|Year : 2014 | Volume
| Issue : 1 | Page : 9-13
Chemical vs. herbal formulations as pre-procedural mouth rinses to combat aerosol production: A randomized controlled study
Koduganti Rekha Rani, Manasa Ambati, Jammula Surya Prasanna, Indumathy Pinnamaneni, Panthula Veerendranath Reddy, Dasari Rajashree
Department of Periodontics, Panineeya Mahavidhyalaya Institute of Dental Sciences & Research Centre, Road No: 5, Kamalanagar, Dilsukhnagar, Hyderabad, Andhra Pradesh, India
|Date of Web Publication||5-Sep-2014|
Department of Periodontics, Panineeya Mahavidhyalaya Institute of Dental Sciences and Research Centre, Road No: 5, Kamalanagar, Dilsukhnagar, Hyderabad - 60, Andhra Pradesh
Source of Support: Free samples provided by Himalaya and
Warren a division of Indoco Remedies Ltd., Conflict of Interest: None
Background: Disease transmission and barrier techniques are the key concerns during ultrasonic instrumentation as this procedure has the hazard of aerosol production which has a multitude of deleterious effects on the body. The aerosol produced can affect both the patient and the clinician. The aim of this study was to assess the importance of pre-procedural rinsing before scaling by ultrasonic instrumentation and to compare the efficacy of commercially available herbal mouth rinse and a Chlorhexidine gluconate mouth rinse with a control group. The study was conducted from 1 st February to 15 th April 2012 in a tertiary referral care hospital. The study was approved by the institutional ethical committee. This was a randomized single blinded interventional study, where in 36 patients equally divided into three groups participated.
Material and Methods: Thirty six patients were recruited in this study aged between 18-35 years. All patients had plaque index scores between1.5-3.0, and were categorized into three groups. Patients with systemic diseases and on antibiotic therapy were excluded. Group A or control group underwent scaling with water as pre-procedural rinse, Group B used 20 ml of 0.2% Chlorhexidine and group C were administered 18 ml of a herbal pre-procedural rinse. Aerosol splatter produced during the procedure were collected on blood agar plates and sent for microbiologic analysis for the assessment of bacterial Colony Forming Units (CFUs). The mean CFUs and standard deviation (SD) for each group were measured. Post hoc test was used to compare the differences between three groups, Control (A) Chlorhexidine (B) and Herbal (C).
Results: The mean Colony Forming Units (CFUs) for control group was 114.50, Chlorhexidine group was 56.75 and herbal rinse group was 47.38.
Conclusion: Pre-procedural rinsing was found to be effective in reducing aerosol contamination during ultrasonic scaling though no statistically significant difference was found between the two test groups Chlorhexidine and Herbal mouth rinse.
Keywords: Aerosols, bacterial colony forming units, pre-procedural rinse, ultrasonic scaling
|How to cite this article:|
Rani KR, Ambati M, Prasanna JS, Pinnamaneni I, Reddy PV, Rajashree D. Chemical vs. herbal formulations as pre-procedural mouth rinses to combat aerosol production: A randomized controlled study. J Oral Res Rev 2014;6:9-13
|How to cite this URL:|
Rani KR, Ambati M, Prasanna JS, Pinnamaneni I, Reddy PV, Rajashree D. Chemical vs. herbal formulations as pre-procedural mouth rinses to combat aerosol production: A randomized controlled study. J Oral Res Rev [serial online] 2014 [cited 2019 Jul 16];6:9-13. Available from: http://www.jorr.org/text.asp?2014/6/1/9/140194
| Introduction|| |
Of late, infection control has been one of the major concerns of the dental community. , Aerosol and splatter are a concern in dentistry because of their potential effects on the health of immuno-compromised patients and of dental personnel.  These aerosols maybe inhaled into the lungs to reach the alveoli or may come in contact with the skin or mucous membranes. Most of the aerosols produced during treatment procedures have a diameter of 5 μm or less, and these can cause respiratory or other health problems because they can penetrate into, and remain within the lungs. , [Figure 1]. Chlorhexidine gluconate, a bisbiguanide , is considered to be the most effective anti-plaque agent  but it also has some side effects, notably tooth staining, taste alteration, enhanced supra gingival calculus formation and less commonly desquamation of the oral mucosa.  On the other hand herbal mouth rinses with their natural ingredients offer a safe and effective option which should be optimally made use of.  The main benefit of using herbal preparations is that they do not contain alcohol or sugar, which are present in over the counter products and which possess the ill effects of causing bacterial growth resulting in halitosis or bad breath. [9 In the present study, a commercially available herbal mouthrinse prepared from Pilu 5 mg (Salvadorapersica), Bibhitaka 10 mg (Terminaliabellerica), Nagavalli 10 mg (Piper betle), Peppermint satva 1.6 mg(Menthaspp), Yavanisatva (thymol) (Carumcopticum) 0.4 mg was used.
The aim of the present study was to:
- Assess the efficacy of the two pre-procedural rinses in reducing the toxicity or microbial load on the aerosol produced, and in turn to
- Compare between both the test groups as to which rinse would be more effective in reducing the colony forming units on the blood agar plates in comparison to control group.
| Materials and Methods|| |
Thirty-six healthy individuals (20 females and 16 males) age range 18 to 35 years were selected for participation in the study. Inclusion criteria was: Dentition with ≥20 teeth (minimum of five teeth per quadrant), with plaque index scores of 1.5-3, with a minimum probing depth of 4 mm. Patients with other oral lesions, wearing any fixed or removable prosthesis, and with any past history of systemic illness or allergy to components of mouth rinse were excluded from the study. All subjects were explained the purpose of the study and informed consent was obtained from them. The study was conducted from 1 st February to 15 th April 2012 in a tertiary referral care hospital. The study was approved by the institutional ethical committee.
This was a randomized single blinded interventional study. Study populations were randomly assigned into three groups. Control group (A) - 12 patients underwent prophylaxis after pre-procedural rinsing with normal water, Group (B) - 12 patients who underwent scaling after rinsing with 20 ml of 0.2% Chlorhexidine, Group (C) -12 patients who used 18 ml of herbal mouth rinse for about 30 s before scaling was performed. To avoid aerosol contamination, the operating area was fumigated on the day before the treatment. Only one patient/day was treated on alternate days with ultrasound scaling.
Before ultrasonic scaling, agar plates were placed and stabilized with adhesive tape on patient's chest as well as on operator's chest for aerosol collection. These two areas were considered to be the most prone for contamination with aerosol. The plates were placed for 10 minutes and then removed and labeled. The treatment was performed by a single operator.
All agar plates were sent for microbiological analysis to the microbiological laboratory for Colony Forming Unit (CFU) count on the same day of ultrasonic scaling procedure.
The aerosols were collected on agar plates prepared from blood agar medium which is considered as a favorable medium for the growth of air borne bacteria.  The plates were incubated at 37°C in an incubation chamber for 24 h and then colony forming units (CFUs) were counted [Figure 2] and [Figure 3].
The mean CFUs and standard deviation (SD) for each group were measured. Post hoc test was used to compare the differences between three groups, Control (A), Chlorhexidine (B) and Herbal mouth rinse (C).
| Results|| |
The mean, standard deviation (SD), P-value, post hoc test value for three groups: Control (A), Rexidin ® (B) and Hi Ora ® (C) is summarized in [Table 1]. It shows that there was a statistically significant reduction in Colony Forming Unit (CFU) count in both experimental groups, Chlorhexidine(B) - 56.75 and Herbal (C) - 47.38 as compared to control group (A) - 114.50 and P-value was <0.001 [Figure 4], [Figure 5], [Figure 6]. But the difference between the Chlorhexidine (B) and Herbal (C) groups was not statistically significant showing that the herbal mouth rinse was as effective as chlorhexidine for pre-procedural rinsing. The log CFUs that was measured also revealed the same [Figure 7] and [Figure 8].
[Table 2] shows the mean, standard deviation (SD), P-value, post hoc test value for three groups, control (A), CHX (B) and Herbal (C) with sub groups i.e., CFUs on operator's agar plate and patient's agar plate. It shows that operator's chest area was more prone to aerosol contamination than patient's chest area. The mean CFUs on operator's agar plate for three groups A, B and C were 186.00, 87.42 and 66.67, respectively, and mean CFUs on patient's agar plate were 15.38, 8.39 and 16.23, respectively.
|Table 2: Mean colony forming units/agar plate (CFU/ plate) according to treatment and locations during use of ultrasonic scaler |
Click here to view
| Discussion|| |
Aerosols are defined as particles less than 50 μm in diameter.  These aerosol particles have the potential to be harmful to the dental personnel as they carry infectious mico-organisms. Both the high speed air-rotor as well as the ultrasonic scaler, which work with water have the propensity of generating numerous air borne particles, (derived from blood, saliva or dental plaque and/or calculus) which in turn have detrimental effects on both the clinician and the patient. , The diseases caused due to these aerosols could be pneumonia, influenza, hepatitis, skin and eye infections to name a few. ,
One of the methods of reducing overall bacterial counts produced during dental procedures is pre-procedural rinsing with a product containing an antimicrobial agent. 
Other methods include flushing of water from ultrasonic scaler devices and turbine hand pieces for 5-10 min in the beginning of the day and for 2 min before treatment, attaching aerosol reduction devices to the ultrasonic scaler units (High volume suction apparatus). Purification of airborne microbial pollutants by physical and chemical means. Minimizing biofilm formation in dental unit water lines by using sterile water or sterile saline. 
In the present study, the efficacy of pre-procedural rinsing with a herbal rinse was compared with 0.2% Chlorhexidine which was considered as a gold standard. In a study conducted by Fine et al,  it was proved that pre-procedural oral rinsing with an antiseptic mouthwash significantly reduces the viable microbial content of bio-aerosols generated during dental procedures. It was suggested that this pre-procedural rinsing may have a potential role in reducing the risk of cross contamination with infectious agents in the dental operatory. ,
Purohit et al,  observed that pre-procedural rinsing with 0.12% chlorhexidine gluconate significantly reduced the colony forming units (CFU) than without rinsing which was due to the ability of antiseptic mouthwash to inhibit the microbial growth. Domingo et al have stated that 1% povidone iodine used as a pre-procedural mouth rinse has a bactericidal effect on the microorganism resulting in the reduction of surviving microorganisms up to 4 h. In another study, Feres et al. have observed that 0.05% cetylpyridinium chloride (CPC) was found to be equally effective as chlorhexidine in reducing splatter bacteria during ultrasonic scaling. 
Contrary to the study done by Purohit et al,  in this study the bacterial colony forming units were found to be more on the operator's chest area than on the patients'. Further studies have to be conducted to ascertain the validity of this finding.
In a study done by Snophia et al,  comparing the efficacy of 10 ml of 0.2% of chlorhexidine mouth rinse and 20 ml of essential oil mouth rinse it was observed that chlorhexidine gluconate was 77% effective in reducing colony forming units (CFU) when compared to 43% reduction by essential oil mouth rinse.
Another study done by Eapen Thomas,  has reiterated the superiority of 0.12% chlorhexidine (Periogard) as a pre-procedural mouth rinse in reducing colony forming units (CFU) i.e., aerobic and anaerobic counts when compared to 0.05% cetyl pyridinium chloride and 0.05% sodium fluoride (Reach) mouthrinse in children.
Devker and colleagues  in their study, which was a split mouth design compared the efficacy of chlorhexidine preprocedural rinsing alone, high volume evacuator alone and both in combination in reducing viable counts in aerosols produced during ultrasonic scaling and found that combination of high volume evacuator and chlorhexidine was the most efficient which was followed by high volume evacuator alone and chlorhexidine prepeocedural rinse alone.
Gunjan gupta et al. compared the efficacy of 0.2% chlorhexidine, and herbal mouth wash(Test Groups) to water (Control group) and found that both the test groups reduced CFUs significantly when compared to the control group. They inferred that chloxhexidine group was superior to herbal mouth wash group. The study conducted by us also correlated with the finding that CFUs reduced significantly in the two test groups when compared to the control rinse i.e., water. But in the present study there was no statistical difference between the test groups i.e., chlorhexidine and herbal mouth rinse.
A recent study by Shanthipriya Reddy and colleagues  observed that 0.2% chlorhexidine which was tempered in a thermostatically regulated water bath at 47 °C was more efficacious than non tempered chlorhexidine.
Though aerosol production cannot be totally eliminated with infection control procedures, the putative potential of these aerosols can be minimised by preprocedural rinsing. A double blinded study design and a qualitative microbial analysis would have better substantiated the results of our study. Pre-rinsing with herbal mouth rinse was as effective as chlorhexdine in this study which promotes the use of herbal rinses in the dental setting.
| Conclusion|| |
Aerosol production during ultrasonic scaling is very hazardous to the patient, the operator and public at large. Hence pre-procedural rinsing should be made a regular practice in all dental set ups, along with high vacuum evacuation and other barrier techniques. In this study herbal rinse was found to be as effective as chlorhexidine in reducing splatter bacteria during ultrasonic scaling. Considering the fact that herbal rinses are more eco-friendly and better accepted by patients, many more studies have to be conducted using these agents to prove their beneficial effects.
| Acknowledgement|| |
The authors would like to thank Himalaya remedies and Warren a division of Indoco remedies for providing free samples of Hiora ® and Rexidin ® . We would also like to extend our thanks to Mr. Siva Prasad, Vista Labs, Hyderabad and the Non-teaching staff of department of Periodontics, Panineeya Dental College, Hyderabad, India, for their help during the entire course of the study.
| References|| |
|1.||Grenier D. Quantitative analysis of bacterial aerosols in two different dental clinic environments. Appl Environ Microbial 1995;61:3165-8. |
|2.||Maghlough Al, Yousef Al, Bagieh N Al. Qualitative and quantitative analysis of bacterial aerosols. J Contemp Dent Pract 2004;5:91-100. |
|3.||Harrel SK, Molinari J. Aerosols and splatter in dentistry: A brief review of the literature and infection control implications. J Am Dent Assoc 2004;135:429-37. |
|4.||Leggat PA, Kedjarune U. Bacterial aerosols in the dental clinic: A Review. Int Dent J 2001;51:39-44. |
|5.||Bentley RD, Burkhart NW, Crawford JJ. Evaluating splatter and aerosol contamination during dental procedures. J Am Dent Assoc 1995;125:579-84. |
|6.||Jones CG. Chorhexidine. Is it still the gold standard? Periodontol 2000 1997;15:55-62. |
|7.||Santos A. Evidence based control of plaque and gingivitis. J Clin Periodontol 2003;30:13-6. |
|8.||Gupta DG, Mitra DD, KP DA, Gupta DA, Soni DS, Ahmed DS, Arya DA. Comparison of efficacy of pre-procedural mouthrinsing in reducing aerosol contamination produced by ultrasonic scalar: A pilot study. July15(E pub ahead of print) Jop.2013.120616. |
|9.||Malhotra R, Grover V, Kapoor A, Saxena D. Comparison of the effectiveness of a commercially available herbal mouthrinse with chlorhexidine gluconate at the clinical and patient level. J Indian Soc Periodontol 2011;15:349-52. |
|10.||Shivakumar KM, Prashanth GM, Madhu Shankari GS, Subba Reddy VV, Madhu GN. Assessment of atmospheric microbial contamination in a mobile dental unit. Indian J Dent Res 2007;18:177-80. |
|11.||Purohit B, Harshpriya, Acharya S, Bhat MS, Ballal M. Efficacy of pre-procedural rinsing in reducing aerosol contamination during dental procedures. J Infect Prev 2009;10:191-3. |
|12.||Infection control recommendations for dental office and the laboratory. ADA council on scientific affairs and ADA council on dental practice. J Am Dent Assoc 1996:127:672-80. |
|13.||Fine DH, Mendieta C, Barnett ML, Furgang D, Meyers R, Olshan A, et al. Efficacy of pre-procedural rinsing with an antiseptic in reducing viable bacteria in dental clinic. J Periodontol 1992;63:821-4. |
|14.||Trenter SC, Walmsley AD. Ultrasonic dental scaler: Associated hazards. J Clin Periodontol 2003;30:95-101. |
|15.||Domingo MA, Farrales MS, Loya RM, Pura MA, Uy H. The effect of 1% povidone iodine as a pre-procedural mouthrinse in 20 patients with varying degrees of oral hygiene. J Philipp Dent Assoc 1996;48:31-8. |
|16.||Feres M1, Figueiredo LC, Faveri M, Stewart B, de Vizio W. The effectiveness of a preprocedural mouthrinse containing cetylpyridinium chloride in reducing bacteria in the dental office. J Am Dent Assoc 2010;141:415-22. |
|17.||Snophia Suresh, M.Manimegalai, Uma Sudhakar, Sopia. Comparison of efficacy of preprocedural rinsing with chlorhexidine and essential oil mouthwash in reducing viable bacteria in dental aerosols-A microbiological study. Int J Contemp Dent 2011;2:1-6. |
|18.||Thomas E. Efficacy of two commonly available mouth rinses used as preprocedural rinses in children. J Indian Soc Pedod Prev Dent 2011; 29:113-6. |
|19.||Devker NR1, Mohitey J, Vibhute A, Chouhan VS, Chavan P, Malagi S, et al. A study to evaluate and compare the efficacy of preprocedural mouthrinsing and high volume evacuator attachment alone and in combination in reducing the amount of viable aerosols produced during ultrasonic scaling procedure. J Contemp Dent Pract 2012;13:681-9. |
|20.||Reddy S, Prasad MG, Kaul S, Satish K, Kakarala S, Bhowmik N. Efficacy of 0.2% tempered chlorhexidine as a pre-procedural mouth rinse: A clinical study. J Indian Soc Periodontol 2012;16:213-7. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2]