Using diluted sodium hypochlorite to supplement periodontal self-care

I frequently get myself in the middle of controversy when I cite the strength of the evidence surrounding periodontal/systemic links. It happened again a couple of weeks ago when I received a group email from a group of dentists who received a 2017 Periodontology 2000 journal article from Dr. Jorgen Slots, a Danish-born periodontist. The author of the email was sharing the article with others and thanked Dr. Slots for his opinion about herpesviruses being a possible causative agent for cardiovascular disease and other systemic diseases associated with periodontitis.

The scientific evidence to support causation between periodontitis and cardiovascular disease is weak.¹ I check in regularly with scientists who are better qualified than me to interpret the literature that pertains to the strength or weakness of these links. Apparently, nothing has changed since the American Heart Association issued a scientific statement concluding that there is no Class A or Class B evidence that periodontal disease causes one or more forms of cardiovascular disease.² A 2016 study called “PAROKRANK” added to the strong evidence for an “association” between periodontitis and myocardial infarction, but it does not prove causation. Association may be partly explained by common risk factors that are important to dentistry because strategies to reduce risk for cardiovascular disease are also likely to reduce risk for periodontal disease and other oral diseases.^1,3

Even though I disagree with Dr. Slots on the periodontal/systemic link evidence, I respect his dedication to research pertaining to the herpesviral-bacterial interactions/synergy in the pathogenesis of periodontal disease. He is continuing his research proposing an infectious disease model for periodontitis in which herpesviral-bacterial interactions assume a major etiopathogenic role.⁴ Theoretically, according to Slots, a herpesvirus infection in the periodontium impairs local defenses that allow overgrowth and increased aggressiveness of periodontopathic bacteria.⁴

I met Dr. Slots 10 years ago at the Herman Ostrow School of Dentistry of USC in Los Angeles where he was teaching an anti-infective course to a crowd of dentists and dental hygienists. It was there where I first heard him talk about the advantages of using sodium hypochlorite as an oral rinse.

To be honest, I was very skeptical at the time of rinsing with a diluted bleach solution in periodontal (and even implant) self-care. Recently, I’ve noticed that periodontists are now recommending it to patients (in an oral irrigator or as an oral rinse) to reduce levels of periodontopathic bacteria, so I’m paying closer attention to the research and clinician preferences.

Most clinicians would agree that periodontal diseases result from disruption of the immune system homeostatis by key periodontal pathogens in biofilm.

Based on our current model for nonsurgical periodontal therapy, scaling and root planing (SRP) is the gold standard treatment for most patients with chronic periodontitis coupled with customized self-care and periodontal maintenance. Customized maintenance and self-care keeps the periodontal (wound) balance in favor of the host (healing) immediately post-debridement, but the balance shifts back to favor the pathogenic biofilm, especially in aggressive presentations.⁵ Therefore, when debridement/maintenance is combined with multiple concurrent strategies to further inhibit the biofilm’s recovery, healing seems to favor the host.

In reviewing several pilot (small-scale) studies, subjects with chronic periodontitis rinsed twice weekly for three months with diluted sodium hypochlorite (percentage of diluted sodium hypochlorite in each pilot study varied) compared to control subjects who rinsed with water. Marked decreases in supragingival plaque biofilm and bleeding on probing were observed.^6-8

In one pilot study (n=40), subjects with chronic periodontitis were randomized into test and control groups. Professional subgingival irrigation with 0.25 percent sodium hypochlorite (test group) and mineral water (control group) into periodontal pockets was done followed by oral rinsing twice a week for three months. At day 14, subgingival irrigation was repeated and oral hygiene instructions were reinforced. Clinical parameters such as gingival index, plaque index, papillary bleeding index, probing depth and clinical attachment level were recorded at baseline and three months. The test group showed significant improvements in PBI, PD reduction and CAL gain compared to the baseline over a period of three months (p < 0.001).⁹

Large, long-term, randomized controlled trials on the effectiveness of a diluted sodium hypochlorite rinse in patients with chronic periodontitis with and without professional subgingival irrigation are needed. No studies on the effectiveness of diluted sodium hypochlorite have been done on patients with aggressive periodontitis.

I searched several periodontal and general dental practice websites around the U.S. that recommend a sodium hypochlorite oral rinse as a means to supplement periodontal self-care. Instructions for diluting and administering diluted sodium hypochlorite on dental practice websites varied. It is safe and readily available as an inexpensive household bleach, but keep in mind that there are no professional clinical guidelines to guide the average practitioner in making these recommendations. Clinical guidelines are systematically developed statements to assist practitioners and patient decisions about appropriate oral health care for specific clinical circumstances.

If you choose to recommend diluted sodium hypochlorite to patients, the recommendation is 8 oz. of water to ¾ teaspoon sodium hypochlorite. It must be mixed fresh every time it is used as chlorine is a gas. It can be used at home two to three times per week, preferably in an oral irrigator.

References:

1. https://www.ada.org/en/science-research/science-in-the-news/new-periodontal-disease-and-cardiovascular-disease
2. http://circ.ahajournals.org/content/early/2012/04/18/CIR.0b013e31825719f3
3. http://circ.ahajournals.org/content/early/2016/01/13/CIRCULATIONAHA.115.020324
4. Slots J. Periodontitis: facts, fallacies and the future. Periodontol 2000 2017: 75: 7–23.
5. Guojing L et al. Shift in the subgingival microbiome following scaling and root planing in generalized aggressive periodontitis. J Clin Periodontol 2018: 45(4): 440-452.
6. Galvin M et al. Periodontal effects of 0.25% sodium hypochlorite twice-weekly oral rinse. J Periodont Res 2014: 49: 696–702.
7. DeNardo R et al. Effects of 0.05% sodium hypochlorite oral rinse on supragingival biofilm and gingival inflammation. Inter Dent J 2012; 62: 208–212.
8. Shah P et al. Clinical evaluation of 0.10% sodium hypochlorite as an oral rinse in chronic generalized periodontitis patients. Adv Hum Biol. 2016: 6(1): 51-56.
9. Konuganti K, Ashwini S, Kumar A. Efficacy of 0.25% sodium hypochlorite oral rinse in patients with chronic periodontitis: a randomized controlled trial. Inter J of Current Adv Res 2017: 6(2): 1966-1969.