FAQS CPC

Why is the oral cavity important in the COVID-19 pandemic?

The mouth is one of the main routes of entry for SARS-CoV-2 (the coronavirus responsible for the COVID-19 pandemic). This virus is transmitted mainly through droplets of saliva that are expelled when an infected person speaks , coughs, sneezes, etc.
Various studies have shown that a large number of specific receptors to which SARS-CoV-2 binds are found in the oral cavity (Xu et al. 2020), numbers larger even than in the lungs. Not only that, but during the first 10 days of infection, when the patient may be asymptomatic and highly contagious, SARS-CoV-2 mainly infects the upper respiratory tract: nose, throat and mouth (Wölfel et al. 2020).
Therefore, the mouth can be considered both a route of entry for viruses into the body, an area where viruses can multiply and a route of transmission of the virus to other people.

What oral health recommendations should be followed during this period?

• Brushing 3 times a day or after meals. Use a brush that comes with a cap to avoid contamination with other brushes or from the environment. Replace your brush after getting over an illness. Disinfect the brush head weekly by soaking it in CPC for 1 minute.
• Daily interproximal hygiene.
• Daily tongue cleaning. This is very important, since the epithelial cells of the tongue have a high density of receptors to which the coronavirus SARS-CoV-2 binds.
• Using toothpastes and mouthwashes with CPC. With regard to mouthwashes, it is advisable to rinse and gargle with them 2 times a day for 1 minute, to reach the outermost part of the pharynx, since the virus actively replicates in this area before passing to the lower respiratory tract.

What is CPC?

CPC (cetylpyridinium chloride) is a safe and effective antiseptic, which has been shown to effectively reduce certain bacteria, fungi and viruses. It is widely used in toothpastes and mouthwashes for the prevention of oral diseases

Specifically, it has shown to be efffective against viruses such as influenza, rotavirus, herpes simplex virus, hepatitis B and some coronaviruses (Popkin et al. 2017; Mukherjee et al. 2017; Shen et al. 2019; Álvarez et al. 2020; Seo et al. 2019), including coronavirus strains that are used to evaluate potential efficacy against SARS-CoV-2 (Green et al. 2020; Meyers et al. 2020). Studies recently completed by the IRSI Caixa group (Barcelona) have confirmed the ability of CPC to be active against SARS-CoV-2.

Why might cetylpyridinium chloride (CPC) be effective against COVID-19?

Because it could help decrease the amount of SARS-CoV-2 virus in the mouth. Having less virus in the oral cavity and in saliva would reduce the risk of a coronavirus-infected person transmitting it to a healthy person. It could also help develop a less severe form of COVID-19 (Herrera et al. 2020).

What is the mechanism of action of CPC on coronavirus SARS-CoV-2?

The membrane of this coronavirus is a fundamental element in the process of infecting human cells. CPC is capable of destabilising this viral membrane, thus preventing it from infecting human cells. In other words, CPC may help reduce the infectivity of SARS-CoV-2.

Would a lower amount of virus in my mouth protect me from getting or transmitting the COVID-19 infection or make it less severe?

If the virus is already in your mouth, it is a sign that you have the infection. However, although there is still no clinical evidence of this, the lesser the amount of virus in saliva, the lower the risk that the virus can be transmitted through saliva when talking, coughing, sneezing, etc.

Some studies have shown that there is a direct relationship between the amount of virus and the severity of COVID-19 (Liu et al. 2020). That is, the greater the viral load, the greater the risk that COVID-19 will be severe. Considering that in the initial days, the virus is located in the oral cavity and in the throat (Wolfel et al. 2020) and that it then enters into the body (to the lungs), reducing the virus in the mouth could help there to be less risk of a severe form of COVID-19. However, other risk factors have an influence such as, mainly, the immune system of each person and not having other pathologies such as hypertension, heart disease, diabetes or obesity.

Can the use of CPC cure COVID-19?

No, CPC does not cure COVID-19 disease, nor does it prevent contagion. CPC may help reduce viral load and prevent transmission from a carrier of the virus. It is one more preventive measure, to be added to the other measures including social distancing, hand washing with soap and water or hydroalcoholic gels, the use of masks, etc.

Why is it important to use mouthwashes with CPC during the COVID-19 pandemic?

Mouthwashes with CPC can play a fundamental role during this period for different reasons:

• They reduce the risk of transmission of the virus from a person carrying the infection to a healthy person (Herrera et al. 2020)
• They reduce the risk of severe forms of COVID-19 by reducing viral load (Herrera et al. 2020)
• They help maintain good oral health and reduce pathogenic microorganisms in the oral cavity. Poor oral health has been associated with several respiratory diseases, including pneumonia and chronic obstructive pulmonary disease (Sampson et al. 2020; Gomes-Filho et al. 2020; Jeronimo et al. 2020; Mammen et al. 2020)

How does COVID-19 affect the oral cavity?

There are no studies restricting the age of CPC use. The main limitation of use with regard to age is provided for mouthwashes, which are recommended as of age 6, when children are believed to have mastered the swallowing reflex. As for toothpastes, it is important to consider that age limitation is usually established if fluoride is included (age-specific) rather than due to the use of CPC and in the case of products with Chlorhexidine + CPC from the age of 12 for the use of CHX.

Can CPC be used by children?

There are no studies restricting the age of CPC use. The main limitation of use with regard to age is provided for mouthwashes, which are recommended as of age 6, when children are believed to have mastered the swallowing reflex. As for toothpastes, it is important to consider that age limitation is usually established if fluoride (age-specific) or Chlorhexidine are included rather than due to the use of CPC.

Which international bodies recommend the use of antiseptics like CPC?

Multiple international organisations [recommend] rinsing with antiseptic mouthwashes, such as CPC, before a patient undergoes an operation in the dental clinic:

National - Health Authority
Germany - Federal Dental Association
Australia - Australian Dental Association
Belgium - Conseil de l’art dentaire de Belgique
Canada - Canadian Dental Association
Chile - Dental Association of Chile
Colombia - Minsalud / Ministry of Health
Spain - General Dental Council of Spain
United - States American Dental Association (ADA)
France - Association dentaire française (ADF)
Netherlands - Nederland Commissie Leidraad Mondzorg Corona
Italy - Associazione Nazionale Dentisti Italiani (ANDI)
Malta - Superintendent of Public Health
Morocco - CCTD - CHU Ibn ROCHD - Casablanca
Norway - Norwegian Institute of Public Health
Netherlands - Royal Dutch Dental Association / Commissie Leidraad Mondzorg Corona
Peru - Dental Association of Peru
Portugal - Ordem médicos dentistas
Switzerland - Swiss Dental Association (SSO)

In addition to being used in the dental clinic, they could be extremely useful for longer-term daily use during the pandemic, to prevent transmission by both symptomatic carriers of the virus and by those who are unaware they have it.

Can pregnant women use products containing CPC?

Yes, they can use them, under the supervision of a dentist. Pregnant women are at a higher risk for gum disease due to the accumulation of bacterial plaque, and this risk is increased by the physiological changes that occur during pregnancy. CPC is considered safe and effective at authorised concentrations, and has shown to improve periodontal and bacterial plaque indices in pregnant women (Jeffcoat et al. 2011; Geisinger et al. 2013; Jiang et al. 2016).

In addition, there is evidence linking periodontitis (the most serious gum disease) with adverse pregnancy outcomes, such as an increased risk of preterm delivery and low birth weight. In fact, studies have been conducted on pregnant women with periodontitis, evaluating whether the use of CPC helped to improve periodontal condition and thereby reduce the risk of adverse pregnancy outcomes (Jeffcoat et al. 2011; Jiang et al. 2016). For this reason, gum care during pregnancy is considered even more important, with measures such as brushing, daily interproximal hygiene and the use of toothpastes and mouthwashes containing CPC.