositis score (3.84 ± 1.28) after controlling for confounding variables (p = 0.000).

CONCLUSION

This study revealed that oral care with honey effectively reduced chemotherapy-induced mucositis in children with cancer. These findings suggest that oral care with honey should be used as a nursing intervention for chemotherapy patients.

TRIAL REGISTRATION

This clinical trial was retrospectively registered in the Australian New Zealand Clinical Trials Registry (ANZCTR) with registration number ACTRN12624001313527 (29/10/2024).

A Crossover Trial of a Novel Toothbrushing Method for Prevention of Aspiration Pneumonia: Toothpaste With Povidone-Iodine and Moisturizing Gel Mixture

INTRODUCTION

Toothbrushing, during which dental plaque is brushed off into the oral cavity, can increase the risk of aspiration pneumonia in older adults and intubated patients.

METHODS

This study examined brushing methods to prevent the spread of bacteria in the oral cavity. Six participants who required assistance with brushing received toothbrushing from a dental hygienist. Toothbrushing was performed using a toothbrush soaked in water (Water group), gel (Gel group), povidone-iodine solution (PV-I group), or a mixture of a moisturizing gel and povidone-iodine gel (PV-I+Gel group). The number of bacteria in the saliva before and after brushing was measured using a delayed real-time polymerase chain reaction, which can quantify the number of viable bacteria.

RESULTS

In the Water group, salivary bacterial counts increased significantly after brushing. The bacterial counts in the Gel and PV-I groups increased slightly after brushing; however, the increase was less than that observed in the Water group. In the PV-I+Gel group, the number of bacteria in the saliva was significantly reduced after brushing.

CONCLUSIONS

In patients at risk for aspiration pneumonia, toothbrushing should be performed with a mixture of PV-I and a moisturizing gel. This method is a novel approach that reduces the risk of aspiration pneumonia in intubated patients and older adults requiring care, and its clinical application is expected in the future.

In vitro antimicrobial activity of non-traditional therapies for infectious endometritis in mares

BACKGROUND

Endometritis is the leading cause of subfertility in horses, and it is a clinical problem where historically antibiotics have not always been used with prudent justification. Because of this, alternative therapies to treat endometritis are necessary for the rational use of antibiotics.

OBJECTIVES

To assess the in vitro antimicrobial activity of non-traditional therapies commonly used in clinical practice against microorganisms causing infectious endometritis in mares.

STUDY DESIGN

In vitro experiments.

METHODS

A microdilution technique was performed to determine the minimum inhibitory concentrations (MIC) of 50%, 90% and 100% of microorganisms and the percentage of inhibition (PI) of each therapy against each microorganism (Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, Staphylococcus aureus and Candida sp.). The MIC 50% and 90% were determined using non-linear regression, while MIC 100% was assessed using the resazurin dye technique. The serial PI was evaluated for each therapy using a spectrophotometer.

RESULTS

All the therapies demonstrated a PI higher than positive controls for all microorganisms (p < 0.05); however, the only therapies that presented MIC 100 values were hydrogen peroxide and platelet-rich and -poor plasma.

MAIN LIMITATIONS

In vivo, safety and treatment efficacy were not tested.

CONCLUSION

Hydrogen peroxide and platelet-rich and -poor plasma might be alternatives to traditional therapies for endometritis to support a reduction in antibiotic use.

Effect of Oral Application of Povidone-Iodine on the Amount of Viable Bacteria Entering the Lower Respiratory Tract in Intubated Patients With Oral Cancer: A Preliminary Study

One of the causes of ventilator-associated pneumonia (VAP) is the aspiration of fluid-containing pathogenic bacteria into the lower respiratory tract. The purpose of this study was to determine whether oral povidone-iodine (PV-I) application reduces bacterial counts in the fluid on the cuff of an endotracheal intubation tube. Patients intubated and managed with tracheostomy for oral cancer surgery were divided into two groups. The PV-I group received a single topical application of PV-I in the oral cavity. The brushing group underwent tooth brushing with suction and cleaning. Before the intervention, and at one, two, three, and six hours after intervention, samples were taken from the mouth and the cuff to determine viable bacterial counts using the delayed real-time polymerase chain reaction method, which quantifies only viable bacteria. Seven patients in the PV-I group and six in the brushing group were included in the study. The brushing group showed an increase in bacterial counts in both the oral cavity and on the cuff up to six hours post intervention. In contrast, the PV-I group showed significantly lower bacterial counts from one to six hours post intervention, both in the oral cavity and on the cuff. These results indicate that topical PV-I application reduces the number of bacteria entering the lower respiratory tract and may help prevent VAP.

Oral Bacteria Counter Using Dielectrophoretic Impedance Measurement: Usefulness and Usage Considerations

BACKGROUND

The oral cavity hosts numerous bacteria that are associated with various systemic diseases. The Oral Bacteria Counter (PHC Corporation, Tokyo, Japan), a microorganism quantitative analyzer that utilizes dielectrophoretic impedance measurements, enables rapid bacterial counting and is widely used in dental practice in Japan. However, it may also detect nonviable bacteria. This study aimed to assess the impact of disinfectants, electrolytes, and viscosity on the accuracy of the Oral Bacteria Counter and to determine whether it measures non-viable bacteria similarly to viable bacteria.

METHODS

To evaluate the effect of the disinfectants, samples of 7% povidone-iodine (PV-I), 0.2% benzethonium chloride, 5% chlorhexidine (CHX), 0.2% CHX, 0.05% CHX, sterile water, and saline were measured using the Oral Bacteria Counter. The effect of viscosity was assessed by mixing sterile water with glycerol in various ratios and measuring the dielectrophoretic impedance of the bacterial counts at different viscosities. For the electrolyte effects, samples of Staphylococcus aureus diluted in sterile water or saline were measured using the Oral Bacteria Counter. Additionally, samples of 7% PV-I or 5% CHX diluted in sterile water or saline were measured. Bacterial counts were then measured and compared using the Oral Bacteria Counter, our developed delayed real-time polymerase chain reaction (DR-PCR) method (which quantifies only viable bacteria), and culture methods.

RESULTS

Disinfectants such as 5% CHX and 7% PV-I produced high readings on the Oral Bacteria Counter, even when no viable bacteria were present. Higher glycerol concentrations, which increased the viscosity, resulted in lower bacterial counts. The presence of electrolytes, particularly saline, led to higher readings on the Oral Bacteria Counter, which detected both viable and non-viable bacteria, whereas DR-PCR and culture methods did not detect non-viable bacteria.

CONCLUSION

The Oral Bacteria Counter may be influenced by disinfectants, viscosity, and electrolytes, leading to potential inaccuracies in bacterial quantification. For accurate bacterial measurements, it is essential to consider these factors and ideally combine the results from the Oral Bacteria Counter with methods such as DR-PCR for more reliable assessment.

New Insights Regarding the Use of Relevant Synthetic Compounds in Dentistry

Worldwide, synthetic compounds are used for both in-office and at-home dental care. They are a valuable resource for both prophylactic and curative treatments for various dental problems, such as tooth decay, periodontal diseases, and many more. They are typically preferred due to their broad range of actions and ability to produce targeted, rapid, and long-lasting effects. Using a 0.12% chlorhexidine mouthwash is capable of reducing the plaque index from 47.69% to 2.37% and the bleeding index from 32.93% to 6.28% after just 2 weeks. Mouthwash with 0.1% OCT is also highly effective, as it significantly lowered the median plaque index and salivary bacterial counts in 152 patients in 5 days compared to a control group (p < 0.0001), while also reducing the gingival index (p < 0.001). When povidone-iodine was used as an irrigant during the surgical removal of mandibular third molars in 105 patients, it resulted in notably lower pain scores after 2 days compared to a control group (4.57 ± 0.60 vs. 5.71 ± 0.45). Sodium hypochlorite is excellent for root canal disinfection, as irrigating with 1% NaOCl completely eliminated the bacteria from canals in 65% patients. A 0.05% CPC mouthwash proved effective for perioperative patient care, significantly decreasing gingival bleeding (p < 0.001) and suppressing Streptococcus levels even one week post-surgery. Lastly, a 6% H2O2 paint-on varnish and 6% H2O2 tray formulations successfully bleached the teeth of 40 patients, maintaining a noticeably whiter appearance up to the 6-month follow-up, with significant color differences from the baseline (p < 0.005). Synthetic compounds have a large research base, which also provides a greater awareness of their mechanism of action and potential adverse effects. For a better understanding of how they work, several methods and assays are performed. These are protocolary techniques through which a compound's efficacy and toxicity are established.

Bone resection methods in medication-related osteonecrosis of the jaw in the mandible: An investigation of 206 patients undergoing surgical treatment

Background /purpose

The standard treatment for medication-related osteonecrosis of the jaw (MRONJ) is surgery. However, reports on the appropriate extent of bone resection are few. We aimed to examine the relationship between the extent of bone resection and postoperative outcomes in patients with mandibular MRONJ.

Materials and methods

The clinical and imaging findings and treatment outcomes of 206 patients (258 surgeries) with mandibular MRONJ undergoing surgery were reviewed. Imaging findings were evaluated using computed tomography (CT) to sequestrum, osteolysis, periosteal reaction, and mixed-type osteosclerosis, and determine the extent of resection. In some cases, samples were taken from within the bone, and real-time polymerase chain reaction was used to confirm the presence of bacteria and fungi.

Results

The three-year cumulative cure rate was 81.7%. Patients with malignant tumors showing no osteolysis and undergoing sequestrum removal or marginal mandibulectomy had significantly worse prognosis than those with osteoporosis showing osteolysis and undergoing segmental mandibulectomy. Furthermore, patients with residual osteolysis, periosteal reactions, and mixed-type osteosclerosis on CT were more likely to develop recurrence. Eleven patients showed no osteolysis on CT images. Patients with cancer administered with high-dose denosumab had significantly poorer prognosis. Bacteria and fungi were also detected in samples obtained from gap-type periosteal reaction and mixed-type osteosclerosis.

Conclusion

Surgery for MRONJ requires resection of the infected bone. Aside from the osteolysis area, the gap-/irregular-type periosteal reaction and mixed-type osteosclerosis must also be included in the resection area. Methods for determining the extent of bone resection in MRONJ without osteolysis are a future challenge.

Effect of oral function and postoperative eating patterns on salivary bacterial counts in gastrointestinal tract surgery patients: A preliminary study

Background/purpose

Perioperative oral care is widely provided to prevent postoperative pneumonia and surgical site infections in patients undergoing surgery under general anesthesia. However, there is a lack of clarity regarding the kind of oral care that should be provided for different patients. The purpose of this study was to clarify the factors that influence the increase in salivary bacterial counts before and after gastrointestinal surgery to identify patients with a particular need for oral care.

Materials and methods

Twenty patients undergoing gastrointestinal surgery were examined before surgery for denture use, number of remaining teeth, regular dental care, Oral Hygiene Index-Simplfied tongue coating, tongue pressure, bite pressure, masticatory efficiency, and dry mouth. Saliva samples were collected before surgery, in the fasting period after surgery, and in the oral feeding period. Total bacterial counts were determined by real-time PCR, and factors associated with bacterial counts were investigated.

Results

Patients with decreased oral functions, such as tongue pressure, bite pressure, and masticatory efficiency, tended to have higher salivary bacterial counts in the preoperative, fasting, and oral feeding periods. Regarding the pre- and postoperative changes, salivary bacterial counts increased in the fasting period compared to the pre-operative period and returned to preoperative values in the oral feeding period.

Conclusion

Perioperative oral care is important for patients with reduced oral function because the number of bacteria in saliva tends to be higher in such patients. As the number of bacteria in saliva increases during the fasting period, oral care is important, and oral feeding should be restarted as soon as possible.

Brushing Methods for Patients Unable to Use a Mouthwash: A Preliminary Study of the Effects of Moisturizing Gel and Povidone-Iodine in Healthy Volunteers

INTRODUCTION

 Brushing older adults or intubated patients who are unable to rinse can transmit bacteria from dental plaque into the oral cavity and increase the risk of aspiration pneumonia. Therefore, this study examined brushing methods to prevent the spread of bacteria in the oral cavity.  Methods: Three types of brushing methods were performed on five volunteers by dental hygienists (water group: brushing with toothbrush bristles soaked in water; gel group: brushing with a moisturizing gel placed on the toothbrush; PV-I group: brushing with toothbrush bristles dipped in povidone-iodine). Neither group spat out the saliva or gargled during brushing but brushed while wiping the water/gel/PV-I solution with a sponge brush. The same five volunteers served as subjects for the three methods. Saliva was collected before and after brushing, and the number of colonies was determined using bacterial culture.  Results: The water group demonstrated a significantly increased number of bacteria in the saliva owing to the spread of bacteria from the dental plaque. The gel group prevented the spread of the bacteria. The PV-I group showed a significant decrease in the number of bacteria in the saliva after brushing.

CONCLUSIONS

 Brushing with toothbrush bristles dipped in a povidone-iodine solution is recommended for intubated or older adult patients who cannot gargle.

Factors affecting the number of bacteria in saliva and oral care methods for the recovery of bacteria in contaminated saliva after brushing: a randomized controlled trial

BACKGROUND

Oral care is important in preventing aspiration pneumonia in older adults. However, it is not clear what kind of oral care can reduce the number of bacteria in saliva. The purposes of this study are to clarify whether there is a relationship between plaque amounts and salivary bacterial counts, and how bacteria dispersed into the oral cavity by brushing can be reduced.

METHODS

First, saliva samples were collected from 10 healthy adult volunteers after 30 h of unbrushing and after thorough brushing, and the total bacterial count was determined by real-time PCR. Next, 40 older adults attending an outpatient dental clinic were randomly assigned into two groups: a wiping group (20 patients) and a mouthwashing group (20 patients). Saliva was collected before and after brushing, and after wiping in the wiping group and after mouthwashing in the mouthwashing group, and the total bacterial count was quantified by real-time PCR.

RESULTS

In a study of volunteers, there was no association between plaque amounts and salivary bacterial counts. In a study of older adult patients, salivary bacterial counts were significantly higher in patients with higher oral hygiene index and fewer remaining teeth. Brushing increased salivary bacterial counts. Wiping did not significantly reduce the number of bacteria, while mouthwash returned the increased number of bacteria after brushing to the pre-brushing level.

CONCLUSIONS

There is no direct relationship between the amount of plaque and the number of bacteria in saliva. Brushing disperses bacteria into the oral cavity, resulting in a marked increase in the number of bacteria in saliva. Wiping does not collect the dispersed bacteria, and it seems essential to rinse the mouth after brushing.

TRIAL REGISTRATION

UMIN000045854.

A novel method for determining viable bacteria from a mixture of dead and viable bacteria: Delayed real-time PCR (DR-PCR) method

Aspiration pneumonia can occur in perioperative and older patients, and various oral care methods have been used to prevent it. To validate the effective oral care methods, measuring bacterial counts before and after oral care is necessary. However, isolating and quantifying viable bacteria from those that are inactivated by agents used in oral care is not possible. In this study, we developed a novel method, Delayed real-time PCR (DR-PCR), that can quantify only viable bacteria from mixed samples of viable and dead bacteria. This method takes advantage of the fact that dead bacteria do not grow but viable bacteria do. When the samples were incubated in a liquid medium for 4 hours, the higher the percentage of viable bacteria, the higher the rate of increase in the number of bacteria. This method showed that povidone‑iodine mouthwashing reduced the number of viable bacteria to approximately 1/4 of that before mouthwashing. Although DR-PCR is slightly more time consuming than real-time PCR, it is effective for studying changes in bacterial counts before and after oral care.

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.

Effect of Oral Care with Povidone-Iodine in the Prevention of Ventilator-Associated Pneumonia; a Systematic Review and Meta-Analysis

Introduction

Ventilator-associated pneumonia (VAP) is one of the most common nosocomial infections affecting one-third of patients with mechanical ventilation. This study aimed to synthesize available evidence regarding the effect of treatment with povidone-iodine (PI) among adult patients admitted to intensive care units (ICUs) for the prevention of VAP.

Methods

An extensive search was conducted in online databases, including PubMed, Web of Science and Scopus, from the earliest records until January 1, 2023. STATA software v14 was used for statistical analysis. Publication bias was assessed via funnel plot, Begg's and Egger's tests. A P-value less than 0.1 was considered statistically significant for publication bias value.

Results

Four studies were included in the meta-analysis. Three studies showed rhat PI decreased VAP compared to the placebo group, but it was not statistically significant (RR: 0.61, 95%CI: 0.25 to 1.47, Z=1.10, P=0.27, I2:71.5%). One study compared the effect of PI with chlorhexidine on the rate of VAP, the difference between which was not statistically significant (RR: 1.50, 95%CI: 0.46 to 4.87, Z=0.67, P=0.50, I2:0). Two studies demonstrated that the use of PI intervention compared to placebo decreased the average length of stay in ICU; however, it was not statistically significant (WMD: -0.35, 95%CI:-3.90 to 3.20, Z=0.19, P=0.85, I2:0). Also, three studies showed that using PI had almost no effect on mortality rate compared to placebo (RR: 1.05, 95%CI: 0.66 to 1.53, Z=0.8, P=0.27, I2:29.0%).

Conclusion

More rigorously designed randomized clinical trials and further evidence are required to make a better decision/comparison about using PI as a suitable choice for preventing VAP among adult patients admitted to the ICU.

A quality improvement study on the relationship between intranasal povidone-iodine and anesthesia and the nasal microbiota of surgery patients

INTRODUCTION

The composition of the nasal microbiota in surgical patients in the context of general anesthesia and nasal povidone-iodine decolonization is unknown. The purpose of this quality improvement study was to determine: (i) if general anesthesia is associated with changes in the nasal microbiota of surgery patients and (ii) if preoperative intranasal povidone-iodine decolonization is associated with changes in the nasal microbiota of surgery patients.

MATERIALS AND METHODS

One hundred and fifty-one ambulatory patients presenting for surgery were enrolled in a quality improvement study by convenience sampling. Pre- and post-surgery nasal samples were collected from patients in the no intranasal decolonization group (control group, n = 54). Pre-decolonization nasal samples were collected from the preoperative intranasal povidone-iodine decolonization group (povidone-iodine group, n = 97). Intranasal povidone-iodine was administered immediately prior to surgery and continued for 20 minutes before patients proceeded for surgery. Post-nasal samples were then collected. General anesthesia was administered to both groups. DNA from the samples was extracted for 16S rRNA sequencing on an Illumina MiSeq.

RESULTS

In the control group, there was no evidence of change in bacterial diversity between pre- and post-surgery samples. In the povidone-iodine group, nasal bacterial diversity was greater in post-surgery, relative to pre-surgery (Shannon's Diversity Index (P = 0.038), Chao's richness estimate (P = 0.02) and Inverse Simpson index (P = 0.027). Among all the genera, only the relative abundance of the genus Staphylococcus trended towards a decrease in patients after application (FDR adjusted P = 0.06). Abundant genera common to both povidone-iodine and control groups included Staphylococcus, Bradyrhizobium, Corynebacterium, Dolosigranulum, Lactobacillus, and Moraxella.

CONCLUSIONS

We found general anesthesia was not associated with changes in the nasal microbiota. Povidone-iodine treatment was associated with nasal microbial diversity and decreased abundance of Staphylococcus. Future studies should examine the nasal microbiota structure and function longitudinally in surgical patients receiving intranasal povidone-iodine.

Perioperative Topical Antisepsis and Surgical Site Infection in Patients Undergoing Upper Aerodigestive Tract Reconstruction

Importance

Surgical site infections (SSIs) after vascularized reconstruction of the upper aerodigestive tract (UADT) are associated with considerable morbidity. The association between perioperative prophylaxis practices, particularly topical antisepsis, and SSIs remains uncertain.

Objective

To assess the association between perioperative topical antisepsis and SSIs in patients undergoing vascularized reconstruction of the UADT.

Design, Setting, and Participants

This cohort study included patients from 12 academic tertiary care centers over an 11-month period, from July 1, 2020, to June 1, 2021. Patients undergoing open surgical procedures requiring a communication between the UADT and cervical skin with a planned regional pedicled flap, free flap, or both were included. Patients with an active infection at the time of surgical procedure were excluded.

Main Outcomes and Measures

The primary outcome measure was an SSI within 30 days of surgery. The association of demographic characteristics, perioperative antibiotic prophylaxis, surgical technique, and postoperative care with SSIs was assessed using univariable and multivariable analyses. The relative risk ratio and 95% CIs for developing SSI were calculated for each of the variables based on predetermined categories. Variables for which the relative risk 95% CI did not include the value of zero effect (relative risk = 1.00) were included in the multivariable model.

Results

A total of 554 patients (median age, 64 years; range, 21-95 years; 367 men [66.2%]) were included. Cancer ablation was the most frequent reason for surgery (n = 480 [86.6%]). Overall, the SSI rate was 20.9% (n = 116), with most infections involving the head and neck surgical site only (91 [78.4%]). The median time to SSI diagnosis was 11 days (range, 1-28 days). Topical antisepsis mucosal preparation was performed preoperatively in 35.2% (195) and postoperatively in 52.2% (289) of cases. Ampicillin and sulbactam was the most common systemic antibiotic prophylaxis agent used (n = 367 [66.2%]), with 24 hours being the most common duration (n = 363 [65.5%]). On multivariable analysis, preoperative topical antisepsis mucosal preparation (odds ratio [OR], 0.49; 95% CI, 0.30-0.77) and systemic prophylaxis with piperacillin and tazobactam (OR, 0.42; 95% CI, 0.21-0.84) were associated with a decreased risk of a postoperative SSI. The use of an osseous vascularized flap was associated with an increased risk of postoperative SSI (OR, 1.76; 95% CI, 1.13-2.75).

Conclusions and Relevance

Findings of this study suggest that preoperative topical antisepsis mucosal preparation was independently associated with a decreased risk of SSIs in a 12-center multi-institutional cohort. Further investigation of the association between individual perioperative practices and the incidence of postoperative SSIs is necessary to develop evidence-based protocols to reduce SSIs after UADT reconstruction.

Virucidal effect of povidone-iodine against SARS-CoV-2 in vitro

Objective

To evaluate the antiviral activity of the oral disinfectant povidone-iodine (PVP-I) against severe acute respiratory syndrome-coronavirus-2 (SARS-CoV2) in vitro.

Methods

The cytotoxic effects of PVP-I were determined in Vero and Calu-3 cell lines using that by Cell Counting Kit-8 assay. Viral load in the cell culture medium above infected cells was quantitated using real-time polymerase chain reaction. The cytopathic effect (CPE) and viral infective rate were observed by immunofluorescence microscopy.

Results

PVP-I at a concentration >0.5 mg/ml in contact with SARS-CoV-2 for 30 s, 1 min, 2 min and 5 min showed up to 99% viral inhibition. For in vitro testing, upon exposure for 1 min, PVP-I showed a virucidal effect. PVP-I had no cytotoxic effects at the range of concentrations tested (0.125–1 mg/ml; CC₅₀ > 2.75 mM) in Vero and Calu-3 cells.

Conclusion

These results demonstrate that the ideal contact time was 1 min and the optimal concentration was 1 mg/ml, which provides an experimental basis for the use of oral disinfectants in dental hospitals.

Use of toothbrushing in conjunction with chlorhexidine for preventing ventilator-associated pneumonia: A random-effect meta-analysis of randomized controlled trials

OBJECTIVE

The oral cavity with poor hygiene is a reservoir of a complex community of commensal and pathogenic bacteria. Improved oral hygiene (OH) may reduce the incidence of ventilator-associated pneumonia (VAP); however, research on the efficacy of different OH treatments and their potential synergistic effects has remained inconclusive. The objective of this study was to examine whether in patients on mechanical ventilation, using a toothbrushing (T) in conjunction with chlorhexidine (CHX), as opposed to only CHX, reduced the incidence of VAP.

METHOD

A random-effect meta-analysis of randomized clinical trials, which compare the effect of CHX+T (intervention) with CHX (control) on the risk of VAP, was conducted. The Mantel-Haenszel model was used to determine the mean differences (MD), relative risks (RR) and 95% confidence intervals (CI).

RESULTS

Seven studies with 1424 patients were included. Oral care with CHX+T reduced the incidences of VAP (RR = 0.67; CI = [0.50, 0.88], p = 0.005) compared with that with CHX alone. The former also reduced the duration of mechanical ventilation (MD = -1.38; CI = [-2.43, -0.33], p = 0.01) and length of stay in the ICU (MD = -1.47; CI = [-2.74, -0.20], p = 0.02), although the risk of ICU mortality did not reduce (RR = 0.87, 95% CI = [0.72, 1.04], p = 0.17).

CONCLUSIONS

Toothbrushing along with CHX significantly reduced the risk of VAP. Further well-designed randomized controlled trials with a careful focus on the OH are needed to fully establish the advantage of toothbrushing along with CHX for reducing the risk of VAP.

Could mouth rinses be an adjuvant in the treatment of SARS-CoV-2 patients? An appraisal with a systematic review

Objective

A wide variety of mouth rinses are available to combat micro‐organisms in the oral cavity. At the present global pandemic, the need of the hour is to control the viral infection due to the novel corona virus SARS‐COV‐2, as its port of entry is through the receptors located in the oral and pharyngeal mucosa. This systematic literature review focuses on the in vivo studies [randomized control trials (RCTs)] done on the efficacy of existing mouth rinses which have been used in reducing the viral loads.

Methods

The electronic database which includes PubMed‐MEDLINE, Google scholar, Scopus, Web of Science, EMBASE, ProQuest and CINAHL was searched from December 2019 to June 2021 with appropriate Medical Subject Headings (MeSH) terms and Boolean operators. Two reviewers independently reviewed the abstracts.

Results

Of the 2438 retrieved titles, 905 remained after removing duplicates. Twelve articles were eligible to be included in this review of which seven were randomized with adequate sample size.

Conclusions

Mouth washes containing povidone iodine and chlorhexidine decrease the viral load transiently. Large amount of in vivo studies are of paramount importance, especially RCTs, to prove the efficacy of these mouth rinses.

Effects of a miconazole oral patch on preventing development of oral candidiasis in patients with head and neck cancer undergoing radiotherapy: results of a preliminary study quantifying the prevalence of Candida albicans in saliva

PURPOSE

Serious oral mucositis develops during radiation therapy (RT) for head and neck cancer, but there is no effective preventive method. We have used a steroid ointment to prevent oral mucositis during RT, but the use of steroid ointment is discontinued when oral candidiasis develops. Therefore, prevention of oral candidiasis is important. The purpose of this study was to examine whether administration of a miconazole oral patch reduced the amount of Candida albicans in saliva and prevented the development of oral candidiasis during RT.

METHODS

Participants were patients with head and neck cancer receiving RT ≥ 60 Gy. Patients in the intervention group received miconazole oral patches for 14 days after the appearance of grade 2 oral mucositis. The control group received oral care only. Total bacteria and C. albicans counts in the saliva were analyzed by real-time polymerase chain reaction. The incidence of oral candidiasis was compared between the groups.

RESULTS

Total bacterial counts did not change throughout RT in either the intervention or the control group. However, C. albicans count significantly increased at 30 Gy and 60 Gy in the control group but was suppressed in the intervention group. The saliva pH did not show a significant change throughout RT in either group. The incidence of oral candidiasis in the intervention group tended to be lower than that in the control group.

CONCLUSION

This study suggested that prophylactic use of a miconazole oral patch was effective in suppressing the growth of C. albicans count in saliva during RT for head and neck cancer.

Oral peroxidases: From antimicrobial agents to ecological actors (Review)

Sialoperoxidase and myeloperoxidase are the two main peroxidase enzymes found in the oral cavity. Sialoperoxidase is present in salivary secretions and in the biofilms that line the oral surfaces, while myeloperoxidase is abundant in the dento-gingival sulcus area. In the presence of hydrogen peroxide (H₂O₂), oral peroxidases catalyze the oxidation of the pseudohalide anion thiocyanate (SCN⁻) to hypothiocyanite (OSCN⁻), a strong oxidant that serves an antimicrobial role. Furthermore, oral peroxidases consume bacteria-produced H₂O₂ and could help inactivate toxic carcinogenic and genotoxic substances. Numerous in vitro studies have reported the antibacterial, antimycotic and antiviral role of peroxidases, suggesting possible applications in oral therapy. However, the use of oral hygiene products incorporating peroxidase systems has not yet been shown to be beneficial for the treatment or prevention of oral infections. This paradox reflects our incomplete knowledge of the physiological role of peroxidases in a complex environment, such as the oral region. While hygiene is crucial for restoring oral microbiota to a symbiotic state, there are no data to suggest that the addition of a peroxidase per se can create a dysbiotic state. Recent investigations have associated the presence of peroxidase activity with gram-positive cocci microbial flora, and its insufficiency with dysbiosis has been linked to pathologies, such as caries, periodontitis or infections of the oral mucosa. Therefore, oxidants generated by oral peroxidases appear to be an essential ecological determinant for oral health through the selection of a symbiotic microbiota capable of resisting oxidative stress. The objective of the present review was to update the current knowledge of the physiological aspects and applications of oral peroxidases in clinical practice.

Effect of periosteal reaction in medication-related osteonecrosis of the jaw on treatment outcome after surgery

INTRODUCTION

Surgical treatment in patients with medication-related osteonecrosis of the jaw (MRONJ) is superior to conservative treatment. However, treatment outcome in patients with periosteal reaction (PR) was significantly poorer than that of those without PR. The purpose of this retrospective study was to analyze the pathophysiology and clinical significance of PR in MRONJ.

MATERIALS AND METHODS

Out of 181 patients with MRONJ undergoing surgery, 38 patients with PR were enrolled in the study. CT examinations, histological examinations, and bacteriological examinations using real-time polymerase chain reaction were performed, and the relationship among the opted surgical method, CT findings, and treatment outcome was investigated.

RESULTS

The pattern of PR was classified into three types: type 1, new bone is formed parallel to the mandible, and no gap was evident between the mandible and new bone; type 2, new bone is formed parallel to the mandible, and a gap was evident between them; type 3, an irregular shape. Histological examinations revealed inflammatory tissue in the area visualized as a gap on CT. Bacteriological examination showed the presence of bacteria in the type 2 or type 3 PR. Complete cure was observed in 21 of 38 (55.3%) patients, which was lower than the cure rate of 73.4% in 143 patients without PR. The cure rate was significantly lower in cases with type 3 PR or with persistent osteolysis.

CONCLUSIONS

It seems that complete resection of both osteolytic area and type 3 PR is necessary to obtain complete healing in patients undergoing marginal mandibulectomy.

Antiviral Activity of Reagents in Mouth Rinses against SARS-CoV-2

The oral cavity, an essential part of the upper aerodigestive tract, is believed to play an important role in the pathogenicity and transmission of SARS-CoV-2. The identification of targeted antiviral mouth rinses to reduce salivary viral load would contribute to reducing the COVID-19 pandemic. While awaiting the results of significant clinical studies, which to date do not exist, the commercial availability of mouth rinses leads us to search among them for reagents that would have specific antiviral properties with respect to SARS-CoV-2. The challenges facing this target were examined for 7 reagents found in commercially available mouth rinses and listed on the ClinicalTrials.gov website: povidone-iodine, chlorhexidine, hydrogen peroxide, cyclodextrin, Citrox, cetylpyridinium chloride, and essential oils. Because SARS-CoV-2 is an enveloped virus, many reagents target the outer lipid membrane. Moreover, some of them can act on the capsid by denaturing proteins. Until now, there has been no scientific evidence to recommend mouth rinses with an anti-SARS-CoV-2 effect to control the viral load in the oral cavity. This critical review indicates that current knowledge of these reagents would likely improve trends in salivary viral load status. This finding is a strong sign to encourage clinical research for which quality protocols are already available in the literature.

Povidone-Iodine Solution: A Potential Antiseptic to Minimize the Risk of COVID-19? A Narrative Review

OBJECTIVES

Patients are mask-free during dental attention. In addition, dentists and dental staff after working for hours need to hydrate or eat. Removing the mask makes them vulnerable to the risk of contamination. For those cases, a prophylactic decontamination protocol could be useful as an adjunct to the most recommended biosecurity protocols. This article aims to provide a comprehensive review of the published evidence about the use of povidone-iodine (PVP-I) against SARS-CoV-2 and to propose a prophylactic protocol for dental attention using PVP-I during the COVID-19 pandemic.

MATERIALS AND METHODS

An electronic search in Medline via PubMed, Scopus, Cochrane Library and Scielo databases was performed up to July 24, 2020, to identify relevant literature focusing on Povidone Iodine, SARS-CoV-2, COVID-19, SARS-COV, MERS, antiviral mouthwashes, and oral cavity.

RESULTS

Clinical studies on the virucidal effectiveness of PVP-I against SARS-CoV-2 have not yet been reported. We identify a recent in vitro study showing PVP-I effectiveness at 0.5, 1, and 1.5% within 15s of contact. Moreover, another in vitro study has shown ≥99.99% virucidal activity as 1% mouthwash and 0.45% throat spray. The only study in SARS-CoV-2 confirmed patients reported a significant 3h drop in viral load after rinsing with 15 mL of 1% PVP-I for 1min.

CONCLUSIONS

Although no clinical trials have reported the efficacy of PVP-I on SARS-CoV-2, recent studies in patients with positive PCR to SARS-CoV-2 found a significant 3-h drop in viral load. We believe that an oral prophylactic protocol with PVP-I for dental healthcare workers and patients as an adjunct to the current biosecurity protocol could minimize the transmission risk during COVID-19 pandemic.

Povidone-iodine solution as SARS-CoV-2 prophylaxis for procedures of the upper aerodigestive tract a theoretical framework

Background

The COVID-19 pandemic has raised concerns of inadvertent SARS-CoV-2 transmission to healthcare workers during routine procedures of the aerodigestive tract in asymptomatic COVID-19 patients. Current efforts to mitigate this risk focus on Personal Protective Equipment, including high-efficiency filtration as well as other measures.

Because the reservoir for SARS-CoV-2 shedding is in the nasopharynx and nasal and oral cavities, the application of viricidal agents to these surfaces may reduce virus burden. Numerous studies have confirmed that povidone-iodine inactivates many common respiratory viruses, including SARS-CoV-1. Povidone-iodine also has good profile for mucosal tolerance. Thus, we propose a prophylactic treatment protocol for the application of topical povidone-iodine to the upper aerodigestive tract.

Conclusion

Such an approach represents a low-cost, low-morbidity measure that may reduce the risks associated with aerosol-generating procedures performed commonly in otorhinolaryngology operating rooms.

Graphical abstract

SARS-CoV-2 Infection: General Characteristics and Specific in Dental Practice

The transmission of the coronavirus and possible routes of infection are still unclear. The most common routes of infection in humans are direct transmission through respiratory droplets and salivа when coughing or sneezing and indirect transmission through contaminated surfaces. Most of the infected people after the incubation period have clinical manifestations with mild or moderate respiratory tract infections (RTIs). Physician of dental medicine performs aerosol procedures which transmit the virus directly from healthy people. Oral fluids, blood, conjunctiva, nasal, and oral mucosa are also a source of infection, so they are highly exposed to the virus, much more than other medical staff and therefore it is crucial to establish appropriate protocols and prevention strategies. Under conditions of a declared global pandemic, dentists are advised to stop their work of all cases that are not urgent. If the dental office is one of those that provide the necessary and urgent medical attention, it is necessary to strictly implement control measures to prevent infection. The basic protocols for the operation of the dental offices have been published by the Dental Chamber of Macedonia and they are recommendations regarding the procedures for the maintenance of the hygiene of the medical staff and the working space. Recent experience has shown that dental health-care services are often neglected and inadequately treated in epidemics. Dental workers are particularly exposed to RTIs due to their specific field and mode of operation, so the current experience will prepare them for future challenges.  

Use of mouthwashes against COVID-19 in dentistry

The proximity to the patient during dental care, high generation of aerosols, and the identification of SARS-CoV-2 in saliva have suggested the oral cavity as a potential reservoir for COVID-19 transmission. Mouthwashes are widely-used solutions due to their ability to reduce the number of microorganisms in the oral cavity. Although there is still no clinical evidence that they can prevent the transmission of SARS-CoV-2, preoperative antimicrobial mouth rinses with chlorhexidine gluconate (CHX), cetylpyridinium chloride (CPC), povidone-iodine (PVP-I), and hydrogen peroxide (H₂O₂) have been recommended to reduce the number of microorganisms in aerosols and drops during oral procedures. This paper therefore aims to provide a comprehensive review of the current recommendations on the use of mouthwashes against the COVID-19 pandemic and to analyse the advantages and disadvantages of most conventional antiseptic mouthwashes used in dentistry.

Inhibitory effect of topical antibiotics/antiseptics administration on bacterial growth in the open wound of the jawbone surgery: Randomized controlled, preliminary study

Background/purpose

TThe bone cavities after extirpation of cysts or tumor of the jawbone requires the insertion of gauze containing various antibiotics/antiseptics to minimize the risk of pain, bleeding, and surgical site infection (SSI). However, there have been few reports on the efficacy of topical administration of antibiotics/antiseptics to an open wound of the jawbone. To compare the inhibitory effects of topical povidone-iodine gel and tetracycline ointment on the jawbone wound bacterial growth after extirpation of cyst or tumor.

Materials and methods

This is a preliminary, randomized controlled, open-labeled trial. Eighteen patients were randomly assigned into two groups. In povidone-iodine (PI) group, gauze mixed with povidone-iodine gel was inserted into the bone cavity wound, and in tetracycline (TC) group gauze mixed with tetracycline ointment was inserted after extirpation of cyst or tumor of the jaw bone. In both groups, gauze was removed 48 h after surgery, and examined by bacterial culture and real-time polymerase chain reaction (PCR) using primers detecting total bacteria and MRSA.

Results

The topical application of tetracycline ointment was superior to that of povidone-iodine gel concerning inhibitory effects of total bacteria and methicillin-resistant Staphylococcus aureus (MRSA).

Conclusion

This preliminary study suggests that the insertion of gauze mixed with tetracycline ointment is recommended for bone wounds after extirpation of cyst or tumor of the oral cavity.

Rapid In-Vitro Inactivation of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Using Povidone-Iodine Oral Antiseptic Rinse

PURPOSE

To investigate the optimal contact time and concentration for viricidal activity of oral preparation of povidone-iodine (PVP-I) against SARS-CoV-2 ('corona virus') to mitigate the risk and transmission of the virus in the dental practice.

MATERIALS AND METHODS

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) USA-WA1/2020 strain, virus stock was tested against oral antiseptic solutions consisting of aqueous povidone-iodine (PVP-I) as the sole active ingredient. The PVP-I was tested at diluted concentrations of 0.5%, 1%, and 1.5%. Test media without any virus was added to 2 tubes of the compounds to serve as toxicity and neutralization controls. Ethanol (70%) was tested in parallel as a positive control, and water only as a negative control. The test solutions and virus were incubated at room temperature (22 ± 2 °C) for time periods of 15 and 30 seconds. The solution was then neutralized by a 1/10 dilution in minimum essential medium (MEM) 2% fetal bovine serum (FBS), 50 µg/mL gentamicin. Surviving virus from each sample was quantified by standard end-point dilution assay and the log reduction value (LRV) of each compound compared to the negative (water) control was calculated.

RESULTS

PVP-I oral antiseptics at all tested concentrations of 0.5%, 1%, and 1.5%, completely inactivated SARS-CoV-2 within 15 seconds of contact. The 70% ethanol control group was unable to completely inactivate SARS-CoV-2 after 15 seconds of contact, but was able to inactivate the virus at 30 seconds of contact.

CONCLUSIONS

PVP-I oral antiseptic preparations rapidly inactivated SARS-CoV-2 virus in vitro. The viricidal activity was present at the lowest concentration of 0.5 % PVP-I and at the lowest contact time of 15 seconds. This important finding can justify the use of preprocedural oral rinsing with PVP-I (for patients and health care providers) may be useful as an adjunct to personal protective equipment, for dental and surgical specialties during the COVID-19 pandemic.

Topical preparations to reduce SARS-CoV-2 aerosolization in head and neck mucosal surgery

AIM

The COVID-19 pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has put health care workers at risk when exposed to aerosolized viral particles during upper airway mucosal surgery. The objective of this review was to discuss topical preparations that could be utilized preoperatively to help to decrease viral load and potentially reduce the risks of viral transmission.

METHODS

A PubMed/MEDLINE database review of articles was performed querying topical preparations with virucidal activity against coronaviruses.

RESULTS

Povidone-iodine (PVP-I) solutions ranging from 0.23% to 7% have been found to demonstrate highly effective virucidal activity against a broad range of viruses including several coronaviruses responsible for recent epidemics including SARS-CoV-1 and MERS-CoV.

CONCLUSIONS

While specific evidence regarding SARS-CoV-2 is lacking, PVP-I-based preparations have been successfully demonstrated to reduce viral loads of coronaviruses. They are relatively safe to use in the upper airway and may reduce risk of SARS-CoV-2 aerosolization during upper airway mucosal surgery.