Efficacy of Commercial Mouth Rinses

International Dental Journal of Student Research 2020;8(2):48–52

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International Dental Journal of Student Research

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Original Research Article Efﬁcacy of commercial mouth rinses containing chlorhexidine, sodium ﬂuoride-triclosan- xylitol against salivary bacteria, streptococcus mutans: A microscopic study

Abhimanyu Rohmetra1,*, Niharika Gupta2, Shubham Gupta3, Srishti Beera3, Nupur3

1Dept. of Orthodontics, Institute of Dental Sciences, Sehora,, Jammu, Jammu & Kashmir, India 2Dept. of Oral Surgery, D.A.V Centenary Dental College, Yamuna Nagar, Haryana, India 3Dept. of Pediatric and Preventive Dentistry, Lucknow, Uttar Pradesh, India

ARTICLEINFO ABSTRACT

Article history: Objective-The purpose of the present study is to compare the efficacy of three commercially available Received 02-06-2020 mouth rinses containing chlorhexidiene and sodium fluoride-triclosan- xylitol respectively against salivary Accepted 09-06-2020 bacteria, streptococcus mutans. Available online 06-08-2020 Materials and Methods: A sample of 72 subjects was selected from the single school and was randomly equally divided into 3 groups. The subjects were instructed to rinse the mouthwash 10 ml of mouthwash for one minute twice daily for fifteen days. Number of colony of Streptococcus mutans were counted by Keywords: using Mitis Salivarius agar plate, at the beginning and at the end of the study period. Chlorhexidine Inter group and intra group comparisons were done. Intra group comparisison was assessed using Wilcoxon signed rank test (non-parametric equivalent to paired‘t’ test) whereas the difference between three groups was assessed using Kruskal-Wallis Annova. Results: In the present study, no statistically significant difference was found between the mouthwashes with regard to their efficacy in reducing S mutans Conclusion: All the commercial available mouthwashes are equally potent in reducing s mutans counts effectively.

1. Introduction mouthwashes are capable of inhibiting bacterial adhesion, colonization and metabolic activity which ultimately affects Prevalence of dental caries in children population is bacterial growth. 2 increasing at an alarming rate. 1 The modern concepts of cariogram demonstrate micro-organisms as one of the major Chlorhexidine gluconate is known as “gold standard” of 2 etiological factor in the formation of dental caries. all mouth rinse. It is a cationic bis-biguanide, active against Streptococcus mutans is considered one of the most an array of micro-organisms, including gram-positive and important cariogenic species of the human oral microbial gram-negative organisms, fungi, yeasts, and viruses. When 3 ﬂora. Therefore, targeting Streptococcus mutans forms is used as a mouthwash, its mode of action is purely topical the most important measure for prevention of dental caries. and because it is poorly absorbed systemically, it is regarded To cut back their level in the oral cavity will provide as a relatively safe drug. 4 Chlorhexidine has got certain 2 an additional goad for the prevention of dental caries. side effects like long-term use like brown discoloration of Mouthwashes have been found to be one of the safe and teeth, some restorative materials and dorsum of tongue; effective delivery system as anti-microbial agent. These taste perturbation; oral mucosal ulcerations and paresthesia; * Corresponding author. unilateral/bilateral parotid swelling, and enhanced supra- E-mail address: [email protected] (A. Rohmetra). gingival calculus formation. 5 https://doi.org/10.18231/j.idjsr.2020.011 2394-708X/© 2020 Innovative Publication, All rights reserved. 48 Rohmetra et al. / International Dental Journal of Student Research 2020;8(2):48–52 49

Fluorides are abundantly used in oral health products cultured. The teachers were educated and trained in the use including mouth rinses. Sodium fluoride mouth rinses of mouthwash so that the children, under the supervision of are effective in reducing caries and inhibit carbohydrate the teachers, could use the mouthwash. Each of the groups utilization of oral microorganisms by blocking enzymes used the respective mouthwash, as a daily, supervised rinse involved in the bacterial gylcolytic pathway. 6 after lunch in the afternoon. The children were advised not Triclosan is a non phenolic, broad spectrum antimicro- to eat or rinse for the next 30 min. They were instructed to bial & anti plaque agent. It is used to increase the ability carry home the mouthwash bottles on weekends. of mouthwashes to bind to oral mucosa and therefore is available for longer period of time. 7 2.2. Incubation and Microbiological Enumeration Xylitol is a naturally occurring non cariogenic sugar Saliva samples were serially diluted in 6 fold steps in substitute that cannot be metabolized by oral bacteria. 6 It normal saline. The serial dilution was carried out in pre- inhibit bacterial growth through two mechanisms: direct prepared sterile water blanks of 9ml each. 20 µl of saliva inhibition of the glycolytic route resulting from the xylitol sample were spread on mitis salivarius agar (Hi Media 5-phosphate derivative and/or indirect inhibition resulting Company, India) supplemented with 0.2 U/ml bacitracin from the competition for the HPr-P carrier between glucose (Hi Media Company, India) and sucrose (15% w/v) using and xylitol. 3 cotton swab for S. mutanscount. The preparation of media, required sterilization and pouring of plates were done one 2. Materials and Methods day before the plating of cultures. All the plates were kept A sample of 72 subjects was selected from the single school in incubator for one hour before the saliva samples were of Jodhpur city and was equally divided into 3 groups. spread on it. Care was taken that all this procedure of serial Group A- Rexidiene mouthwash (Chlorhexidine) dilutions and plating was done in work station called as Group B- Kidodent mouthwash (Sodium Fluoride- Laminar Air Flow work station, it provides work space for Xylitol- Triclosan) sterile transfers. Petri-dishes were then kept in candle jar Group C- Distilled water (Positive control) at 37ºC for 48 hours, than the plates were kept in anaerobic Prior to the study, written consent was obtained of chambers and then placed in incubators at 37ºC for 48 hours. school. Ethical clearance was obtained from the ethical The identification of colonies were done using morphology committee of the institution. The subject with at least one and characteristics observed under light microscope. The active white spot on smooth surfaces (facial or lingual) confirmation of MS was done under light microscopy after was considered a high caries activity subject. The presence heat fixed smear slide. Additional confirmation was done of the active lesions on these surfaces and a high caries using gram staining and catalase negative confirmation test. activity imply that the subject has a high infection of mutans Microbial counts were further expressed as colony forming streptococci which means that he/she belongs to high caries units (CFU) per ml of stimulated saliva. risk group. 1. Score 1 < 104CFU/ml 2. Score 2 104- 105CFU/ml 2.1. Exclusion criteria 3. Score 3 105 -106 CFU/ml 1. Physical limitations, which precluded the normal tooth 4. Score 4 > 106 CFU/ml brushing and mouth rinsing Data was analyzed using SPSS software version 17. Intra 2. Marked intra oral soft tissue pathology group comparison was done using Wilcoxon signed rank 3. 3. Medically compromised patients and subjects with test (non-parametric equivalent to paired‘t’ test) whereas history of taking antibiotics 3 months prior to or during the difference between three groups was assessed using the course of study. Kruskal-Wallis Annova. 4. Subjects undergoing orthodontic treatment or with extensive intra prosthesis 3. Results 5. Children who could not brush their teeth or rinse on their own This study was conducted to compare the effectiveness 6. Presence of any intraoral soft tissue pathology of commercially available mouthwashes against salivary Streptococcus mutans among 8-12 years old school Stimulated saliva was collected for microbial analysis. children. The subjects were asked to simulate chewing action with The mean streptococcus mutans counts of Group A sterilized cotton rolls for 4 min. At the end of 4 min, the (chlorhexidienr group) post rinsing is 1.87, Group B students were made to expectorate into sterile container. The (Sodium Fluoride-Xylitol- Triclosan group ) is 2.00 stimulated saliva was then transported for analysis within It showed statistically significant reduction in Streptoco- 30 min in ice boxes. Standardization of the saliva collection cusmutans count (P=0.001) technique was followed and the same day all samples were It showed statistically non significant results (0.08) 50 Rohmetra et al. / International Dental Journal of Student Research 2020;8(2):48–52

Table 1: Comparison of mutans streptococci counts between study groups and control group before and after rinsing Group A Group B Group C Mutans Streptococci Scores Pre Rinse Post Rinse Pre Rinse Post Rinse Pre Rinse Post Rinse 1 2 6 2 5 2 3 2 2 6 3 6 3 2 3 5 2 6 3 6 6 4 6 1 4 1 4 4

Table 2: The means of streptococcus mutans count of all the test groups and control group before rinsing and after rinsing Group -A n Mean SD Median Range Pre Rinsing 15 3 1.07 3.0000 3 Post Rinsing 15 1.87 0.92 2.0000 3 Group -B Pre Rinsing 15 2.80 1.01 3.0000 3 Post Rinsing 15 2.00 0.96 2.0000 3 Group -D Pre Rinsing 15 2.80 1.01 3.0000 3 Post Rinsing 15 2.64 1.08 3.0000 3

Table 3: Comparison of Pre-rinse and Post-rinse between Group A Group A n Mean SD p-value Pre- Rinse 15 3 1.07 0.002* Post –Rinse 15 1.87 0.92

Table 4: Comparison of Pre Rinse And Post Rinse Between Group B Group B n Mean SD p value Pre- Rinse 15 2.80 1.01 0.001* Post –Rinse 15 2.00 0.96

Table 5: Comparison of Pre Rinse and Post Rinse between Group C (Water) Group D n Mean SD p value Pre- Rinse 15 2.80 1.01 0.08 Post –Rinse 15 2.64 1.08

4. Discussion previous study conducted by Bajaj N and Tandon S. 10 This study was undertaken to evaluate the efficacy of According to the review by Lemos-Junior CA and commercially available mouthwashes on salivary Strepto- Villoria GE ingestion of large amount of alcohol in mouth- coccus mutans on school children aged 8-12 years. These wash affect normal glycogenolysis and glyconeogenesis, students were divided into three groups. Group A used causing hypoglycemia. 11 The extrahepatic metabolism of Rexidiene (0.2% chlorhexidiene) mouthwash, Group B alcohol in oral tissue has been testified. In the human Kidodent (Sodium Fluoride-Triclosan-Xylitol) mouthwash, mouth, aldehyde dehydrogenase (ALDH), an enzyme that Group C used Distilled water. converts acetaldehyde into a nontoxic acetate compound, In the present study saliva samples were used in this occurs less frequently than alcohol dehydrogenase (ADH). study to assess the microbial aspect of dental caries. This imbalance allows for the accumulation in oral tissues According to Mundroff et al and Sullivan et al detection of of a toxic, reactive and irritating acetaldehyde. The Streptococci in saliva was an excellent means as compared continuous use of mouthrinses containing alcohol should be to either pooled plaque or oral swab samples, as these avoided. Due to a point mutation, aldehyde dehydrogenase samples do not explain the variation in caries better than 2(ALDH2) isoenzyme is deficient in 30–50% of Asians. the stimulated whole saliva. 8,9 These individuals have a genetic inability to remove In the present study the subjects were asked to simulate acetaldehyde and consequently have very high salivary chewing action with sterilized cotton rolls for 4 min. At acetaldehyde levels after moderate dose of alcohol. 6 the end of 4 min, the students were made to expectorate Therefore all the mouthwash selected for this study been into sterile penicillin bottles. This was in accordance to the alcohol free. Rohmetra et al. / International Dental Journal of Student Research 2020;8(2):48–52 51

Children in Group A used commercially available 1. Group A, using Rexidine mouthwash (0.2% Chlorhex- mouthwash Rexidiene, containing 0.2% chlorhexidiene. idiene) showed significant reduction in reducing Ernst stated that the increase in concentration of chlorhex- streptococcus mutans count. (p= 0.002) idine from 0.1 to 0.2% provided no clinical advantages 2. 2. Group B, using Kidodoent mouthwash (Sodium or disadvantages. 12 An another study also states that Fluoride-Xylitol-Triclosan) showed significant reduc- the chlorhexidine used in different concentrations (0.02%, tion in reducing streptococcus mutans count. (p=0.001) 0.06%, 0.12%) efficiently reduced the S mutans count 3. When all the mouthwashes were compared there was and also by reducing the concentration of chlorhexidine, no significant difference in reduction of streptococcus the bitter taste sensation is also reduced, making it mutans count.(p= 0.16) more acceptable to children. 13 Hence, in this study 0.2% concentration was used.In the present study 0.2% 6. Source of Funding chlorhexidine has shown significant reduction in the mutans streptococci count (Table 3).This observation adds to the None. earlier studies 14–17 Children in Group B used commercially available mouth- 7. Conflict of Interest wash Kidodent containing Sodium Fluoride-Triclosan- None. Xylitol as main ingredients. According to a study 18 conducted, the use of fluoride mouthwash seems to be References effective in both large group and individual studies. 0.05% sodium fluoride mouthwash is a weak solution which can 1. Hegde PP, Kumar BA, Ankola VA. Dental caries experience and salivary levels of Streptococcus mutans and Lactobacilli in 13-15 years be used daily, whereas 0.2% sodium fluoride mouthwash old children of Belgaum city, Karnataka. J Indian Soc Pedod Prev is stronger and should be used once a week. Xylitol has Dent . 2005;23(1):23–6. been incorporated into fluoride–containing mouthwashes. In 2. Kulkarni VV, Damle SG. Comparative evaluation of efficacy of sodium fluoride, chlorhexidine and triclosan mouth rinses in reducing vitro studies have suggested that fluoride and xylitol exert an the mutans streptococci count in saliva: An in vivo study. J Indian additive inhibitory effect on growth and acid fermentation SocPedod Prev. 2003;21:98–104. by S.mutans. 19,20 3. Paula VAC, Modesto A, Santos KRN, Gleiser R. Antimicrobial In the present study there was a significant reduction effects of the combination of chlorhexidine and xylitol. Br Dent J . 2010;209(12):E19. in the S.mutans count scores within the group after 4. 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