Accepted: 4 March 2018

DOI: 10.1111/idh.12342

ORIGINAL ARTICLE

Evaluation of substantivity of hypochlorous acid as an

antiplaque agent: A randomized controlled trial

GI Lafaurie1  | C Zaror2,3 | D Díaz-Báez1 | DM Castillo1 | J De Ávila1 | 

TG Trujillo1 | J Calderón-Mendoza4

1
Unit of Basic Oral Investigation-UIBO,
School of Dentistry, El Bosque University, Abstract
Bogotá, Colombia Background: Hypochlorous acid (HOCl) is a non-­antibiotic antimicrobial substance
2
Centre for Research in Epidemiology,
with significant effects on pathogenic oral micro-­organisms. The effects of HOCl as
Economics and Oral Public Health
(CIEESPO), Faculty of Dentistry, Universidad an antiplaque agent have not been studied.
de La Frontera, Temuco, Chile
Objective: The aim of this study was to evaluate the substantivity of HOCl mouth-
3
Centro de Excelencia CIGES, Faculty of
washes compared with chlorhexidine (CHX) rinses and a placebo.
Medicine, Universidad de La Frontera,
Temuco, Chile Materials and Methods: A double-­blind randomized controlled trial with 75 partici-
4
Scientific& Regulatory Affairs, Aquilabs US, pants was conducted. Participants were divided into five groups using block rand-
Miami, FL, USA
omization: 0.025% HOCl, 0.05% HOCl, 0.12% CHX, 0.2% CHX, and sterile water as a
Correspondence placebo. Participants were instructed to use each rinse solution for 30 seconds after
Gloria Inés Lafaurie, Universidad El Bosque,
Bogotá, Colombia. dental prophylaxis. Samples of saliva were taken at baseline and after 30 seconds, 1,
Email: institutouibo@gmail.com 3, 5 and 7 hours to assess substantivity, and bacterial viability was established by the

Funding information fluorescence method. Visible plaque in all participants was assessed with the Turesky
Departamento Administrativo de Ciencia, index at baseline and at 7 hours, and adverse events were also assessed.
Tecnología e Innovación, Grant/Award
Number: 130850227678 Results: HOCl led to a 33% reduction in bacterial counts in the saliva after 30 sec-
onds compared with a 58% reduction by CHX. HOCl has no substantivity, and bacte-
rial counts returned to baseline after 1 hour. Placebo treatment led to the highest
plaque count after 7 hours compared with the CHX and HOCl groups, although the
differences were not significant. HOCl rinsing induced the highest percentages of
unpleasant taste and dryness sensations.
Conclusions: HOCl rinses have an initial effect on bacterial viability in saliva but have
no substantivity. Other mechanisms may explain its antiplaque effect.

KEYWORDS
antiplaque agents, chlorhexidine, hypochlorous acid, substantivity

1 |  I NTRO D U C TI O N (CHX) is the most effective substance in inhibiting dental plaque due
to its high substantivity, and its effects on inhibiting plaque and re-
The formation of dental biofilm has been extensively studied, and ducing gingivitis have been well-­documented.4 However, some side
the interactions necessary for the start of the training process have effects, such as dental pigmentation, poor microbicidal activity, der-
been characterized.1 A systematic review found that mechanical re- matitis, mucosal injury and drying of tissues and altering and delay-
moval of dental biofilm in a controlled manner significantly reduces ing the healing process, have discouraged its clinical use.5-7
2
plaque and gingivitis. However, for a more effective reduction in Hypochlorous acid (HOCl) is a non-­
antibiotic antimicrobial
dental plaque, multiple antimicrobial substances have been devel- agent used to prevent infection, reduce inflammation and promote
oped to inhibit plaque formation on dental surfaces.3 Chlorhexidine wound healing with minimal adverse effects.8 Nevertheless, in vitro

Int J Dent Hygiene. 2018;1–8. wileyonlinelibrary.com/journal/idh   © 2018 John Wiley & Sons A/S. |  1
Published by John Wiley & Sons Ltd
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2       LAFAURIE et al.

studies have demonstrated important effects of HOCl on patho- A balanced random permuted block method was used to pre-
genic micro-­organisms of the oral cavity that are found in the dental pare the randomization table in order to avoid imbalance balance be-
biofilm of teeth and dental implants, including Streptococcus mutans, tween the two treatments. A clinical epidemiologist (L.F.G) realized
Streptococcus sanguinis, Porphyromonas gingivalis, Aggregatibacter ac- the randomization table in blocks of five, and the list was sent to a
tinomycetemcomitans, Campylobacter rectus and enteric rods.9,10 clinical centre separate from the study centre. The clinical coordina-
The primary objective of this study was to evaluate the substan- tor applied the allocation (D.D). Operating from this list, treatment
tivity of different concentrations of HOCl rinses compared with assignments were issued via sealed numbered opaque envelopes.
CHX rinses and a placebo based on the reduction in bacterial viabil- The treatment codes of the study were not accessible to the investi-
ity in saliva over a period of 7 hours. The secondary objective was gators or the examiner until the data were analysed. The participants
to quantify the dental plaque count on the dental surfaces after use were enrolled by a research assistant (J.D).
of the different mouthwashes at 7 hours post-­intervention and to
evaluate the possible adverse effects of hypochlorous acid on soft
2.4 | Interventions and measurements
and dental tissues.

2.4.1 | Clinical and microbiological evaluation

2 | M ATE R I A L S A N D M E TH O DS
All participants were evaluated for visible plaque (Turesky, Gilmore &
Glickman, 1970)14 and the modified gingival index (Lobene, 1986)11
2.1 | Study design
at the start of the study, but only the plaque index was evaluated
A double-­blind randomized controlled trial with five arms was con- during the follow up at 7 hours. Two calibrated periodontists (L.A.G.
ducted. The study design was approved by the Ethics Committee of and M.A.S.) with intra-­examiner kappa indexes of 0.93 and 0.94,
the School of Dentistry of the El Bosque University according to the respectively, and an interexaminer kappa index of 0.92 performed
Declaration of Helsinki on experimentation involving human subjects blinded assessments throughout the study. One hour after a stand-
and was registered at ClinicalTrials.gov under no. NCT03174756 ardized breakfast, all participants received dental prophylaxis with
(available at https://clinicaltrials.gov/ct2/show/NCT03174756). We a rubber cup without fluorinated paste to evaluate plaque counts
used Consolidated Standards of Reporting Trials (CONSORT) check- after 7 hours. Non-­stimulated saliva samples were obtained before
11
list for reporting this clinical trial. rinsing and at 30 seconds (T1), 1 hour (T2), 3 hours (T3), 5 hours (T4)
and 7 hours (T5) to assess bacterial viability. Participants were also
evaluated at 24 hours and completed a questionnaire about any self-­
2.2 | Participants
perceived side effects of the rinses/placebo.
All subjects were informed about the objectives, probable risks
and benefits of the protocol treatment and signed informed con-
2.4.2 | Microbial sampling
sent forms. Young men, over 18 years of age, who were students
at El Bosque University with a minimum of 22 teeth were consid- Saliva samples were immediately sent to the microbiology laboratory
ered eligible for the study. Participants had good dental and gingival to evaluate bacterial viability via a fluorescence test using SYTO-­9/
status (DMFT index ≤3, median of Lobene gingival index12 ≤1) and IP fluorochrome stains following the methodology described by
detectable levels of dental plaque at 7 hours after brushing during Tomás et al, 2009.12 A solution containing 3.34 mM SYTO-­9/IP and
the selection process. Exclusion criteria were smoking, orthodontic, 20 mM propidium iodide (LIVE/DEAD®/BacLight™) was used. The
orthopaedic or rehabilitation treatment, cavitated carious lesions saliva samples were centrifuged at 358 g for 6 minutes, the super-
and consumption of systemic antimicrobials or anti-­inflammatory natant was discarded, and the pellet obtained was resuspended in
drugs in the last 6 months. Recruitment of participants began on 15 100 μL of sterile water. After homogenization by stirring, the bacte-
January 2015 and ended on 15 November 2016. rial suspension was mixed with 1 μL of the fluorescence solution and
stored in the dark at room temperature for 15 minutes. Observations
were made with a fluorescence microscope (Axio-­Imager A2; Zeiss,
2.3 | Randomization
Jena, Germany) for greater magnification, and digital images were
A total of 75 participants were randomly assigned by a computer-­ acquired using AxioVision LE 4.8 software (Zeiss Microscopy). The
generated table using Minitab 18 statistical software to receive dyes were used to differentiate the bacteria with intact membranes
one of the five therapies: 0.025% HOCl, 0.05% HOCl, 0.2% CHX, (green fluorescence) from the bacteria with abnormal membranes
0.025% CHX and placebo (sterile water). The mouthwashes were (red fluorescence). Viable and non-­viable bacteria were counted at
indistinguishable in terms of consistency, packaging and labelling, high magnification (×100) in 20 microscopic fields with a minimum of
but the taste still varied. Ten millilitres of each rinse was pack- 100 bacteria, excluding bacterial aggregates.
aged and masked by a centre outside the study. A pilot sample was The mean percentage of viable bacteria was calculated for
used based on previous studies of the substantivity of antiplaque each saliva sample, and the viability reduction (VR) was calculated
agents.13 by the difference in the percentage of viable bacteria between
LAFAURIE et al. |
      3

F I G U R E   1   CONSORT flow diagram of this study

two saliva samples. Two bacteriologists previously calibrated established with one-­
way ANOVA. All analyses were performed
made blind measurements during the study. The levels of interob- with a significance level of 5% using STATA 12 statistical software
server agreement by the intraclass correlation coefficient (ICC) (Stata Corp, College Station, TX, USA).
were 0.95/1 and 0.96/1, and the level of intra-­observer agree-
ment of the experts was 0.97/1, corresponding to almost perfect
agreement. 3 | R E S U LT S

One hundred participants were examined. Of these, 25 (25%) were

2.4.3 | Adverse effects
excluded due to orthodontics, cavitational caries and smoking
A survey was administered to each of the patients to determine (Figure 1). The age, plaque index and initial gingival index at the time
whether any adverse effects, such as burning or pain in the oral of selection were similar between the groups evaluated without sig-
mucosa, occurred after the use of each of the interventions, and nificant differences (Table 1).
the taste of the substances and sensation of dryness were also
evaluated. Oral examinations were also performed at the begin-
3.1 | Viability at different time points
ning of the experiment and at 24 hours. An examiner evaluated
the buccal, labial, lingual, pharyngeal and teeth tissues to establish Table 2 shows the percentages of reduction in bacterial viability for
changes, visible alterations and the presence of candidiasis during the different groups at different times. The greatest reduction in via-
the clinical examination. All changes were recorded on case report bility was observed 30 seconds after mouth rinsing. The CHX groups
forms. showed the highest percentages of reduction in bacterial viability
(48.5% to 58.4%), followed by the HOCl groups (31.8% to 33.1%).
The control group showed a slight effect on viability of 3.95%. After
2.5 | Statistical analysis
the allotted time, only the CHX groups showed effects on bacte-
Mean values ± SD and the frequency and percentages were calcu- rial viability and substantivity. At 7 hours, only the 0.2% CHX rinse
lated for data analysis. Categorical data were analysed with the chi-­ showed some effects on bacterial viability.
square test. For comparisons of the viability of the different rinses Figure 2 shows a fluorescence microscopy sequence with the
between time points, a generalized linear mixed model (GLMM) viability test for saliva samples after treatment with 0.05% HOCl at
adjusted for treatment, time and treatment–time interaction was pH 5.8. The initial effect of HOCl on bacterial viability and how this
developed. Differences in the plaque index among the groups were effect is lost over 7 hours after treatment can be seen.
 |
4       LAFAURIE et al.

TA B L E   1   Baseline characteristics of the population under study

HOCl 0.025%
Variables Placebo n = 15 CHX 0.2% n = 15 CHX 0.12% n = 15 HOCl 0.05% n = 15 n = 15

Age 20 ± 1.5 20.4 ± 1.45 19.5 ± 1.6 19.3 ± 1.57 20 ± 1.2

Plaque index 1.6 ± 0.39 1.6 ± 0.52 1.74 ± 0.50 1.75 ± 0.42 1.69 ± 0.54
Gingival index 0.43 ± 0.52 0.41 ± 0.28 0.63 ± 0.61 0.88 ± 0.61 0.60 ± 0.54

Data expressed as mean and standard deviation.

One way ANOVA P > .05.

TA B L E   2   Percentage reduction of
T1 T2 T3 T4 T5
bacterial viability at different times
Based 3.95 ± 8.14 0.56 ± 5.3 1.75 ± 4.9 2.13 ± 2.51 0.77 ± 4.19
Comparison
Placebo
CHX 0.2% 48.5 ± 34.3 38.0 ± 24.9 24.0 ± 24.8 18.2 ± 23.7 14.4 ± 29.4
P value <.001 <.001 <.001 <.001 .001
CHX 0.12% 58.4 ± 29.8 42.0 ± 33.2 28.8 ± 30,6 10.2 ± 16.0 −2.3 ± 27.3
P value <.001 <.001 <.001 <.001 .229
HOCl 0.05% 33.1 ± 30.2 7.2 ± 11.9 3.2 ± 7.9 −1.5 ± 9.7 −3.1 ± 9.6
P value <.001 .092 .341 .959 .633
HOCl 0.025% 31.8 ± 30.2 2.7 ± 12.4 −2.6 ± 13.7 −9.6 ± 16.6 −6.3 ± 20.0
P value <.001 .113 .310 .697 .829

T1, 30 s; T2, 1 h; T3, 3 h; T4, 5 h; T5, 7 h.
For the comparisons of the viability of the different rinses between times, a generalized linear mixed
model (GLMM) adjusted to treatment, time and treatment–time interaction was carried out. Base
comparison placebo. Data expressed as mean and standard deviation.

Table 2 shows treatment-­

adjusted values and time–treatment
3.3 | Adverse effects
interactions for each observation time in the different groups eval-
uated using the placebo as the basis for comparisons. To establish if Of the evaluated groups, HOCl presented as the most unpleasant
there were differences in the different groups evaluated over time, taste. The 0.025% HOCl rinse was disagreeable to 42% of the in-
a generalized linear mixed model was developed. For this analy- dividuals, and the 0.05% HOCl rinse (P < .001), to 55% of the indi-
sis, we assessed the significant differences between the different viduals. The HOCl rinses showed greater dry tissue sensation after
times and treatments along with their interaction. The probability rinsing compared with CHX (P = .005). Both CHX rinses and the
values showed that the response of the treatments was influenced 0.05% HOCl rinses induced similar sensations of irritation. At the
by these variables (P < .001). In this adjusted model, only the CHX clinical examination 24 hours after rinsing, no clinical or mucosal
groups showed an effect on bacterial viability over time. CHX at changes or dental pigmentation were observed in any group.
0.2% showed better effects than CHX 0.12% over time, with signif-
icant effects until 7 hours after rinsing and substantivity for up to
5 hours. The HOCl groups did not show effects on bacterial viability 4 | D I S CU S S I O N
with time in the adjusted model but showed significant differences
from the placebo group immediately after rinsing (Table 2, Figure 3). Existing evidence from long-­term studies supports the favourable
effects of various antiplaque substances used as an adjunct to me-
chanical means of oral hygiene to reduce gingivitis.15 However, ef-
3.2 | Plaque index
fective reduction in plaque and gingivitis by antiplaque agents in the
The lowest average plaque at 7 hours after rinsing was found for short-­term remains under study. CHX does not seem to be more ef-
0.2% CHX rinse at 1.12 ± 0.38 (95% CI 0.90-­1.34), followed by fective than a mouthwash with essential oils in reducing gingivitis
0.025% HOCl rinse at 1.18 ± 0.44 (95% CI 0.93-­1.43) and 0.05% according to long-­term studies, and its main mechanism of action
HOCl rinse at 1.22 ± 0.46 (95% CI 1.10-­1.56). The highest val- reported in short-­and long-­term studies is the reduction in dental
ues were observed for 0.12% CHX and placebo, with averages of plaque.16,17
1.33 ± 0.41 (95% CI 1.10-­1.56) and 1.3 ± 0.50 (CI 95% 1.0-­1.58), The substantivity, or prolonged effect in the oral cavity, is one
respectively. No significant differences were found among the 5 of the main effects of CHX.18 In the analysis of antiplaque mouth-
groups (Figure 4). washes, substantivity tests were developed to establish the ability of
LAFAURIE et al. |
      5

(A) (B)

(C) (D)

(E) (F)

F I G U R E   2   Viability test for saliva

samples after treatment with HOCl 0.05%
pH 5.8. A: No treatment; B: 30 s after
rinsing; C: 1 h after rinsing; D: 3 h after
rinsing; E: 5 h after rinsing; F: 7 h after
rinsing. (Viable green bacteria, non-­viable
red bacteria)

a substance to maintain its effect on the salivary flora for a prolonged of 50 ppm, and some commercial products include chlorine diox-
period of time.19,20 Few antiplaque substances have substantivity in ide for mouth rinses and root canal irrigation. However, it has been
the oral cavity despite showing antiplaque effects. Antiplaque sub- reported that low concentrations of ClO2 can induce cell cycle ar-
stances, such as cetylpyridinium and triclosan, maintain their action rest in human gingival fibroblasts. 24 The Environmental Protection
for 30 minutes, and essential oils show slight substantivity action for Agency (EPA)25 and the National Institute for Occupational Safety
18
5 hours. However, acidified sodium chlorite (ASC) was shown to and Health (NIOSH) of the United States have reported that chlorine
20-22
have similar effects as CHX. dioxide is rapidly absorbed from the gastrointestinal tract, causing
ASC is produced by lowering the pH of a solution of sodium deaths in rats exposed repeatedly to approximately 100 ppm for
chlorite (NaClO2), and its mode of action is derived from the un- 4 hours daily. 26 Therefore, while considering its clinical use as a
charged chlorous acid, which gradually decomposes to form chlorate mouthwash, it is important to consider the safety of these solutions
ions, chlorine dioxide and chloride ions, which are responsible for at high concentrations27
23
its antibacterial effect. Chlorine dioxide is highly unstable and is HOCl is also an oxidant substance obtained during the respi-
used to disinfect the water lines of dental units at concentrations ratory burst in the phagocytosis of antigens in reactions with the
 |
6       LAFAURIE et al.

effects and ability to induce cell proliferation, which could favour

the reduction in gingivitis. Although there are in vitro effects of
HOCl efficacy on Gram-­positive and Gram-­negative bacteria that
form the dental biofilm,9,10 no studies have been performed to eval-
uate its clinical effectiveness.
Regarding the substantivity of HOCl observed at concentrations
of 0.025% and 0.05% at pH 5.8, HOCl rinses reduced bacterial vi-
ability by an average of 32% compared with 54% for CHX rinses.
However, HOCl rinses have no substantivity, and recovery of via-
ble flora was evident after one hour after mouthwash. Only CHX
0.2% maintains prolonged action until 7 hours; CHX 0.12% loses
its action in saliva faster, with substantivity being maintained only
until 5 hours. These findings on the action of chlorhexidine sub-
stantivity are similar to those reported by other studies using similar

F I G U R E   3   Reduction of viability over time among the groups methodologies.13,19

evaluated in adjusted model. 0, Base line; 1, 30 s after rinsing; 2, The lower antimicrobial effect in the saliva observed for the
1 h after rinsing; 3, 3 h after rinsing; 4, 5 h after rinsing; 5, 7 h after use of the HOCl may be due to the greater effectiveness of CHX
rinsing. (Mean with confidential interval (CI 95%) on Gram-­p ositive bacteria present in the saliva. Gram-­p ositive
bacteria are the primary colonists of the dental biofilm that colo-
nize the dental surface in the first hours of formation. HOCl shows
greater effects on Gram-­n egative bacteria associated with peri-
odontal diseases such as P. gingivalis and A. actinomycetemcom-
itans 9; clearly, its action on saliva does not exceed CHX, which
was more effective than the HOCl mouthwashes at all times of
evaluation.
In addition, we evaluated the clinical effect on initial plaque for-
mation using a visible plaque index. Although the reduction in visible
plaque formation at 7 hours was not significantly different between
the groups evaluated, the 0.2% CHX rinse showed the greatest re-
duction in initial plaque formation at 7 hours, followed by the HOCl
rinses. As no significant differences were found in the evaluation
of initial plaque formation, it is necessary to evaluate plaque reduc-
tion in longitudinal trials. Previously, 3-­to 21-­day studies have been
mostly used to study these effects in the short term.30,31

F I G U R E   4   Visible plaque index after 7 h of rinses The substantivity of CHX in saliva and in dental biofilm was eval-
uated by García-­C aballero et al, in 2013.32 The formulation of CHX
myeloperoxidase enzyme, hydrogen peroxide (H2O2) and a chlorine 0.2% showed greater substantivity in the biofilm than in salivary
ion. It functions as a chemotactic substance that allows excellent mi- flora at 5 and 7 hours, which could be related to a slower growth
crobial control and activation of the defence system that facilitates rate of the micro-­organisms in the biofilm as a possible mechanism
rapid and harmless tissue repair. 28 Stabilized hypochlorous acid has for its antiplaque function. The effect of HOCl on the inhibition of
been proven to be safe. Data from a 28-­day toxicity study suggest initial plaque formation does not depend on substantivity, and other
that in full-­thickness wounded rats and mini-­pigs, the daily applica- factors, such as its oxidizing action, may exert an effect on the mech-
tion of stabilized HOCl at 0.01%, 0.03% and 0.1% w/v, together with anisms of bacterial adhesion.9,33
a 24-­hour occluded dressing, showed no evidence of systemic toxic- HOCl also showed adverse effects, such as the sensation of mu-
ity. 28 Although the acidification of hypochlorite ions is the most used cosal dryness and unpleasant taste, but it does not present the main
method to generate HOCl, the solutions obtained lack the necessary adverse effect—dental pigmentation—generated by CHX, which may
stability for prolonged use. In 1993, by implementing a modified deter clinical use. It is also necessary to evaluate organic flavourings
acidification protocol plus secondary processes of super oxidation to improve the flavour of the substance.
of water, a technique for the stabilization of HOCl for its use in med-
icine was patented (U.S patent: US2004/0062818A1), and this prod-
4.1 | Limitations
uct was used in this study. 29
Our study evaluated hypochlorous acid rinses for plaque control One limitation of this study was the inability to calculate a pre-
due to its low toxicity, high antimicrobial efficacy, anti-­inflammatory dicted samples size before the study, and a pilot sample was used.12
LAFAURIE et al. |
      7

However, significant differences were observed between the HOCl 5. Jones CG. Chlorhexidine: is it still the gold standard? Periodontol
groups and the placebo in T1. The power of the sample was calcu- 2000. 1997;15:55‐62.
6. Balloni S, Locci P, Lumare A, Marinucci L. Cytotoxicity of three com-
lated, and a power of 80% was obtained for the differences between
mercial mouthrinses on extracellular matrix metabolism and human
the 0.025 HOCl rinse and the placebo at T1 (α = 0.05, difference be- gingival cell behaviour. Toxicol In Vitro. 2016;34:88‐96.
tween groups = 27%, SD = 20). 7. Eberhard J, Jepsen S, Jervøe-Storm PM, Needleman I, Worthington
In conclusion, HOCl rinses have an initial effect on bacterial via- HV. Full-­ mouth treatment modalities (within 24 hours) for
chronic periodontitis in adults. Cochrane Database Syst Rev
bility in saliva and can be used to reduce the bacterial count in saliva.
2015;4:CD004622.
Long-­term studies are necessary to evaluate its effects as an anti- 8. Totoraitis K, Cohen JL, Friedman A. Topical approaches to improve
plaque agent. surgical outcomes and wound healing: a review of efficacy and
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5.1 | Scientific rationale for the study
reduce the biofilms on titanium alloy surfaces in vitro. Int J Mol Sci.
2016;17:1161.
HOCl is an antimicrobial substance with important effects on the
11. Schulz KF, Altman DG, Moher D. CONSORT Group. CONSORT
oral microflora and should be evaluated as a new antiplaque sub-
2010 Statement: updated guidelines for reporting parallel group
stance for oral use. randomised trials. J Clin Epidemiol 2010 63:834‐840.
12. Lobene RR. Discussion: current status of indices for measuring gin-
givitis. J Clin Periodontol. 1986;13:381‐382.
5.2 | Principal findings 13. Tomás I, García-Caballero L, Cousido MC, Limeres J, Alvarez
M, Diz P. Evaluation of chlorhexidine substantivity on sali-
HOCl has an effect on the flora of saliva and on the formation of vary flora by epifluorescence microscopy. Oral Dis. 2009;15:
dental plaque, but it has no substantivity like CHX. 428‐433.
14. Turesky S, Gilmore ND, Glickman I. Reduced plaque forma-
tion by the chloromethyl analogue of victamine C. J Periodontol.
5.3 | Practical implications 1970;41:41‐43.
15. Prasad M, Patthi B, Singla A, et al. The clinical effectiveness of post-­
HOCl is a new antiplaque substance under study. HOCl reduces bac- brushing rinsing in reducing plaque and gingivitis: a systematic re-
terial counts in saliva and may delay the formation of dental plaque. view. J Clin Diagn Res. 2016;10:1‐7.
16. Van Leeuwen MP, Slot DE, Van der Weijden GA. Essential oils
compared to chlorhexidine with respect to plaque and parame-
AC K N OW L E D G E M E N T S ters of gingival inflammation: a systematic review. J Periodontol.
2011;82:174‐194.
The authors thank the Colombian Department for Science, 17. Neely AL. Essential oil mouthwash (EOMW) may be equivalent to
chlorhexidine (CHX) for long-­term control of gingival inflammation
Technology and Innovation (COLCIENCIAS) as the sponsor of this
but CHX appears to perform better than EOMW in plaque control.
project through Grant No 130850227678. Additionally, we thank J Evid Based Dent Pract. 2012;12(3 Suppl):69‐72.
Dr. Nathaly Delgadillo and Yineth Neuta for assistance in the micro- 18. Jenkins S, Addy M, Wade W, Newcombe R. The magni-
bial analysis, Dr. Maria Alejandra Sabogal and Luz Amparo Gómez tude and duration of the effects of some mouthrinse prod-
ucts on salivary bacterial counts. J Clin Periodontol. 1994;21:
for assistance in the clinical evaluations and Justo Calderon at the
397‐401.
Scientific & Regulatory Affairs, AQUILABS US.
19. Cousido MC, Tomás Carmona I, García-Caballero L, Limeres J,
Alvarez M, Diz P. In vivo substantivity of 0.12% and 0.2% ch-
lorhexidine mouthrinses on salivary bacteria. Clin Oral Investig.
ORCID
2010;14:397‐402.
GI Lafaurie  http://orcid.org/0000-0003-3986-0625 20. Moran J, Addy M, Wade W, Milson S, McAndrew R, Newcombe RG.
The effect of oxidising mouthrinses compared with chlorhexidine
on salivary bacterial counts and plaque regrowth. J Clin Periodontol.
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