An Effective Mouth Rinse for In-office Preprocedural and Home Use

Various rinses are commonly used in dental practices as an in-office preprocedural mouth rinse (PPMR) and for patient homecare to achieve oral bacterial and infection control in the post-surgical initial healing phase.¹ Clinicians, healthcare workers, and patients potentially come in contact with bio-aerosols which originate from various sources. These and the potentially pathogenic nature of bioaerosols possesses severe biohazards.² Cross-infection can be caused by aerosols released during dental procedures, including the commonly occurring oral microorganisms like Streptococcus pyogenes, Veillonella parvula, Actinomyces species, and Fusobacterium nucleatum. This also includes pathogenic organisms like Mycobacterium tuberculosis, Legionella pneumophilia, and Staphylococcus species.^3,4 Evidence suggests that aerosol in a dental clinic can spread 1-3 meters from its source and can cause infection on distant surfaces.² On the contrary, spatter spreads over shorter distances and settles down rapidly. Regarding airborne illness, aerosol in dental clinics is a significant concern.² Accordingly, the use of preprocedural mouth rinses (PPMRs) is universally recommended to reduce oral bacterial counts prior to surgery and potentially minimize the spread of contaminated aerosols.^1,5

Mouth rinses have been used due to their ability to potentially reduce the number of microorganisms in the oral cavity before and after surgery.¹ One such rinse that has been critically evaluated, is Chlorhexidine Gluconate (CHX). CHX, a bisbiguanide base, is a cationic antiseptic with broad-spectrum antibacterial activity (against Gram-positive and Gram-negative bacteria and certain mycetes).⁶ Different concentrations are available on the market (ranging from 0.02% to 0.3%). The action of CHX is dose-dependent: bacteriostatic at low concentrations (0.02%-0.06%) and bactericidal at higher concentrations (0.12-0.2%).^6,7 It has been widely used in dentistry for years to reduce dental plaque and treat periodontal disease; and was believed to be the gold standard in antiseptic treatment of the oral cavity.⁷ It is a lipophilic cationic molecule that can interact with the lipopolysaccharide and phospholipids within the bacterial cell membrane, entering the cell through an active transport mechanism.⁸ However, recent advancements in research indicates their cytotoxic effects on cell viability.⁹ Multiple in vitro studies have supported the claims that CHX has demonstrated cytotoxicity to fibroblast cells,⁹ decrease in the fibroblast cell proliferation and cell divisions,^9,10 negative affect on cell migration and reduced survival rate of myoblasts and osteoblasts.⁹ These essential cells are responsible for the extracellular matrix and collagen that form the structural framework of tissues and play an important role in tissue repair.¹⁰ In addition, CHX has recently been reported to exert dose-dependent, mild trans-dentinal toxic effects on odontoblast-like cells,¹² as well as inhibiting the mineralization potential of multipotent stem cells derived from human exfoliated deciduous teeth.¹³ This brings to question the safety and clinical effects of CHX on wound and tissue healing post-surgery.

Several clinical trials have described the occurrence of side effects associated with the use of CHX, such as tooth and mucosa pigmentation, staining of teeth, restorations, and tongue; taste alteration; and increased calculus formation.^14,15 Studies have shown reports of rare hypersensitivity reactions to CHX following topical application on the mucosae.^16-18 CHX was also compared for its efficacy against viral components in a recent review article published in the British Journal of Oral and Maxillofacial Surgery, which showed that: 0.12% CHX gluconate has little or no effect against coronaviruses when compared with other mouthwashes.¹⁹ In addition, both Imran et al.²⁰ and Meister et al.²¹ have shown that CHX did not significantly reduce the viral load of SARS-CoV-2.

X-PUR Opti-Rinse Plus

X-PUR Opti-Rinse Plus is a Health Canada approved non-prescription mouth rinse that includes a patented formulation that includes:

• Cetylpyridinium Chloride (CPC)
• Bioflavonoid compounds (Citrox®)
• Sodium Fluoride (NaF)
• Xylitol

The mouth rinse is available as X-PUR Opti-Rinse Plus 0.05% (225 ppm F) and X-PUR Opti-Rinse Plus 0.2% (905 ppm F) (Fig.1). The X-PUR Opti-Rinse Plus as a mouth rinse is alcohol-free; has a pH in the neutral zone; does not have side effects such as tooth staining, taste alteration, or increased calculus formation and is available over the counter without a prescription. X-PUR Opti-Rinse Plus is sweetened with 10% xylitol which provides a pleasant taste to the users.

Fig. 1

In terms of mechanism of action, the X-PUR Opti-Rinse Plus (0.05% and 0.2%) provides a synergistic and effective combination of CPC, xylitol, Citrox®, and NaF. Cetylpyridinium chloride (CPC) has been safely and effectively used for decades as an antimicrobial ingredient in mouth rinses.^22,23 By disrupting the microbial lipid bilayer, CPC is effective both preventatively and therapeutically against bacterial and fungal infections.^22-24 More recently, CPC has demonstrated effectiveness against respiratory viral pathogens, with no acquired resistance to CPC, despite prolonged exposure.²³

Bioflavonoids are plant-based antimicrobials derived from citrus fruits and used by plants in response to microbial infection – viral, bacterial, and fungal.^25-28 Citrox® is a potent and patented combination of antimicrobials that aids in keeping the oral mucosa protected and reduces the risk of infection. Citrox® has been proven to have antimicrobial effectiveness in both planktonic microorganisms and in biofilms,^25,27,29 potentially functioning well as a PPMR to reduce microbial contamination. With a demonstrated higher antiviral activity than traditional antiseptics, Citrox® has been tested for virucidal activity against both enveloped and non-enveloped viruses, destroying the viral envelope in less than 1 minute and deactivating the viral ability to infect cells.²⁸

The use of 0.05% sodium fluoride oral rinse two times a day provides a caries preventive fraction of 24%, which is the equivalent of the preventive fraction gained from a fluoride toothpaste used two times a day. The weekly use of a sodium fluoride rinse with a stronger concentration of 0.2% provides a similar caries preventive fraction of 21%. This means there are no significant differences on the preventive fraction between a daily use of 0.05% and 0.2% sodium fluoride rinses.

The Instructions for Use as an in-office preprocedural mouth rinse (PPMR) suggests rinsing with 10 ml for 1 minute and then expectorate. As a home-care rinse it is suggested to rinse with 10 ml for 1 minute daily and then expectorate. It is advisable to not eat, drink, or rinse for 30 minutes. X-PUR Opti-Rinse Plus (0.05 and 0.2%) helps prevent/reduce plaque accumulation and gingivitis, aids remineralization of enamel, has an anti-cavity effect, helps prevent the tooth decay process at the earliest stage, offers protection of teeth from acid wear/erosion, and kills microbes that cause halitosis.

The Anti-Bacterial and Anti-Viral Efficacy of X-PUR Opti-Rinse Plus

Research conducted upon X-PUR Opti-Rinse Plus 0.2% and the X-PUR Opti-Rinse Plus 0.05% (at the Faculty of Dentistry at the University of Toronto) compared favourably to a prescription rinse containing 0.12% chlorhexidine for their ability to kill and/or inhibit several oral pathogens, including:

• Porphyromonas gingivalis, a proteolytic anaerobe associated with periodontal disease, that mainly affects adults by causing destruction of alveolar bone resulting in eventual tooth loss. This bacterium has also been shown to colonize within distal organs, including the heart^30,31 and brain,³² potentially causing systemic disorders such as heart and Alzheimer’s disease.
• Streptococcus mutans, the most common bacteria associated with the initiation of caries, predominant in childhood caries.³³
• Streptococcus sobrinus, an additional risk factor exacerbating caries activity.³³
• Lactobacillus casei, predominant in childhood caries.³⁴
• Candida albicans, positively associated with early childhood caries,^35,36 a comorbidity of hyposalivation,³⁷ predominant in long-term care residents with prostheses, and a risk factor for pneumonia.³⁸

After exposure to the full strength rinses for one minute, all rinses demonstrated: a 3-log reduction (i.e. 99.9% killing) against P. gingivalis; in C. albicans, there was at least a 4 log reduction (>99.9% killing); L. casei was killed with >99.9% efficiency; S. mutans showed at least 99% of the tested cells were killed; for S. sobrinus, no colonies were detected with any of the rinses for the exposure time detected (>99.9% killing). When compared to two leading chlorhexidine gluconate rinses, X-PUR Opti-Rinse Plus rinses had equivalent effectiveness at killing (Table 1). The Minimum Inhibitory Concentration (MIC) values of both Opti-Rinse Plus formulations demonstrate effective inhibition even at low concentrations of the rinses. At just 0.39% strength, both Opti-Rinse Plus mouth rinses exhibited effective killing of S. mutants, S. sobrinus, and L. casei. The MIC are expressed as the lowest concentration of an antimicrobial that will inhibit the visible growth of a microorganism after overnight incubation. Additionally, neither X-PUR Opti-Rinse Plus formulations were shown to produce IL-8, a pro-inflammatory mediator.

Table 1

Treatment	MIC (%) for S. mutans	MIC (%) for S. sobrinus	MIC (%) for L. casei	MIC (%) for C. albicans
No Treatment	No Inhibition	No Inhibition	No Inhibition	No Inhibition
X-PUR 0.05%	0.39%	0.39%	0.39%	3.12%
X-PUR 0.2%	0.39%	0.39%	0.39%	6.25%

In the natural environment of dental plaque, bacteria grow as a biofilm attached to the tooth surface. When the rinses were tested against biofilm-grown cells, the most prominent effect was observed with P. gingivalis and X-PUR Opti-Rinse Plus 0.2% treatment, with a 50% reduction in biofilm biomass after 10 minutes of exposure. With X-PUR Opti-Rinse Plus 0.05%, there was a 40% reduction in biofilms, while the chlorhexidine rinse was only able to reduce biofilms by 10%. These findings suggest that X-PUR Opti-Rinse Plus (0.05% & 0.2%) are proven mouth rinses for optimal outcomes.

An effective pre-procedural oral rinse was previously discussed in a study from 2017 by Retamal-Valdes et al.³⁹ reviewing the effectiveness of the use of combining CPC and NaF (neutral sodium fluoride). Their results showed that oral aerosol/splatter from subjects who rinsed with a mouthwash containing CPC and fluoride, before receiving an ultrasonic prophylaxis, harbored a significantly lower bacterial content.³⁹ Research also concluded that when study subjects rinsed with a 0.05% CPC before ultrasonic scaling, the amount of bacteria in the spatters and also the virulent potential of the spatter was reduced.²⁴

Oral Science initiated the process for testing X-PUR Opti-Rinse Plus against the SARS-CoV-2 virus with the Institute for Antiviral Research (IAR) at Utah State University, established 40 years ago to identify antiviral agents and vaccines against a wide range of human pathogenic viruses. Testing was completed by the IAR in January 2021, confirming the X-PUR Opti-Rinse Plus 0.2% and the X-PUR Opti-Rinse Plus 0.05% were both cytotoxic to SARS-CoV-2 viral cells, and exhibited virucidal activity, reducing the virus below the limit of detection after a 1-minute contact time (LRV>1.9, >90%), equivalent to a 98.74% reduction. X-PUR Opti-Rinse Plus, due to the presence of Citrox®, contains enzyme inhibitors that are essential for coronaviral replication.⁴⁰

Current scientific evidence validates the use of X-PUR Opti-Rinse Plus for in-office application as a PPMR and for homecare, and unlike chlorhexidine, there is an added benefit of no contraindications or side effects. This information should assist the dental professional with selecting X-PUR Opti-Rinse Plus for their patients.

Conclusion

Mouth rinses have been used due to their ability to not only reduce the number of microorganisms in the oral cavity before and after surgery, but to also play a vital role in the wound healing phase post-surgery. X-PUR Opti-Rinse Plus is a cost-effective, preventative, and non-prescription mouth rinse. The safety and efficacy of X-PUR Opti-Rinse Plus for use as an in-office preprocedural mouth rinse (PPMR) has been demonstrated in addition to its efficacy with consistent use as a preventive and therapeutic mouth rinse at home. Considering the bactericidal and anti-viral capacity of X-PUR Opti-Rinse Plus, this mouth rinse (with the benefits to oral health), can be recommended and utilized by today’s dental professional as a replacement to the traditional chlorhexidine.

Oral Health welcomes this original article.

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About the Author

Dr. Zeeshan Sheikh was trained as a dental clinician, periodontist, biomaterials scientist and clinical scientist in Periodontics and an Assistant Professor at Dalhousie University in the departments of Applied Oral Sciences & Dental Clinical Sciences.

Dr. Umer Daood graduated from Baqai Dental College (BDS) and holds a Master of Science (MSc) in Oral Sciences and Biomaterials from the National University of Singapore as well as an MSc in Dental Materials from Queen Mary University of London. He obtained his PhD from Prince Philip Dental Hospital at the University of Hong Kong. He has more than 80 international high impact publications, and a few book chapters and patents to his name.