applied sciences Article Evaluation of new Seawater-based Mouth Rinse Versus Chlorhexidine 0.2% Reducing Plaque and Gingivitis Indexes. A Randomized Controlled Pilot Study José Luis Calvo-Guirado 1,* , Manuel Fernández Domínguez 2, Juan Manuel Aragoneses 3 , José María Martínez González 4, Enrique Fernández-Boderau 5 , Miguel Angel Garcés-Villalá 6 , Georgios E. Romanos 7 and Rafael Arcesio Delgado-Ruiz 8 1 Oral and Implant Surgery Faculty of Health Sciences, Universidad Católica San Antonio de Murcia (UCAM), 30170 Murcia, Spain 2 Department of Oral Surgery and Implantology and Director of Research in Dentistry in the Doctoral Program of Translational Medicine, CEU San Pablo University, 28223 Madrid, Spain; [email protected] 3 Department of Dental Research, Universidad Federico Henríquez y Carvajal (UFHEC), Santo Domingo 10107, Dominican Republic; [email protected] 4 Department Oral Surgery, University Complutense of Madrid, 28223 Madrid, Spain; [email protected] 5 Carrera Especialización en Prótesis Fija, Removible e Implantología, Facultad de Odontología, Universidad Nacional de Córdoba, Córdoba X5000HUA, Argentine; [email protected] 6 Department of Implant and Biomaterial Research, Fundación Corazón de Jesús, Av. Rawson 1373 sur, San Juan 5400, Argentina; [email protected] 7 Department of Periodontology, School of Dental Medicine, Stony Brook University, Stony Brook, NY 11794-8712, USA; [email protected] 8 Department of Prosthodontics and Digital Technology, School of Dental Medicine, Stony Brook University, Stony Brook, NY 11794-8712, USA; [email protected] * Correspondence: [email protected] Received: 23 December 2019; Accepted: 26 January 2020; Published: 3 February 2020 Featured Application: The use of this seawater mouth rinse reduce the effect of aggressive oral bacteria, taste, and numbness problems. Abstract: For a long time, Chlorhexidine digluconate (CHX) has been considered the most used mouth-rinse for reducing plaque and gingivitis. Sea4® Encias is a new seawater-based mouth rinse with a similar action to CHX. Its prolonged use produces fewer side effects. This study compared the effects of two oral rinses: Chlorhexidine 0.20% and Sea 4® Encias (seawater) for reducing plaque and gingivitis indices. This double-blind crossover study recruited and monitored 93 volunteer dental students, hygienists and doctors from the Universidad Católica de Murcia (UCAM), for 1 month, and compared the efficacy of Chlorhexidine 0.20% (Group A); Sea4® Encías (Group B); and a placebo saline solution (Group C) mouth-rinses for reducing plaque and gingivitis indices. Plaque and gingival inflammation (Löe and Silness test) were evaluated at baseline and after each study stage. Group A reduced plaque growth and gingivitis significantly compared with Groups B and C; Group B was more effective than Group C. The mean P.I. decreased similarly in groups A and B. However, Group A showed the statistically significant value compared with other groups. Group A and group B, showed greater reduction in Gingival Indexes compared with group C. The Sea4 mouthwash showed better inhibitory activity on plaque (1.32 0.22) compared with CHX (1.97 0.34) and saline ± ± (2.78 0.11). Sea4 Encias and Chlorhexidine 0.20% mouth-rinses significantly reduce plaque growth ± and G.I. compared with saline mouth-rinse; Sea4 Encías mouth-rinse is more effective against plaque regrowth than Chlorhexidine in this pilot study. Keywords: chlorhexidine; gingivitis; oral mouth rinse; plaque; seawater mouth rinse Appl. Sci. 2020, 10, 982; doi:10.3390/app10030982 www.mdpi.com/journal/applsci Appl. Sci. 2020, 10, 982 2 of 10 1. Introduction Many bacteria present in the mouth cannot be eliminated properly with daily brushing, and can be present in the preservation of healthy dental and periodontal tissues [1]. Gingivitis begins with plaque build-up, which will end in periodontitis [2]. In this context, much research has investigated the efficacy of several types of mouthwash, which are designed to improve plaque and gingivitis levels. V-Sol containing alcohol, as well as essential oils (E.O.), have been shown to offer beneficial effects on plaque and gingivitis index, where it seems to significantly improve oral health six months after use [3,4]. Different mouthwashes containing natural compounds (NCCM) versus E.O. mouthwash (Listerine®) demonstrated their effectiveness for plaque control [4,5]. Another study evaluated the effects of E.O. that reduces plaque and gingivitis compared to cetylpyridinium chloride (CPC) and a placebo. Essential oils showed a better effect than mechanical plaque control (MPC) and CPC, reducing plaque and gingival inflammation in patients who may suffer gingivitis. Therefore, mouthwashes containing E.O. should be the first option for mechanical plaque control [6–8]. The therapeutic application of natural compounds showed that these compounds have some efficacy in the fight against gingivitis and periodontitis [9–13]. However, evidence that the efficiency and effectiveness of NCCM, as routine methods that help mechanical oral hygiene practices for plaque control and gingivitis has remained low, and it seems that some NCCMs may offer various oral health benefits by reducing the plaque and gingivitis [14]. The main side effects of alcohol-containing mouthwashes (ACM) were oral pain, burning sensation, and taste disturbances [14–17]. When the clinical efficacy of two 0.2% chlorhexidine mouthwash (CHX) formulations are compared, the alcohol-free chlorhexidine rinse demonstrated action levels similar to the use of frequently used alcohol-formed rinses [18]. Some of the most frequent side effects from the use of CHX are staining of the tongue and teeth, as well as taste alteration, as CHX is a rinse that is very effective in reducing plaque and gingivitis. Some authors describe moderate evidence when oxygenating agent (OA) and CHX work together to reduce teeth staining, without interfering with the inhibition of plaque growth [19,20]. Mouthwashes with seawater could offer a promising alternative for CHX to overcome its possible adverse effects. Balneotherapy with spa water or the Dead Sea water can be used to treat inflammatory skin diseases (psoriasis and atopic dermatitis). This effect of seawater has been attributed to the preservation of the skin barrier induced by NaCl and KCl [21]. Only one study has investigated the use of a mouthwash solution with sea salt in street children in Manila, demonstrating its effectiveness in reducing mild to severe forms of periodontal disease. The authors proposed sea salt mouthwash for its antimicrobial action, which is highly effective and well-tolerated by the user and could be implemented worldwide using low-cost resources [22]. This is considered to be the first pilot study t which compares the clinical efficacy of 0.2% chlorhexidine with a new mouthwash formulated with seawater (analyzed for the first time) and a saline solution, in reducing gingiva inflammation and plaque formation. 2. Material and Methods Undergraduate students, hygienists and doctors of the Universidad Católica de Murcia (UCAM, Catholic University of Murcia), School of Medicine and Dentistry, volunteered to take part in the study. The sample included 39 males and 54 females aged between 19 and 42 years, as a pilot study. This double-blind crossover study recruited 93 volunteer dental students (eighty one), hygienists (four) and doctors (eight). The UCAM Research and Ethics Committee at the Faculty of Medicine and Dentistry approved the study protocol, and subjects gave their informed consent to participate. The study was conducted in accordance with the CONSORT statement. The inclusion criteria were as follows: - Healthy patients with at least 26–32 permanent teeth; Appl. Sci. 2020, 10, 982 3 of 10 Appl. Sci. 2019, 9, x FOR PEER REVIEW 3 of 10 - Non-smokers, with good oral health, presenting probing depths 3 mm, no active dental caries, ≤ no fixed- Non-smokers, or removable prostheses,with good andoral orthodontic health, presenting devices. probing depths ≤ 3 mm, no active dental caries, no fixed or removable prostheses, and orthodontic devices . Exclusion criteria Exclusion criteria Exclusion criteria were as follows: Exclusion criteria were as follows: - Subjects- Subjects with systemic with systemic diseases, diseases, caries, or caries, active or periodontal active periodontal disease; disease; - Subjects- Subjects with crowns, with orcrowns, an orthodontic or an orthodontic treatment; treatment; - Subjects- Subjects taking antibiotics taking antibiotics or anti-inflammatory or anti-inflammatory drugs, or drugs, any other or an medication;y other medication; - Subjects- Subjects with an allergywith an to allergy any of to the any ingredients of the ingredients of the mouth of the rinse. mouth rinse. The presence of plaque was evaluated using the Plaque Index (PI Silness and Löe). These index measurementsThe presence were of plaqueperformed was evaluatedat three points using of the bo Plaqueth, the Indexlingual (PI and Silness buccal and surfaces Löe). These of all indexteeth, measurementsclassifying the data were as performed a 0–3 score: at 0 three = absence points of of plaque; both, the1 = no lingual plaque; and 2 buccal= moderate surfaces accumulation of all teeth, of classifyingplaque; 3 = the abundant data as aaccumulation 0–3 score: 0 = ofabsence plaque of on plaque; the dental 1 = no surfaces. plaque; 2Ging= moderateival Inflammation accumulation was ofevaluated plaque; 3using= abundant the