Hypochlorous Acid and Game Changing Paradigms in Medicine and Dentistry

Hypochlorous Acid (HOCl) mouth rinse preserves the commensal (good) oral bacteria. It also is surprisingly efficacious at killing oral pathogens-even the really bad guys.^1-5 What makes HOCl a super-hero is its compatibility with our physiological needs.^11,13 Our fragile, essential oral microbiome can be affected by many things including oral products, antibiotics, diet, health which can indirectly contribute to chronic disease states. Medical and dental practitioners are in the position to sound the alarm, educate patients about this and offer solutions.

There is emerging knowledge of the ability to harness these natural occurring, disinfecting signaling molecules to more stable and usable forms. Hypochlorous acid makes it possible to do less harm than other disinfectants that kill in a broader spectrum, because of their ability to selectively kill pathogens while not harming commensals.

WHAT IS HYPOCHLOROUS ACID?

Hypochlorous Acid (HOCl), often called by other names such as E-Water, is one of the most powerful disinfectants available today and yet it is one of the safest. It consists of one oxygen atom, one chlorine atom and one hydrogen atom. Hypochlorous acid is produced by all mammals naturally to fight infection. It is generated by neutrophils, white blood cells, when an invading pathogen is detected. In the body, the HOCl produced by neutrophils lasts about a second. We now can capture this molecule in stable solutions and dissolved solid tablets. Commercial products are readily available to produce this in our dental offices.

AN EFFECTIVE DETERGENT WITHOUT SUDS

HOCl is made by mixing the correct amounts of water, non-iodized salt and an acid such as vinegar and running electricity through it to produce two new molecules: hypochlorous acid and sodium hydroxide. (Depending on the unit type employed, sodium hydroxide may not be present). Sodium hydroxide is used in many oral care products already as it has detergent properties but is very gentle at these levels. Sodium hydroxide has many uses and is often put into toothpaste. It cleans safely without all the bubbles. One can adjust the concentration of HOCl by dilution with water, to an appropriate level for the desired use.

Hypochlorous acid kills bacteria, viruses, fungi, mold and spores. It appears to not kill “good” bacteria. Since HOCl has no charge, it is not repelled by negatively charged pathogenic bacteria. It is an excellent product for the breakdown of biofilms.^5,7,16

Hypochlorous Acid works by several mechanisms:

It reacts with protein sulfhydryl groups to inactivate proteins. It also reacts with protein amino groups for chloramines to cleave proteins. It inhibits glucose oxidation starving bacterial and viral pathogens of nutrient uptake. It causes post-translational modifications to proteins like cysteine and methionine and it oxidizes bacterial and viral walls and cytoplasm. HOCl is a powerful oxidizer having an oxidation reduction potential of approximately 1000.¹⁶

HOCL does not harm “good bacteria’. Most bad bacteria carry a negative charge and hence repel anti.microbials.⁶ HOCL can attach and penetrate the cell wall since it is neutral. The negative effect of HOCl on good bacteria is minimal. Sodium hypochlorite, peroxide etc. carry a negative charge and are repulsed by bad bacteria. Articles indicate excellent efficacy for HOCL in the oral microbiome, including in the presence of saliva, which inactivates many other anti-microbials. HOCL has demonstrated excellent efficacy against fusobacterium nucleatum, strep mutans, spirochetes, porphyromonas gingivalis, etc in the presence of saliva.

Uses of HOCl in Dentistry:

HOCl has the widest and safest use application in dentistry of any disinfectant. It is a potent hard surface disinfectant, a dental water line disinfectant, an effective hand sanitizer and has multiple use applications in the oral cavity. It kills the pathogens responsible for gingivitis, periodontitis and decay. It can be used for root canal therapy. It disinfects effectively while not disturbing the normal oral microbiome. The only application not approved is for sterilizing dental instruments. It is not affected by saliva like many other oral disinfectants and does not lower the salivary pH. Dental offices may purchase the product commercially with a 1-2 year shelf life or generate it themselves in the dental office, providing only about a two week shelf life.^7,10

HOCl is not only recognized in Canada but is also on the list of recommended products for COVID-19 disinfection as safe and effective.¹ Many products exist for air and surface disinfection with HOCl, limited products are also available for oral hygiene, tongue scrapping, ENT and even ophthalmology use.

WHAT IS THE CONNECTION BETWEEN NITRIC OXIDE (NO) PRODUCTION AND HOCL?

It is essential to have a healthy oral microbiome to effectively produce NO, especially in your older years. IF NO is thought to be the Holy Grail of health, think of HOCl as an essential molecule to protect and support NO in a most natural way. To understand the significance of introducing HOCL, one needs to appreciate the important role of oral bacteria in the pathway producing Nitric Oxide (NO). HOCL is unique in that it is a signaling molecule, produced naturally by our own neutrophils, which protects the mechanism that allows our bodies to inherently produce Nitric Oxide (NO).^12-14

WHAT IS NITRIC OXIDE (NO)?

Nitric Oxide is a gaseous molecule that was discovered about 1980. The significance and potential of this molecule was immediately appreciated. The three scientists who discovered NO were rewarded for this discovery with Nobel prizes. Since then, over 160,000 articles and many books have been published about this game changing discovery.

Nitric Oxide is a signaling molecule produced in our bodies that affects cardiovascular, immunological, gastroenterological, pulmonary, muscular skeletal and other systems. It is a potent vasodilator, reduces blood pressure, decreases oxidative stress and inflammation, reduces vascular and cardiac smooth, muscle growth, inhibits platelet aggregation, inhibits leukocyte adhesion to the endothelium, decreases atherosclerosis and coronary artery disease, diabetes, dyslipidemia, and stroke. Every single chronic disease involves loss of nitric oxide production. Loss of Nitric Oxide production leads to aging and chronic disease.^12.13 NO physiology is the basis of new popular drugs like Viagra and Cialis.

NO is a prime essential molecule for mammalian health. Insufficient NO leads to chronic health issues and advanced aging. According to NO expert, Nathan S. Bryan, PHD, there are two known pathways for NO

production in humans. The endogenous L-arginine/NOS pathway reduces with age-production declining 10.20% per decade and by age of 50, only produces 50%. Loss of NO production is due to the inability to convert L-arginine into NO so products that contain L-arginine or L-citrulline (e.g. beet products) are not always effective at NO production.¹²

The other way we produce NO is a dietary pathway and is highly dependent on a good oral microbiome, saliva, healthy diet full of nitrates and nitrites as well as an acidic stomach. Both pathways can be easily compromised, and it is important that we appreciate the fragility of the systems and encourage best practices. Dr. Nathan S. Bryan’s advice to physicians and dentists can be read in his article in Oral Health, his numerous books (Functional Nitric Oxide Nutrition) and articles, online webinars of which I recommend the Fullscript you-tube video at https://www.youtube.com/watch?v=t4vb5GEdFFk, or his website (see references).

Dr. Bryan recommended regular tongue cleaning. He also suggests limiting mouth washes and antibiotics or anything that can lead to a deleterious effect on a healthy oral microbiome. He discusses the relevance of the NO/oral microbiome connection and how dentists can improve lives through this appreciation and corrective actions. (see references) ¹²

Dr Bryan states, “There is enormous interest and research on the microbiome but most of the focus is on the gut microbiome. It is time we focus on the most proximal part of our gastrointestinal system, the mouth. The oral cavity is an attractive target for probiotic and/or prebiotic therapy because of the ease of access. The potential to restore the oral flora to provide NO production is a completely new paradigm for NO biochemistry and physiology as well as to cardiovascular medicine and dentistry. These studies provide new insights into the host-oral microbiome symbiotic relationship. If we are going to make a leap forward in health, we need to take another look at boosting oral health as it relates to NO production and the role it plays in disease or find safe and effective therapeutic strategies to recapitulate NO production in the oral cavity.”¹²

IS MOUTHWASH RAISING YOUR BLOOD PRESSURE?

In Dr. Bryan’s research, the use of mouth wash raised blood pressure within minutes. He demonstrated that mouth products, when chronically used, have potential damaging effects on the composition of the oral microbiome and this can be leading to the increase in chronic conditions specifically because it can lead to a deficiency of NO production, and rise in hypertension.^12-14 HOCl is unique amongst a few products in how it respects the microbiome and still targets pathogens. When treatment might affect the oral microbiome balance, perhaps prebiotics and probiotics can be considered to help replenish the lost commensals once offending pathogens are removed. New products to meet these ideals are emerging and the future holds promise.

A host of things like free radical damage, mouthwash, smoking, dry mouth, alcohol, poor oral hygiene, compromised immunity, poor diet, medications (especially antibiotics, PPI’s, antidepressants), sleep disorders, and even mouth breathing/ compromised nasal breathing all can contribute to inefficiencies in the dietary pathway and a NO deficiency.¹⁴ Our population is sick and we now have a better handle of what we can do to reverse it. We need to improve our health by sustaining NO signaling and homeostasis. Education will lead to change and research to find ways to make this happen.

The following lists help to recognize and treat the common condition of NO deficiency, which leads to accelerated aging, CVD and common degenerative conditions. Consider asking patients if they are chronic mouthwash users and if they do demonstrate signs of an NO deficiency either switch them to a physiologic mouth wash alternative like HOCl or counsel them to avoid mouth wash altogether. Anyone on PPI’s, antibiotics need to be aware of the dangers of altered enteric pH and reduced NO production.^12-14

How do you recognize a NO deficiency? A NO deficiency leads to the first stages of all human chronic age-related diseases. Signs such as elevated blood pressure, some degree of sexual dysfunction, decreased circulation, lack of energy, increased plasm R-CRP and other inflammatory markers¹⁶ all indicate a possible lack of NO.

How do you avoid/treat a NO deficiency? Here are some suggestions:

1. Eat a healthy diet full of colorful nonorganic vegetables full of nitrates and nitrites. E.g. Beets and dark leafy greens. Note: Nitrates and nitrites in food are about 100 times less than would cause any toxicity. Organic foods tend to be devoid of the nitrates and nitrites that we need in our diet. At the same time avoid sweet and processed food, opting more for whole foods.

2. Ensure you have an acidic stomach and avoid chronic use of antacids and PPI’s

3. Get a healthy amount of exercise, nasal breath and look after any sleep disordered breathing

4. Encourage a healthy production of saliva which is essential to the oral pathway of NO production. Many medications reduce quality and quantity of saliva. One must swallow their saliva.

5. Protect the healthy bacteria in the mouth by not using broad spectrum mouth washes and other such mouth products, limit antibiotics and repair an unhealthy microbiome with prebiotics (which includes Xylitol and Erythritol) and probiotics. Use appropriate NO promoting products when warranted and as they become available. Prescribe oral products that target pathogens while respecting commensal populations such as HOCl.

6. Practice good oral hygiene including tongue scraping, see dental/medical professionals regularly. 

Oral Health welcomes this original article.

References

1. Kento Tazawa, Rutja Jadhav, Mariane Maffei Azuma, Christopher Fenno, Neville J. Mcdonald, Hajime Saski
2. Hypochlorous Acid inactivates oral pathogens and a Sars-Cov-2 surrogate BMC Oral Health, 2023 Fe. 18;23 (1) 111
3. Olivia Aherna, Roberto Ortiz, Magnus M. Fazli and Julia R. Davies Effects of stabilized hypochlorous acid on oral biofilm bacteria BMC Oral health, 2022; 22:415 doi 10 1128/JB, 00542-10
4. Diana Marcela Castillo, Yomaris Castillo, Nathaly Andrea Delgadillo, Yineth Neuta, Johana Jola, Justo Leonardo Calderon, Gloria Ines Lafaurie Viability and Effects on bacterial proteins by Oral rinses with Hypochlorous Acid Brazilian dental journal 26 (5) Oct. 2015 doi. Org /10 1590 /0103.644020 1300 388
5. C. Sam, Hsein-Kun Lu The role of hypochlorous acid as one of the reactive oxygen speciesvin periodontal disease. Journal of dental Sciences June 2009
6. G. I. Lafaurie, C. Zaror, D. diax-Baez, D. m. Castillo, J. DeAvila, T. G. Trujillo, J. Calderon Mendoza
7. H. Evaluation of Substantivity of Hypochlorous acid as an antiplaque agent: A randomized controlled trial International Journal of Dental Hygiene 2018 Nov; 16 (4) ; 527-534
8. Yi-Ling hsieh, Jivn-Cheng Yao, Sung-Chih Hsieh, Nai-Chia Teng, You-tai Chu, Wen -Xin Yu, Chung-He Chen, Liang-yu Chang, Ching-Shuan Huang Tzu-Hsin Lee,Alvaras Kareiva and Jen-Chang Yang The In Vivo Toxicity and Antimicrobial Properties for Electrolyzed Oxidizing (EO) water Based mouthwashes MDPI 26 September 2020
9. Chun-Ju Chen, Chun-Cheng Chen and Shinn -Jyh DingEffectiveness of Hypochlorous Acid to reduce the Biofilms on Titanium Alloy Surfaces in VitroInternational Journal of Molecular Sciences 2016 Vol. 17/Issue 7/ doi. Orz/ 10 3390/ ijms 17071161
10. Soo-Byeong kimDevelopment of a mouthwash alternative using a low-level hypochlorous acid solution with macroporous platinum electrodes and its application to oral healthInt’l J. Clinical Experimental Medicine 2016; 9(11) 21304.21311
11. Xiaogang Cheng, DDS. yuTian, PhD, DDS . Chunmiao Zhao.MDS. Chi Ma, PhD. Xiaohua Liu, Phd. Qing Yu, PhD, DDSBactericidal effect of Strong Acid Electrolyzed Water against Flow Enterococcus faecalis biofilmsJournal of Endodontics Volume 42 ,issue 7, P 1120-1125 July 2016
12. Naoki Horiba ,PhD, Kouiti Hiratsuka DDS, Takaya Onoe DDS, PhD, Tsutomu Yoshida DDS, PhD, kazuyoshi Suzuki DDS, PhD, Toru Matsumoto DDS, PhD, Hiroshi Nakamura, PhD, Bactericidal effect of electrolyzed neutral water on bacteria isolated from root canals, Oral surgery, Oral medicine, Oral Pathology and Endodontology vol. 87, Issue 1 ,January 1999 pp. 83-87
13. Micahael S. Block, DMD and Brian G. Roman , DMD, MDHypochlorous Acid: A ReviewJournal Oral Maxillofacial Surgery 2020 Sep; 78(9) 1461-1466
14. Nathan S Bryan, PHD Functional Nitric Oxide Nutrition. Dietary strategies to treat chronic Disease. Crescendo Publishing LLC, 2-558 Upper Gage Ave. Suite 246, Hamilton Ontario L8V4J6. Also, website www.drmathansbryan.com; also the
15. Fullscript you-tube video at https://www.youtube.com/watch?v=t4vb5GEdFFk
16. Li,H et al, “Nitrate-reducing bacteria on the back of rat tongues” App/Environ Microbial 63, no3,(1997) 924-30
17. Lundberg, J.O. et al, “Nitrate, bacteria and human health” Nat. Review Microbiol 2 no 7, (2004) 593-602 Raphael KellmanMD, Microbiome Diet: the scientifically proven way to Restore your Gut Health and achieve permanent weight loss. Hachet books New York (2022)
18. Dirk Boecker 1, Zhentian Zhang 2, Roland Breves 3, Felix Herth 4, Axel Kramer 5, Clemens Bulitta 6Antimicrobial efficacy, mode of action and in vivo use of hypochlorous acid (HOCl) for prevention or therapeutic support of infections; GMS Hyg Infect Control, 2023 MAR 27, 18:DOC07; DOI:10.3205/DGKH000433. ECOLLECTION 2023

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About the Author:

Dr. Janice Goodman received her MSc in Oral Medicine/Orofacial pain from USC in 2015 after practicing general dentistry for 36 years in downtown Toronto, Canada. She is an editorial Board member of Oral Health Dental Journal and the AAPMD. Diplomate of the American Academy of Cranialfacial pain as well as American Board of Cranialfacial Dental Sleep Medicine. Her focus is functional dentistry based. She can be reached at jangoodman@rogers.com.