PERIO

1. CHLORHEXIDINE
DEPARTMENT OF
PERIODONTOLOGY
-JANANI.A

2. INTRODUCTION
Dentalplaqueisdefinesa
sahighlyspecificvariablestructural
entityformedbysequentialcolonizationofmicroorganismonthe
toothsurface,epitheliumandrestorations
Plaquecontrolistheremovalofmicrobialplaqueandthe
preventionofitsaccumulationontheteethandadjacentgingival
tissues.Italsodealswiththepreventionofcalculusformation

3. Plaquecontrol
Mechanical
plaquecontrol
Chemical
plaquecontrol

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

5. C
H
L
O
R
H
E
X
I
D
I
N
E-INTRODUCTION
1. Second generation
chemical plaque control
agent
2. Highly bacteriostatic in
nature
3. Also used as
antiseptic in various
specialities
4. Available in different forms
for use

6. H
I
S
T
O
R
Y
Developed in 1940s by Imperial Chemical
Industries, England
Marketed in 1954 as antiseptic for skin wounds
Later, widely used in medicine and surgery
including obstetrics, gynaecology, urology and pre-
surgical skin preparation
In dentistry, initially as pre-surgical disinfectant of
mouth and in Endodontics

7. 1969 - Schroeder investigated
Plaque inhibition by CHX
1970 - Loe and Schiott did a definitive
study on it
Rinsing for 60 sec BD with 10ml of a
0.2% CHX solution without normal tooth
cleaning inhibits plaque regrowth and
development of gingivitis

8. C
H
E
M
I
S
T
R
Y
BISBIGUANIDE antiseptic
Symmetrical molecule
4 CHLOROPHENYL rings and 2
BIGUANIDE groups
Connected by a Central
HEXAMETHYLENE bridge
2 POSITIVE CHARGES on either
side of the hexamethylene bridge
Strong BASE
DICATIONIC at pH levels >3.5
Extremely INTERACTIVE with anions
due
to its dicationic nature

9. F
O
R
M
S
O
FC
H
L
O
R
H
E
X
I
D
I
N
E
WATER SOLUBLE
Digluconate
Acetate
SPARINGLY
SOLUBLE
Hydrochloride

10. M
E
C
H
A
N
I
S
MO
FACTI
O
N

11. M
E
C
H
A
N
I
S
MO
FACT
I
O
N
ONT
H
E
T
O
O
T
HS
U
R
F
A
C
E
:
C
H
Xgetsattachedtothesalivaryproteinsand
desquamatedepithelialcells
Blocksacidicgroupsonsalivaryglycoproteins
Reducesglycoproteinadsorptionontoothsurface
Preventspellicleformation

12.  Prolongedantisepticrelease
Bacteriostaticactionthatlastsformorethan12hours
Preventstheadsorptionofbacterialcellwallontothe
toothsurface
Preventsplaqueformation

13.  Competeswithcalciumions
Blocksagglutinationofplaque
Preventsbindingofmatureplaque

14. ONT
H
E
B
A
C
T
E
R
I
A
LC
E
L
LM
E
M
B
R
A
N
E
:
A
TL
O
WC
O
N
C
E
N
T
R
A
T
I
O
N
S
:
C
H
Xadherestobacterialcellmembrane
Bindstophospholipidsintheinnercellmembrane
Leakageoflessermolecularweightcomponents
S
u
blethalstage– reversiblebacteriostaticaction

16. A
THIGHC
O
N
C
E
N
T
R
A
T
I
O
N
S
:
Theactioncontinues
Intracellularcoagulation
Leakageofintracellularcomponentsslowdown
Cytoplasmiccoagulation
Celldeath
(Bactericidalaction)

17. AnionicsubstanceslikeSodiumlaurylsulfatebasedtoothpastesreduce
plaqueinhibitioneffectofC
H
X
DoserelatedplaqueinhibitionbyC
H
X
:
–10mlof0.2%solution(20mg)
–Highvolumesoflowconcentrationsolutions
–T
opicalapplicationof0.2%solutions
Radio-labelledC
H
X-slowreleaseofantisepticfromsurfaces
-prolongedantibacterialeffect

18. C
H
L
O
R
H
E
X
I
D
I
N
EP
R
O
D
U
C
T
S
a) Mouthrinses
b) Gels
c) Sprays
d) T
oothpastes
e) V
arnishes

19. M
O
U
T
HR
I
N
S
E
S
• Aqueoussolutionsof
0.2%C
H
X(useda
s10ml
rinse)
• Otheravailable
concentrations:
0.1%,0.12%
(recommendeda
s15ml
rinses)
• Boththeseprovidethe
equalefficacywhenused
inequivalentdoses

20. D
O
S
A
G
E
AND
ADMINI
S
T
R
ATION
:
•Recommendeduseistwicedaily
oralrinsingfor30secondsafter
toothbrushing
•Usualdosageis15mlofundilutedC
H
Xrinse
•Patientshouldbeinstructednottorinsewithwaterorbrushteeth
immediatelyafterC
H
Xoralrinse
•Careshouldbetakentoavoidingestionoftherinse

21. G
E
L
S
Availablea
s1
%,0.2%and0.12%gels
Deliveredintoothbrushesandtrays
Forhandicappedindividuals,traydeliveryhasbeenfoundtobeeffective
againstplaqueandgingivitis
DISADV
:
• Ineffectivedeliverybytoothbrushes
•T
raysystemofdeliveryispoorlyacceptedbyhandicappedpatientsand
theircaretakers

22. S
P
R
A
Y
S
0.1%and0.2%spraysarecommercially
available
0.2%sprayappliedindosesof1-2m
gonall
toothsurfacesproduceeffectsimilartoa0.2%
mouthrinse
Usefulinhandicappedpatients
Foundbetteracceptedbysuchpatientsand
theircaretakers

23. T
O
O
T
HP
A
S
T
E
S
Availablea
s1
%pasteswithorwithout
fluorides
Highlyeffectiveagainstplaque
comparedtootherforms
DISADV
:
•Highstainscoresandincreasedsupra
gingivalcalculusformation

24. V
A
R
N
I
S
H
E
S
Usedforprophylaxisagainstrootcaries

25. CLINICALU
S
E
S
† A
sanadjuncttooralhygieneandprofessionalprophylaxis
† Immediatepreoperativerinsingandirrigation
† Post-oralsurgery
† Patientswithjawfixation
† Fororalhygieneandgingivalhealthbenefitsinmentallyandphysically
handicappedpatients
† Medicallycompromisedindividualspredisposedtooralinfections
† High-riskcariespatients
† Recurrentoralulceration
† Removableandfixedorthodonticappliancewearers
† Indenturestomatitis

26. 1)A
S
A
NA
D
J
U
N
C
TT
OO
R
A
LH
Y
G
I
E
N
EANDP
R
O
F
E
S
S
I
O
N
A
L
P
R
O
H
Y
L
A
X
I
S
C
H
Xprovidesadequateplaquecontrolfollowingprofessional
prophylaxiswhichisessentialforsuccessfultreatmentand
preventionofrecurrence

27. 2)P
R
EO
P
E
R
A
T
I
V
ERINSINGANDIRRIGATION
• Usedpreoperativelyforultrasonicandhighspeed
instrumentations
•Reducesbacterialloadandcontaminationofoperatingarea,
operatorandstaff
•Insusceptiblepatients,C
H
Xirrigation,a
sanadjunctto appropriate
systemicantibioticprophylaxis,aroundgingivalmarginreduces
incidenceofbacteremia

28. 3)P
O
S
T
O
R
A
LS
U
R
G
E
R
Y
•Reducesbacterialloadandplaqueformationattimeswhen
mechanicalcleaningmaybedifficultorisnotindicated
•PeriodontaldressingscanbereplacedbyC
H
Xrinsinga
sit
providesimprovedhealing
•Butit isoflimitedusewhenit isusedalongsideaperiodontal
dressing
•C
H
Xuseisrecommendedthroughoutthetreatmentphaseand
forperiodsaftertreatment
•Itseffectivenessalsodependsontimeoverwhichthenon-
surgicaltreatmentisperformed

29. 4)P
A
T
I
E
N
T
SWITHJ
A
W
FIXATION
Patientswith
intermaxillaryfixationare
pronetohavean
increasedbacterialload
alongwithdifficultyin
mechanicalcleaning

30. 5)F
O
RO
R
A
LH
Y
G
I
E
N
EAND
GINGIVALH
E
A
L
T
HB
E
N
E
F
I
T
S
IN
M
E
N
T
A
L
L
YA
ND
P
H
Y
S
I
C
A
L
L
YH
A
N
D
I
C
A
P
P
E
D
P
A
T
I
E
N
T
S
Forinstitutionalisedmentally
andphysicallyhandicapped
patients,
Spraydeliveryof0.2%C
H
Xhas
beenproventobeveryuseful

31. 6)M
E
D
I
C
A
L
L
YC
O
M
P
R
O
M
I
S
E
DINDIVIDUALSP
R
E
D
I
S
P
O
S
E
D
T
OO
R
A
LI
N
F
E
C
T
I
O
N
S
Patientssucha
s
•thosereceivingchemoand/or
radiotherapy
,bonemarrow
transplants
• immuno-compromisedthose
includingblooddyscrasias
aresusceptibletooralinfections,
mostcommonly
,candidalinfections

32. C
H
Xishighlyeffectiveagainstoralinfectionswhen
combinedwithspecificanti-candidalagentssucha
sNystatin
andAmphotericin-B
Interminallyill patients,C
H
Xsprayscanbeused
effectivelyformaintenanceofbetteroralhygiene

33. 7)HIGH-RISKC
A
R
I
E
SP
A
T
I
E
N
T
S
C
H
XrinsesandgelsreduceStreptococcus
mutans
Ithasasynergisticeffectwithfluoride
Hence,providesbetteranti-carious
effectwhencombinedwithfluoride
rinses

34. 8)R
E
C
U
R
R
E
N
T
O
R
A
LU
L
C
E
R
A
T
I
O
N
C
H
Xgelsandrinsesreduceincidence,
durationandseverityofrecurrentminor
aphthousulcersby
causingareductionincontamination
ofulcersthereby
,reducingnaturalhistory
C
H
Xhasalowtherapeuticpotential
It showsnoeffect in majoraphthous
ulcers

35. 9)R
E
M
O
V
A
B
L
E
A
NDF
I
X
E
DO
R
T
H
O
D
O
N
T
I
CA
P
P
L
I
A
N
C
E
W
E
A
R
E
R
S
Duringthefirst4-8weeksoforthodontictreatment,plaque
controlwillbecompromised
C
H
Xalsoreducesthenumberandseverityoftraumaticulcers
duringthefirst4weeks

36. 10)D
E
N
T
U
R
ES
T
O
M
A
T
I
T
I
S
C
H
Xgelscanbeappliedtothefitting
surfacesofthedentures– slowand
incompleteresolutionofthecondition
C
a
nalsobeusedintreatmentofcandida
associatedinfectionsalongwithspecific
anticandidaldrugs
L
e
s
seffectiveintherapeuticmode
Denturecanbesterilizedbysoakingin
chlorhexidinesolutions

37. T
O
X
I
C
O
L
O
G
YANDS
A
F
E
T
Y
•CationicnatureofC
H
Xminimisesabsorptionthroughskin and
mucosaincludingthegastrointestinaltract
Hence,systemictoxicityfromtopicalapplicationoringestion
hasnotbeenreported.
•Neurosensorydeafnesscanoccurif C
H
Xisintroducedinto the
middleear
Shouldnotbeplacedintheouterearincasetheeardrumis
perforated

38. •Longtermoralusecancauseaslightshiftin theoral
floratowardsless-sensitiveorganismsbutthis is
rapidlyreversible
•Ingestionof 1or2ouncesof C
H
Xoral rinseby a
smallchildmaycausesignsandsymptomsofgastric
distress,nauseaandintoxication

39. SIDEE
F
F
E
C
T
S
1. T
asteperturbationwherethesalttasteispreferentiallyaffectedtoleave
thefoodanddrinkswitharatherblandtaste

40. 2.Chlorhexidinestaining
4mechanismshavebeen
proposedtoexplainC
H
Xstaining:
• DegradationofC
H
X
:
DegradationofC
H
Xreleasesparachloraniline
• 2.Maillardreactions:
Non-enzymaticbrowningreactionscatalysedbyC
H
X

41. • ProteindenaturationproducedbyC
H
Xwith
theinteractionofexposedsulfideradicalwith
metalions
Thistheorydoesn’ttakeintoaccountother
antisepticsandmetalionsthatproduce
staining
• Precipitationofanionic
chromogens:
Locallyboundantiseptics
andpolyvalentmetalionsreact
withthepolyphenolsondietary
substancesandprecipitate
anionicdietarychromogens
Thecolouroftheprecipitate
iss
a
m
ea
sthatoftheirmetal
sulfidesalts

42. 3.Oralmucosalerosionappearstobeidiosyncraticreactionand
concentrationdependent
Dilutionofthe0.2%formulationto0.1%,butrinsingwiththe
wholevolumetomaintaindoseusuallyalleviatestheproblem

43. 4.Unilateralorbilateralparotidswelling
V
eryrareoccurrence

44. 5.Enhancedsupragingivalcalculusformation
Thismaybeduetotheprecipitationofsalivaryproteinsontothetooth
surfacethereby
,increasingthepelliclethicknessand/orprecipitationof
organicsaltsontothepelliclelayer
Pellicleformationundertheinfluenceofchlorhexidineshowsa
searlyand
highlycalcifiedstructure

45. CONCLUSION
Chlorhexidinetodateistheprovenmosteffectiveantiplaqueagent
Itisfreefromsystemictoxicity,microbialresistanceandsupra-
infection
Antiplaqueactionofchlorhexidineappearsdependentonprolonged
persistenceofantimicrobialactioninthemouth
Localsideeffectsarereportedwhicharemainlycosmeticproblems