Chlorhexidine: The Good, the Dangerous and the Ugly

While you hear the phrase chlorhexidine it’s straightforward to guess the primary issues that pop into your thoughts: stain, poor affected person compliance, nice bacterial killer, horrible style, works effectively however causes calculus, and provides much more work. In the event you converse with a dental skilled about chlorhexidine there are often two camps of thought. Those that hate it and refuse to make use of it or those that select to miss the unintended effects and nonetheless use it.

Principally, when dental professionals are requested about utilizing chlorhexidine the response isn’t, “As a result of I adore it!” Sometimes, you hear, “as a result of it was taught to me at school,” or just that there isn’t a different. Utilizing one thing simply because we discovered it at school isn’t ok and there’s another that kills the identical micro organism with out the unintended effects. Let’s take a tough have a look at chlorhexidine: the nice, the unhealthy and the ugly.

The Good:
When used as designed

Chlorhexidine is a good bacterial killer.  There isn’t any must deny this as research after research has confirmed it. Nonetheless, it has to make use of an extremely excessive focus to attain outcomes. It makes use of 1,200 elements per million to kill that micro organism.2 The rinse is so potent that it isn’t meant for use longer than 2 weeks.

Chlorhexidine was launched into dentistry in 1954; it’s a broad-spectrum biocide efficient towards Gram-positive and Gram-negative micro organism.3  When designed it was meant for use to briefly assist sufferers reverse gingivitis. Although efficient for gingivitis, it’s truly contraindicated to be used with periodontal illness (see “The Ugly” part).

Although it has many unintended effects, chlorhexidine, if the one possibility, may be safely used to deal with gingivitis.  Nonetheless, that’s the place “the nice” stops. Too many dental professionals use chlorhexidine off-label and for this reason the contraindications and security issues come into play.

The Dangerous:
The unintended effects

The primary purpose many dental professionals hate chlorhexidine is due to the unintended effects. Everyone knows that it stains enamel.  Sufferers hate the stain in addition to hygienists. It’s sort of loopy that we clear a affected person up after which give them a rinse that causes stain. One other quite common facet impact is extra calculus build-up. Once more, this isn’t one thing that you really want after scaling, prophies or surgical procedures.

Sufferers battle to remain compliant with the rinse due to the style. They will’t even rinse with water afterwards as a result of it renders the rinse ineffective, and truly will increase the bitterness!5 Then there’s the lingering aftertaste and alter to the style buds.6 Most sufferers complain of a metallic aftertaste that sticks round for a number of hours. Some sufferers expertise an alteration in style throughout therapy. In different uncommon situations, everlasting style alteration is skilled after the therapy has run its course.7

The Ugly:
Stuff you may not know

Unintended effects like staining and calculus aren’t ultimate however they aren’t harmful. Many dental professionals are prepared to compromise with these unintended effects in an effort to get higher outcomes with therapy.  Nonetheless, research and actual world circumstances present and inform us that we might need to rethink this compromise. The priority for the severity of unintended effects are elevated when chlorhexidine will get used for something aside from what it was meant for: treating gingivitis.

Even with the therapy of gingivitis, there are unrealistic directions and expectations for sufferers to observe. Since chlorhexidine is well inactivated, it ought to be used half-hour after different dental merchandise. It’s deactivated by anionic compounds, together with the anionic surfactants utilized in toothpaste.8 So sufferers shouldn’t rinse instantly after brushing.8 Moreover, they have to then keep away from consuming, consuming and smoking for not less than one hour after use. There may be additionally info that states that saliva and blood inactivate chlorhexidine.12, 15 So, how will we keep away from saliva within the mouth? You possibly can’t. Does it actually even make sense to make use of chlorhexidine in any respect?

Critical unintended effects proceed with their affect on fibroblast formation within the periodontal pocket.  Probably the most astounding findings date again to 1991 the place Dr. Charles D. Alleyn studied the re-establishment of misplaced connective tissue attachment to the foundation floor following periodontal remedy. Chlorhexidine broken the fibroblasts, that are important elements in reattachment.1 Reattachment is the complete objective of scaling and root planing. Frankly, chlorhexidine is destroying the therapeutic course of. If we harm this, the therapeutic section takes longer, and the probability of a beneficial final result with remedy is low. This was the primary of many subsequent research. Discovering out {that a} product we’ve been utilizing for a few years has been impacting sufferers negatively was described as a “crucial occasion.”  One other research printed in 2006 discusses the cytotoxic impact of chlorhexidine on cells, and cautions in utilizing it for publish SRP procedures like irrigation, on account of it damaging the cells (like fibroblasts), which assist within the therapeutic course of.14 But, one other research said the upper focus (≥0.04%) of CHX inhibits cell proliferation and, to a sure extent, impacts cell morphology. Thus, “the applying of CHX within the post-surgical antiseptic therapy of the oral cavity ought to be restricted.”17 However in chlorhexidine’s protection, it was by no means meant for use that means.

Off label makes use of in dentistry is the place lots of the critical points originate.  Chlorhexidine was not created for use with implants, periodontal remedy, or oral surgical procedure. The FDA has reported greater than 52 circumstances of anaphylaxis between 1998-2010 and this quantity has been rising.7 The intense allergic response circumstances reported outcomes that required emergency division visits or hospitalizations to obtain drug and different medical remedies. Two of those circumstances truly resulted in dying. In each eventualities every affected person had left the dental workplace after an extraction with chlorhexidine rinse for use at residence. As said earlier, it takes 1200 ppm of chlorhexidine to attain outcomes.2 For that reason it shouldn’t be used with open wounds. Within the circumstances the place sufferers died, they each had open wounds and the uptake of the lively ingredient was too excessive, inducing a extreme allergic response.7

The Various

Many dental professionals really feel “the unhealthy” and “the ugly” of chlorhexidine outweigh the nice, and so they have seemed for another. Over 10 years in the past a gaggle of dentists who all shared this identical feeling determined to develop another. After years of analysis and growth they got here up with OraCare. The lively ingredient, activated chlorine dioxide, kills the identical micro organism as chlorhexidine however with solely 44 elements per million.2 So it’s secure to make use of on a regular basis. Past simply killing micro organism, activated chlorine dioxide has been proven to successfully take away biofilm, neutralize risky sulfur compounds, and kills fungi and viruses.2 So, it could probably provide extra advantages to sufferers with out compromise, and with out concern for security. Chlorine dioxide is a fuel, so it dissipates via the tissues shortly, and doesn’t go away lingering unintended effects. There isn’t any stain, no extra calculus build-up, and no detrimental affect on fibroblasts.
Dental hygienists have been selecting OraCare to interchange chlorhexidine for almost 10 years.  It makes use of activated chlorine dioxide and xylitol to assist sufferers with a lot of points. The commonest makes use of are bleeding gums, periodontitis, implant upkeep, dry mouth, unhealthy breath, mouth sores, and the record goes on. In case you are able to make the swap, OraCare can present you the nice, and allow you to keep away from “the unhealthy” and “the ugly.”

References

1. Alleyn, C. D., DDS, O’Neal, R. B., Sturdy, S. L., Scheidt, M. J., Van Dyke, T. E., & McPherson, J. C. (1991). The Impact of Chlorhexidine Remedy of Root Surfaces on the Attachment of Human Gingival Fibroblasts In Vitro. Journal of Periodontology, 62(7), 434438. Retrieved from https://onlinelibrary.wiley.com/doi/10.1902/jop.1991.62.7.434.
2. An in Vitro Research Evaluating a Two-Half Activated Chlorine Dioxide Oral Rinse to Chlorhexidine. Perio Implant Advisor, 15 Jan. 2015, perioimplantadvisory.com/clinical-tips/hygiene-techniques/article/16411500/an-in-vitro-study-comparing-a-twopart-activated-chlorine-dioxide-oral-rinse-to-chlorhexidine.
3. Carolyne Horner, Damien Mawer, Mark Wilcox, Diminished susceptibility to chlorhexidine in staphylococci: is it rising and does it matter?, Journal of Antimicrobial Chemotherapy, Quantity 67, Difficulty 11, November 2012, Pages 2547–2559, https://doi.org/10.1093/jac/dks284
4. “Chlorhexidine (Oral Route) Aspect Results. “Mayo Clinic, Mayo Basis for Medical Schooling and analysis, 1 Feb. 2020, mayoclinic.org/drugs-supplements/chlorhexidine-oral-rout/side-effects/drg-20068551?p=1.
5. “Chlorhexidine Details.” Chlorhexidine Details: Mechanism of Motion, 2019, chlorhexidinefacts.com/mechanism-of-action.html.
6. Scientific implications of the growth-suppressive results of chlorhexidine at high and low concentrations on human gingival fibroblasts and adjustments in morphology. Marzena Wyganowska-Swiatkowska, Malgorzata Kotwicka, Paulina Urbaniak, Agnieszka Nowak, Ewa Skrzypczak-Jankun, Jerzy Jankun Int J Mol Med. 2016 Jun; 37(6): 1594–1600. Revealed on-line 2016 Apr 7. doi: 10.3892/ijmm.2016.2550
7. FDA warns about uncommon however critical allergic reactions with the pores and skin antiseptic chlorhexidine gluconate. S. Meals & Drug Administration. 9 Feb. 2017, https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-warns-about-rare-serious-allergic-reactions-skin-antiseptic.
8. Ioannis Tsourounakis, Angela A. Palaiologou‐Gallis, Diana Stoute, Pooja Maney and Thomas E Lallier, Impact of Important Oil and Chlorhexidine Mouthwashes on Gingival Fibroblast Survival and Migration, Journal of Periodontology, 84, 8, (1211-1220), (2013).
9. Kolahi J, Soolari A. Rinsing with chlorhexidine gluconate answer after brushing and flossing enamel: a scientific evaluation of effectiveness. Quintessence Int. 2006;37(8):605–612.
10. Schmidt, V. Zyba, Okay. Jung, S. Rinke, R. Haak, R.F. Mausberg and D. Ziebolz, Results of octenidine mouth rinse on apoptosis and necrosis of human fibroblasts and epithelial cells – an in vitro research , Drug and Chemical Toxicology, 10.1080/01480545.2017.1337124, 41, 2, (182-187), (2017).
11. I. R. Teixeira, A. M. L. Denadai, R. D. Sinisterra and M. E. Cortés, Cyclodextrin modulates the cytotoxic results of chlorhexidine on microrganisms and cells in vitro , Drug Supply, 10.3109/10717544.2013.879679, 22, 3, (444-453), (2014).
12. Mehmet Sağlam, Uğur Arslan, Şerife Buket Bozkurt and Sema S. Hakki, Boric Acid Irrigation as an Adjunct to Mechanical Periodontal Remedy in Sufferers With Continual Periodontitis: A Randomized Scientific Trial, Journal of Periodontology, 84, 9, (1297-1308), (2013).
13. “The Benefits and Disadvantages of Chlorhexidine Mouthwash.” 1 Feb. 2020, https://www.healthline.com/health/chlorhexidine-mouthwash#side-effects.
14. Polimeni, G., Xiropaidis, A. V., & Wikesjö, U. M. (2006). Biology and Ideas of Periodontal Wound Therapeutic/Regeneration. Periodontology 2000, 41, 30-47. Retrieved from https://pdfs.semanticscholar.org/55c8/4509fcd32afafb67b16b34e46076f4b2d165.pdf.
15. Van Maanen-Schakel NW, Slot DE, Bakker EW, Van der Weijden GA. The impact of an oxygenating agent on chlorhexidine-induced extrinsic tooth staining: a scientific evaluation. Int J Dent Hyg. 2012;10(3):198–208. doi:10.1111/j.1601-5037.2012.00555.x
16. Van Strydonck DA, Demoor P, Timmerman MF, van der Velden U, van der Weijden GA. The anti-plaque efficacy of a chlorhexidine mouthrinse utilized in mixture with toothbrushing with dentifrice. J Clin Periodontol. 2004;31(8):691–695. doi:10.1111/j.1600-051X.2004.00546.
17. Wyganowska-Swiatkowska, M., Kotwicka, M., Urbaniak, P., Nowak, A., Skrzypczak-Jankun, E., & Jankun, J. (2016). Scientific implications of the growth-suppressive results of chlorhexidine at high and low concentrations on human gingival fibroblasts and adjustments in morphology. Worldwide Journal of Molecular Drugs, 37, 1594-1600. Retrieved from https://doi.org/10.3892/ijmm.2016.2550.

Concerning the Writer

Lou Shuman is the CEO of Cellerant Consulting Group, dentistry’s main company incubator and accelerator. He’s a venturer in-residence at Harvard’s i-Lab, co-founder of LightForce Orthodontics, a member of the Oral Well being advisory board and founding father of the Cellerant Better of Class Know-how Awards. He was chosen in 2021 by International Summits Institute one of many World’s High 100 Docs.