A Study on Using Mouthwash before Providing Dental Treatment to Patients in Dental Clinics during the COVID-19 Pandemic
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Original Article Int J Clin Prev Dent 2021;17(1):21-26ㆍhttps://doi.org/10.15236/ijcpd.2021.17.1.21
ISSN (Print) 1738-8546ㆍISSN (Online) 2287-6197
A Study on Using Mouthwash before Providing Dental
Treatment to Patients in Dental Clinics during the
COVID-19 Pandemic
Ki seok Hong
Moon Dental Hospital, Cheonan, Korea
Objective: The objective of the present study was to identify the level of recognition of personnel working for dental care in
Korea upon using mouthwash before providing dental treatment for patients during the COVID-19 pandemic.
Methods: Medical personnel currently working in institutions of dental care were selected randomly regardless of their work-
places and types of occupational groups for the survey employing a questionnaire.
Results: Results of the survey revealed that 55.0% of subjects participated in the survey replied that the use of mouthwash
would be useful before providing dental treatment while 45.0% of subjects replied that mouthwash may be useful before
providing surgical treatment such as extracting teeth or procedures creating aerosols or splashes. Younger subjects, not those
over 50s, appeared to dominantly show positive replies upon using mouthwash. Subjects except dentists tended to reply that
mouthwash might be employed before providing surgical treatment or procedures that might create aerosols and splashes.
Conclusion: Personnel working in institutions of dental care in Korea appeared to regard the use of mouthwash for patients
before providing dental care could help to prevent them from being infected or to prevent the propagation of COVID-19
pandemic virus. Responses varied according to age and occupation. Thus, further studies and more active campaigns equip-
ped with pertinent guidelines seem necessary for the current COVID-19 pandemic.
Keywords: COVID-19, dentistry, SARS-CoV-2, mouthwashes, salivary gland
Introduction care [1]. The SARS-CoV-2 virus that caused the epidemic was
found in 91.7% of the saliva samples of patients in the initial
The recent COVID-19 outbreak has resulted in a global stage of infection [2]. Thus, the saliva of patients is regarded
pandemic, affecting the global economy as well as people as a potential channel of COVID-19 propagation [3]. Saliva
worldwide. It also has significant effects in the field of dental aerosols containing SARS-CoV-2 viruses seem to be created
by coughing, sneezing, breathing, and talking, thereby, be-
Corresponding author Ki seok Hong coming sources of propagation of the COVID-19 epidemic. It
E-mail: periohong@gmail.com has been estimated that approximately 40,000 saliva droplets
https://orcid.org/0000-0002-8308-585X are created from a single cough, which can travel a few meters
Received March 1, 2021, Revised March 19, 2021, in the air, propagating the spread of aerosol particulates and
Accepted March 24, 2021 promoting the epidemic [4].
In dental clinics, aerosols are created from dental care pro-
Copyright ⓒ 2021. Korean Academy of Preventive Dentistry. All rights reserved.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/
by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
21International Journal of Clinical Preventive Dentistry
cedures for patients treated with rotating apparatuses such as survey was carried out in January 2021. The following ques-
hand-pieces and supersonic scaler, contributing to the creation tionnaire was used for the survey conducted in the present
of aerosols containing water, saliva, blood, and micro- study. Medical institutions targeted for the distribution of the
organisms during the procedure. Since it is difficult to dentists survey questionnaires were randomly selected. The ques-
and personnel providing medical services to maintain a dis- tionnaires were completed anonymously to maintain privacy
tance from their patients of more than 1 meter, they are ex- and the confidentiality of the collected information.
posed to the risk of infection with SARS-Cov-2 through
1. Questionnaire
aerosols. These aerosols created during dental care procedures
may also cause cross-infection in other patients coming to the 1) Do you think the use of mouthwash by all patients before
clinics. However, it would also be very difficult to suppress dental care would help prevent infection and propagation
the potentially risky aerosols created from dental care proce- of the COVID-19 epidemic?
dures [5,6]. 1. Yes, of course
In general, saliva or water droplets splashes can con- 2. It should be applied only in patients before surgical treat-
taminate an area 3-feet in diameter, whereas aerosols created ment including tooth extraction and dental procedures
therefrom may induce sustainable contamination over a wide creating aerosols
area, and thus, trigger potential propagation through infection
in the clinics [7]. To reduce the risk of SARS-CoV-2 prop- 2) What is the type of your occupational group?
agation by COVID-19 patients in dental clinics, alleviating 1. Dentist
the viral load is essential, for which the use of mouthwash has 2. Another group that provides patients with dental care
been recommended as an efficient measure [8]. According to
recently conducted studies, the use of mouthwash before med- 3) Identify your age group.
ical treatments can decrease the load of microorganisms in 1. 20s
aerosols created in dental clinics [9]. Many dental clinics have 2. 30s
employed mouthwash before providing patients with medical 3. 40s
treatment such as tooth extractions to reduce the oral micro- 4. Over 50s
organism counts and control dental plaque, a major cause of
2. Statistical analysis
periodontal disease and dental caries [10-13]. Clinical evi-
dence for preventing the propagation of SARS-CoV-2 through IBM SPSS Statistics for ver. 21.0 (IBM Co., Armonk, NY,
the use of mouthwash has yet to be reported. However, some USA) was used for all statistical analysis conducted in the
countries including the United States have recommended the present study. To determine differences by age and occupa-
use of mouthwash before providing patients with dental care tional position in recognizing the use of mouthwash to combat
[14,15]. The Korean Dental Association also recommends the COVID-19 infections from dental procedures, the Chi-
use of mouthwash through its website. The emergence of mu- squared test was performed after conducting cross-analysis.
tated viruses and the insufficient employment of mouthwash The level of significance was set at pKi seok Hong：Mouthwashes in Dental Practice during the COVID-19 Pandemic
Table 1. Differences in the recognition on the use of mouthwash of Table 2. Differences in the recognition on the use of mouthwash of
respondents in respective age groups during the COVID-19 pandemic respondents in respective occupational groups during the COVID-19
pandemic
It can be applied only for
cases before providing It can be applied
patients with surgical only for cases before
Yes, of
Age treatment including teeth 2 (p) providing patients
course
extraction of and dental with surgical
Yes, of
procedure that can create Occupation treatments including 2 (p)
course
aerosols teeth extraction and
dental procedures
20s 19 (70.4) 8 (29.6) 9.673 (0.022*)
known to create
30s 21 (46.7) 24 (53.3)
40s 20 (47.6) 22 (52.4) aerosols
Over 50s 6 (100.0) 0 (0.0) Dentist 15 (100.0) 0 (0.0) 14.026 (0.000*)
Total 66 (55.0) 54 (45.0) Respondents 51 (48.6) 54 (51.4)
Values are presented as frequency number (%). *p＜0.05. other than dentist
Total 66 (55.0) 54 (45.0)
Values are presented as frequency number (%). *p＜0.001.
1) Differences in the recognition of respondents in different
age groups on the use of mouthwash during the COVID-19
pandemic teraction between the protein and the ACE2 receptor plays a
The response of the participants on the use of mouthwash role in allowing the virus to enter host cells [17]. The ACE2 re-
showed significant differences among age groups ( =9.673, ceptor is distributed in several parts of the human body. The
pInternational Journal of Clinical Preventive Dentistry [27] stated that the nose and oral cavity of all patients requir- for preventing infection with and the propagation of COVID- ing dental care must be rinsed with 0.5% PVP-I solution. The 19. The personnel providing medical services to patients must mouthwash targets the sensitivity of the virus to oxidation. In be acquainted with the symptoms of COVID-19 and be capa- a study conducted recently on 4 patients with COVID-19, the ble of identifying patients suspected of having COVID-19 in- SARS-CoV-2 viral load was decreased significantly by the ap- fections requiring immediate segregation. Wearing PPE is im- plication of 15 ml of mouthwash containing 1% PVP-I for 1 portant for infection control in dental clinics in that splashes minute [28]. and water droplets may contain pathogens mediated through CPC is a quaternary ammonium compound that exhibits an saliva. Thus, dental care providers are obliged to wear pro- antiviral effect in patients with influenza. The lysosomotropic tective goggles, face shields, masks, gloves, and caps. mechanism together with its ability to destroy viral capsids Avoiding the use of a 3-way syringe is desirable to mini- may exert a similar effect on COVID-19 [29,30]. Chlorhexi- mize splashes and water droplets while performing oral dine (CHX) is a mouthwash mainly employed in dental clinics inspections. Extra-oral radiography such as panoramic ra- to treat periodontal disease and reduce dental plaque. It can in- diography and cone-beam computed tomography can be an al- crease the permeability of the bacterial cell wall, inducing the ternative since intra-oral radiography stimulates salivary se- dissolution of the bacteria. Therefore, it has been applied as a cretions and sneezing [6,34]. The creation of splashes con- broad-spectrum antiseptic to treat gram-positive and gram- taminated with saliva and water droplets or aerosols can be re- negative bacteria, aerobic bacteria, facultative anaerobic bac- duced significantly by using a dental hand-piece or scaler in teria, and mold [31]. The in vitro effects of CHX on lip- dental clinics with rubber dams [35]. High-speed dental hand- id-enveloped viruses such as Influenza A, parainfluenza, her- pieces without anti-retraction valves can reduce the backflow pesvirus 1, cytomegalovirus, and hepatitis B have been re- of oral microorganisms into tubes in the equipment used for ported. However, the effects of CHX on COVID-19, an envel- dental care because it can absorb and discharge saliva into the oped virus, have not been compared to other kinds of mouth- oral cavity during dental treatment. The saliva may be ab- wash. sorbed into the hand-piece and microorganisms in the saliva Nonetheless, Yoon et al. [2] reported that the use of 15 ml of might contaminate tubes in the equipment used for dental 0.12% CHX once for 2 hours could inhibit SARS-CoV-2, sug- care, resulting in cross-infection if rubber dams are not used. gesting that the mouthwash could help prevent the prop- Therefore, dental hand-pieces equipped with no shrink-pre- agation of COVID-19. Hydrogen peroxide (H2O2) is an odor- vention function should not be used during the COVID-19 less, transparent, and colorless liquid mouthwash that has pandemic. Fortunately, there have been no reports of mass in- been used in dental clinics [32]. Since SARS-CoV2 is vulner- fections or COVID-19 propagation via dental clinics. Howev- able to oxidation, the use of mouthwash containing an oxidant er, it seems necessary to be prepared for a possible mass in- such as 1% H2O2 before dental procedures may contribute to fection and the propagation of COVID-19. reducing the viral load in saliva [33]. Since few studies have been conducted so far, sufficient sci- Conclusion entific evidence supporting the recommended use of mouth- wash to control of the risk of infection in dental clinics and In the present study, personnel working in institutions of communities is yet to be reported. Thus, further studies on the dental care were found to commonly think that the use of use of mouthwash during the COVID-19 pandemic are mouthwash by patients before dental procedures could help needed. According to the World Health Organization, pre- prevent infections and propagation of the epidemic COVID- ventive measures against SARS-CoV-2 infection generally in- 19, although the responses varied according to age and occu- clude wearing a mask, scrubbing hands, ventilating buildings, pation of the respondents. Thus, more active campaigns and and maintaining social distance. However, aerosols created preparation of specific guidelines promoting the use of from dental procedures can increase the risk of infection and mouthwash in dental clinics seem necessary. SARS-CoV2 propagation, and thus, require attention. Beyond the use of mouthwash before providing dental treatment, there Conflict of Interest are several ways to reduce the risk of infection and prop- agation of disease, such as the appropriate use of personal pro- No potential conflict of interest relevant to this article was tective equipment (PPE) and employing effective sterilization reported. procedures. Above all, screening patients in dental clinics is important 24 Vol. 17, No. 1, March 2021
Ki seok Hong：Mouthwashes in Dental Practice during the COVID-19 Pandemic
ORCID dental settings during the COVID-19 pandemic [Internet].
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