presentation on chlorhexidine as a chemical plaque control agent

1. CHLORHEXIDINE
DEPARTMENT OF
PERIODONTOLOGY
- JANANI.A

2. INTRODUCTION
Dental plaqueis defines as a highly specific variablestructural
entity formed by sequential colonization of microorganism on the
tooth surface, epithelium and restorations
Plaquecontrolis the removal ofmicrobial plaque andthe
prevention of its accumulation on the teeth and adjacent gingival
tissues. It also deals with the prevention of calculus formation

3. Plaquecontrol
Mechanical
plaque control
Chemical
plaque control

4. First
generation
• Antibiotics, Phenol,Quaternaryammonium
compounds, Sanguinarine
Second
generation
• Bisbiguanides (CHLORHEXIDINE)
Third
generation
• Delmopinol

5. CHLORHEXIDINE- INTRODUCTION
Secondgeneration chemical
plaque control agent
Highly bacteriostatic in nature
Also used as antiseptic in
various specialities
Available in different forms for
use

6. HISTORY
Developedin1940sbyImperial ChemicalIndustries,England
Marketedin1954as antisepticforskinwounds
 Later,widelyusedinmedicineandsurgeryincludingobstetrics,
gynaecology,urologyandpre-surgicalskinpreparation
Indentistry,initiallyas pre-surgicaldisinfectantofmouthandin
Endodontics

7. 1969 - Schroeder investigatedPlaque inhibition
by CHX
1970 - Loe and Schiott did a definitivestudy on it
Rinsingfor 60 sec BD with 10ml of a 0.2% CHX solution
withoutnormal tooth cleaninginhibitsplaque regrowth and
development of gingivitis

8. CHEMISTRY
BISBIGUANIDEantiseptic
Symmetricalmolecule
4 CHLOROPHENYLrings and2 BIGUANIDE
groups
Connectedbya CentralHEXAMETHYLENE
bridge
2 POSITIVECHARGESoneithersideof the
hexamethylenebridge
StrongBASE
DICATIONICatpHlevels >3.5
ExtremelyINTERACTIVEwithanionsdue
toits dicationicnature

9. FORMS OF CHLORHEXIDINE
WATER SOLUBLE
Digluconate
Acetate
SPARINGLY SOLUBLE
Hydrochloride

10. MECHANISM OF ACTION

11. MECHANISM OF ACTION
ON THE TOOTH SURFACE:
 CHX gets attached to the salivaryproteins and
desquamated epithelial cells
Blocks acidicgroups on salivary glycoproteins
Reduces glycoprotein adsorption on tooth surface
Prevents pellicle formation

12.  Prolonged antiseptic release
Bacteriostatic action that lasts for more than 12 hours
Prevents the adsorption of bacterial cellwallon to the
tooth surface
Prevents plaque formation

13.  Competes with calciumions
Blocks agglutinationof plaque
Prevents binding of mature plaque

14. ON THE BACTERIAL CELL MEMBRANE:
AT LOWCONCENTRATIONS:
CHX adheres to bacterial cellmembrane
Binds tophospholipids in the inner cellmembrane
Leakage of lesser molecular weight components
Sub lethal stage – reversible bacteriostatic action

16. AT HIGH CONCENTRATIONS:
The action continues
Intracellular coagulation
Leakage of intracellularcomponents slow down
Cytoplasmic coagulation
Cell death
(Bactericidal action)

17. Anionicsubstances like Sodium lauryl sulfate based toothpastes reduce
plaque inhibition effect of CHX
Dose related plaque inhibition by CHX:
–10ml of 0.2% solution (20mg)
–High volumes of low concentration solutions
–Topical application of 0.2% solutions
Radio-labelled CHX - slow release of antiseptic from surfaces
- prolonged antibacterial effect

18. CHLORHEXIDINE PRODUCTS
a) Mouth rinses
b) Gels
c) Sprays
d) Toothpastes
e) Varnishes

19. MOUTH RINSES
• Aqueous solutions of
0.2% CHX (used as 10 ml
rinse)
• Other available
concentrations:
0.1% , 0.12%
(recommended as 15 ml
rinses)
• Both these provide the
equal efficacy when used
in equivalent doses

20. DOSAGE AND
ADMINISTRATION:
•Recommended useis twice daily
oral rinsing for 30 seconds after
tooth brushing
•Usual dosage is 15 ml of undiluted CHX rinse
•Patient should beinstructed notto rinse with water or brush teeth
immediately after CHX oral rinse
•Careshould betaken to avoid ingestion of the rinse

21. GELS
Available as 1% , 0.2% and 0.12% gels
Delivered in tooth brushes and trays
Forhandicapped individuals, tray delivery has been found to beeffective
against plaque and gingivitis
DISADV:
• Ineffective delivery by tooth brushes
• Tray system of delivery is poorly acceptedby handicapped patients and
their caretakers

22. SPRAYS
0.1% and 0.2% sprays are commercially
available
0.2% spray applied in doses of 1-2 mg on all
tooth surfaces produce effect similar to a 0.2%
mouth rinse
Useful in handicapped patients
Found better acceptedby such patients and
their caretakers

23. TOOTH PASTES
Available as 1% pastes with orwithout
fluorides
Highly effective against plaque
comparedtoother forms
DISADV:
• High stain scoresand increased supra
gingival calculus formation

24. VARNISHES
Used for prophylaxis againstroot caries

25. CLINICALUSES
† As an adjunct to oral hygiene and professional prophylaxis
† Immediatepre operative rinsing and irrigation
† Post-oral surgery
† Patients with jaw fixation
† Fororal hygiene and gingival health benefits in mentally and physically
handicapped patients
† Medically compromised individuals predisposed to oral infections
† High-risk caries patients
† Recurrentoral ulceration
† Removable andfixed orthodontic appliance wearers
† In denture stomatitis

26. 1) AS AN ADJUNCT TO ORAL HYGIENE AND PROFESSIONAL
PROHYLAXIS
CHX provides adequate plaque control following professional
prophylaxis which is essential for successful treatment and
prevention of recurrence

27. 2) PRE OPERATIVE RINSING AND IRRIGATION
• Usedpre operatively for ultra sonic and high speed
instrumentations
• Reduces bacterial load and contamination of operating area,
operator and staff
• In susceptible patients, CHX irrigation, as an adjunct to
appropriate systemic antibiotic prophylaxis, around gingival margin
reducesincidence of bacteremia

28. 3) POST ORAL SURGERY
• Reduces bacterial load and plaque formation at times when
mechanical cleaning may be difficult oris not indicated
• Periodontal dressings can be replaced byCHX rinsing as it
provides improved healing
• But it is of limited use when it is used alongside a periodontal
dressing
• CHX use is recommended throughout the treatment phase and
for periods after treatment
• Its effectiveness also depends on time overwhich the non-
surgical treatment is performed

29. 4) PATIENTS WITH JAW FIXATION
Patients with
intermaxillary fixation are
pronetohavean
increased bacterial load
along with difficulty in
mechanical cleaning

30. 5) FOR ORAL HYGIENE AND
GINGIVAL HEALTH BENEFITS
IN
MENTALLY AND
PHYSICALLY HANDICAPPED
PATIENTS
Forinstitutionalised mentally
and physically handicapped
patients,
Spray delivery of 0.2% CHX has
beenproven to be veryuseful

31. 6) MEDICALLY COMPROMISED INDIVIDUALS PREDISPOSED
TO ORAL INFECTIONS
Patients such as
• those receiving chemoand/or
radio therapy, bone marrow
transplants
• immuno-compromised those
including blood dyscrasias
are susceptible to oral infections,
most commonly, candidal infections

32.  CHX is highly effective against oral infections when
combined with specific anti-candidal agents suchas Nystatin
and Amphotericin-B
 In terminally ill patients, CHX sprays can be used
effectively for maintenance of better oral hygiene

33. 7) HIGH-RISK CARIES PATIENTS
CHX rinses and gels reduce Streptococcus
mutans
It has a synergistic effect with fluoride
Hence, provides better anti-carious
effect when combined with fluoride
rinses

34. 8) RECURRENT ORAL ULCERATION
CHX gels and rinses reduceincidence,
duration and severity of recurrentminor
aphthous ulcersby
causing a reduction in contamination
of ulcers thereby, reducing natural history
CHX has a low therapeutic potential
It shows no effect in majoraphthous
ulcers

35. 9) REMOVABLE AND FIXED ORTHODONTIC APPLIANCE
WEARERS
During the first 4-8 weeks of orthodontic treatment, plaque
control will be compromised
CHX also reduces the number and severity of traumatic ulcers
during the first 4 weeks

36. 10) DENTURE STOMATITIS
CHX gels can be applied to the fitting
surfaces of the dentures –slow and
incomplete resolution of the condition
Can also beused in treatment of candida
associated infections along with specific
anti candidal drugs
Less effective in therapeutic mode
Denture canbe sterilized by soaking in
chlorhexidine solutions

37. TOXICOLOGY AND SAFETY
• Cationicnature of CHX minimises absorption through skin
and mucosa including the gastro intestinaltract
Hence, systemic toxicity from topical application or ingestion
hasnot been reported.
• Neurosensory deafness can occur if CHX isintroduced into
the middle ear
Should not be placed in the outer ear in case the ear drum is
perforated

38. • Long term oral use can cause aslight shift in
the oral flora towards less-sensitiveorganisms but this
is rapidly reversible
• Ingestion of 1 or 2 ounces of CHX oral rinse by
a smallchild may causesigns and symptoms of gastric
distress, nauseaand intoxication

39. SIDE EFFECTS
1. Taste perturbation wherethe salt taste is preferentially affected to leave
the food and drinks with a rather bland taste

40. 2. Chlorhexidine staining
4 mechanisms have been
proposed to explain CHX staining:
• Degradation of CHX:
Degradation of CHX releases parachloraniline
• 2. Maillard reactions:
Non-enzymatic browning reactions catalysed by CHX

41. • Protein denaturation produced by CHX with
the interaction of exposed sulfide radical with
metal ions
This theory doesn’t take into account other
antiseptics and metal ions that produce
staining
• Precipitation of anionic
chromogens:
Locally bound antiseptics
and polyvalent metal ions react
with the polyphenols on dietary
substances and precipitate
anionic dietary chromogens
The colour of the precipitate
is same as that of their metal
sulfide salts

42. 3. Oral mucosal erosion appears to beidiosyncratic reaction and
concentration dependent
Dilution of the 0.2% formulation to 0.1% , but rinsing with the
whole volume to maintain dose usually alleviates the problem

43. 4. Unilateral or bilateral parotid swelling
Veryrare occurrence

44. 5. Enhanced supragingival calculus formation
This may be due to the precipitation of salivary proteins on to the tooth
surface thereby, increasing the pellicle thickness and/or precipitation of
organic salts on to the pellicle layer
Pellicle formation under the influence of chlorhexidine shows as early and
highly calcified structure

45. CONCLUSION
Chlorhexidine to date is the proven most effective antiplaque agent
It is freefrom systemic toxicity, microbial resistance and supra-
infection
Antiplaque action ofchlorhexidine appears dependent onprolonged
persistence of antimicrobial action in the mouth
Local side effects are reported which are mainly cosmetic problems