Conditions: COVID-19
Keywords: Mouth Wash Viral Load
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 60
Healthy volunteers: yes

Brief summary:
Existing evidence confirmed that saliva and oral cavity to be a reservoir for SARS-CoV-2. In dental clinic aerosol-producing-procedures pose a significant risk for transmission of the infection . It is very important to minimize the risk of transmission in dental office reducing the load of SARS-CoV-2 in saliva if possible, in suspect or conformed cases. Preprocedural mouth rises have been used widely to minimize the number of oral microorganisms. Multiple studies confirmed the efficacy of those mouth rinses in reducing the possibility of transmission of SARS-CoV-2 infection .

Detailed description:
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is one of the coronaviruses such as (SARS \& MERS) which are commonly known for causing severe respiratory illnesses. SARS-CoV-2 is considered to be the leading cause of coronavirus disease (COVID-19) . On March 11th 2020, the WHO announced that SARS-CoV-2 is a global pandemic. Based on COVID-19 Saudi Arabia Ministry of Health Dashboard, globally, as of April 5th 2021, there have been more than 131 million confirmed cases of the disease including more than 2 million deaths. Nationally, as of April 5th 2021, there have been 392,682 confirmed cases including 6,697 deaths .

The diagnosis of COVID-19 involves molecular testing which is the gold standard and the WHO most recommended method of diagnosis. SARS-CoV-2 seemed to be very contagious and the chances of its transmission even before any symptoms occur are very high. It has been documented that COVID-19 disease incubation period to range between 1-14 days, most reported to be between 3 to 7 days with some evidence suggested the incubation period of 5 days. Evidence concerned about the spread of infection due to missed screened cases especially when individuals are unaware of their infection status and didn't show any symptoms yet.

Existing evidence confirmed that saliva and oral cavity to be a reservoir for SARS-CoV-2 . Multiple studies suggested SARS-CoV-2 to be airborne infection, and get transmitted through aerosols. In dental clinic aerosol-producing-procedures pose a significant risk for transmission of the infection. It is very important to minimize the risk of transmission in dental office reducing the load of SARS-CoV-2 in saliva if possible, in suspect or conformed cases. Preprocedural mouth rises have been used widely to minimize the number of oral microorganisms. Multiple studies confirmed the efficacy of those mouth rinses in reducing the possibility of transmission of SARS-CoV-2 infection .

The aim of our study is to determine the efficacy of different mouthwash in reducing the SARS-CoV-2 viral load in saliva of COVID-19 confirmed cases compared with tap water.

The objectives of the study are to determine the viral load, assess the cases clinical information \& disease manifestation, plus the cases demographic characteristics believed to have an influence on the disease characteristics.

Arms:
arm 1: None arm 2: None arm 3: None arm 4: None

Interventions: intervention 1: Chlorhexidine digluconate, povidone iodine
Intervention descriptions: intervention 1: This is a mouth wash that can be used over the counter.

Protocol document:
Prot_SAP_002.pdf: 
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Short-term Efficacy of Chlorhexidine and 
Povidone-Iodine Mouth Rinses in 
Reducing Salivary SARS-CoV-2 Viral Load: 
A Randomized Controlled Clinical Trial 
NCT04941131 
June 24, 2021 
 
 
Dr. Zuhair Natto 
 
 


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1. Background and Rationale 
Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is primarily transmitted 
through respiratory droplets and aerosols. Dental procedures pose a significant transmission risk 
due to close proximity to the oral cavity and aerosol generation. Saliva has been identified as a 
potential reservoir for SARS-CoV-2. Therefore, reducing viral load in saliva prior to dental 
treatment may reduce the risk of cross-infection. 
Several antiseptic mouth rinses have been proposed as preprocedural interventions to reduce 
viral load in the oral cavity. This study evaluates and compares the short-term effects of 
chlorhexidine (in both rinse and lozenge forms) and povidone-iodine mouth rinse on salivary 
viral load in confirmed COVID-19 patients. 
 
 
2. Objectives 
Primary Objective 
• 
To evaluate the short-term efficacy of different mouth rinses and lozenges (chlorhexidine 
rinse, chlorhexidine lozenges, and povidone iodine rinse) in reducing salivary SARS-
CoV-2 viral load. 
Secondary Objective 
• 
To compare each intervention with saline as a control. 
• 
To assess changes in viral load using Ct values of E and S genes via RT-PCR. 
 
Material and methods: 
3. Study Design 
• 
This study is a four-arm, open-label, randomized controlled clinical trial designed to 
evaluate the short-term efficacy of three oral antiseptic interventions—chlorhexidine 
digluconate mouth rinse, chlorhexidine digluconate lozenges, and povidone-iodine (PVP-


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I) mouth rinse—compared to a saline control in reducing salivary SARS-CoV-2 viral 
load in COVID-19-positive patients. 
• 
Type of Study: Open-label, randomized controlled clinical trial 
• 
Study Setting: King Fahad General Hospital and Al-Hamra Community Health Center, 
Jeddah, Saudi Arabia 
• 
Registration: ClinicalTrials.gov (NCT04941131) 
• 
Ethical Approval: Jeddah Health Affairs (#1485) 
 
Study Design 
Randomization and Blinding 
• 
Randomization: Participants will be allocated using a simple 1:1:1:1 randomization 
schedule generated via computer-based random number sequencing. 
• 
Allocation Concealment: Allocation will be performed using sealed opaque envelopes. 
• 
Blinding: This is an open-label study due to the obvious physical and functional 
differences between interventions (rinse vs. lozenge), which preclude participant and 
clinician blinding. However, the laboratory personnel and statisticians will be blinded 
to group allocation. 
 
4. Participants 
Inclusion Criteria: 
• 
Adults aged ≥18 years 
• 
Positive nasopharyngeal RT-PCR for SARS-CoV-2 
• 
Ability to provide informed consent 
Exclusion Criteria: 
• 
Known allergy to study substances (chlorhexidine or povidone-iodine) 
• 
Pregnancy 


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• 
Prior COVID-19 treatment 
• 
Severe oral lesions that contraindicate rinse use 
 
 
5. Interventions 
Participants were randomized into four arms: 
1. Chlorhexidine Mouth Rinse (CHX): 
10 mL undiluted solution, used for 30 seconds. 
2. Chlorhexidine Lozenges (CHX Lozenges): 
2 mg lozenge to dissolve slowly in the mouth. 
3. Povidone Iodine Mouth Rinse (PVP-I): 
10 mL undiluted solution, used for 30 seconds. 
4. Control (Saline): 
10 mL normal saline rinse, used for 30 seconds. 
All participants were instructed to refrain from eating, drinking, or oral hygiene procedures for at 
least 30 minutes before the intervention. 
 
 
6. Sample Collection and Laboratory Testing 
• 
Saliva Collection: Passive drool technique; 3 mL of saliva collected before and after 
intervention (5 minutes apart). 
• 
Analysis Method: 
Real-time RT-PCR using LabGun COVID-19 Kit (Biosewoom, Korea). 
o Targets: E gene and S gene 
o Measurement: Threshold cycle (Ct) values 
 


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7. Sample Size Calculation 
• 
Software: G*Power 3.1 
• 
Effect size: 1.1 
• 
Power: 80% 
• 
Alpha: 0.05 
• 
Required Sample: 15 participants per group (Total N = 60) 
Sample Size Justification: 
• 
Based on an expected moderate-to-large effect size (Cohen’s f = 0.4), α = 0.05, power = 
0.80, and four groups: 
o Required sample = 60 participants (15 per group) 
o Power calculation was performed using G*Power 3.1. 
• 
To account for 10% attrition, a total of 66 participants will be recruited. 
 
 
8. Statistical Analysis 
Statistical Analysis 
Software: 
• 
Data will be analyzed using IBM SPSS Statistics version 25 and R (v4.3 or later) for 
confirmatory and exploratory analyses. 
Analysis Population: 
• 
Intention-to-treat (ITT): All randomized participants will be included in the primary 
analysis, with imputation for missing data. 
 
Primary Outcome Analysis: 
• 
Primary Endpoint: 
o Change in Ct value of SARS-CoV-2 E and S genes from baseline to post-
intervention (ΔCt). 


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• 
Between-Group Comparison: 
o One-way ANOVA to assess differences in mean ΔCt across all four groups. 
o Post-hoc Bonferroni test for pairwise comparisons. 
o If assumptions of ANOVA are violated, Kruskal–Wallis test with Dunn’s test 
for post-hoc comparisons will be used. 
• 
Within-Group Comparison: 
o Paired t-test to compare pre- and post-intervention Ct values within each group. 
o Wilcoxon signed-rank test will be used if normality is not met. 
 
Assumptions and Validation: 
• 
Normality: Assessed using Shapiro-Wilk test and QQ plots. 
• 
Homogeneity of variance: Evaluated using Levene’s test. 
• 
Effect Size Reporting: Partial η² for ANOVA, Cohen’s d for t-tests. 
 
Missing Data Handling: 
• 
For the ITT analysis, missing outcome data will be handled using multiple imputation 
(MI) under the assumption of missing at random (MAR). 
• 
Sensitivity analyses using last observation carried forward (LOCF) will be conducted 
to assess the robustness of findings. 
 
9. Expected Outcomes 
• 
Povidone-iodine rinse will demonstrate the highest reduction in viral load. 
• 
Chlorhexidine lozenges may show moderate efficacy. 
• 
Chlorhexidine rinse may show variable outcomes. 
• 
Control (saline) is expected to have no significant effect. 
 


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10. Ethical Considerations 
• 
All participants provided informed written consent. 
• 
Ethical approval was secured from local ethics board. 
• 
All data were anonymized and securely stored. 
• 
Participants had the right to withdraw at any time without consequences. 
 
11. Timeline 
Phase 
Duration 
Ethical Approval 
Completed 
Participant Recruitment 
2 months 
Data Collection 
2 months 
Laboratory Analysis 
Concurrent 
Data Analysis & Manuscript 1 month 
 
12. Dissemination Plan 
The study results will be disseminated through: 
• 
Peer-reviewed publication 
• 
Scientific conferences 
• 
Institutional and ministry health updates 


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References 
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CoV-2 viral load: An open label randomized controlled clinical trial study. Medicine, 101(30), 
e28925.   
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In vivo evaluation of the virucidal efficacy of chlorhexidine and povidone-iodine mouthwashes 
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