The Gold Standard Antiseptic in Dentistry. Its composition, mechanism of action, available forms, uses, disadvantages. Its role in Periodontics. Done by : Ivan Obadiah (CRI) Guided by : Dr. Veejay Chandran (MDS).

1. DEPT. OF PERIODONTICS
Seminar by : A. Ivan Obadiah [ CRI ]
Guided by : Dr. Veejai Chandran
M.D.S

3. WHAT IS CHLORHEXIDINE ?
 Developed in 1940’s by England
 Broad spectrum antiseptic since 1950’s
 Antiplaque, anti-gingivitis agent from 1970’s
 Chemical plaque control agents
1st generation: Antibiotics, Phenol, Quaternary ammonium
compounds, Sanguinarine
2nd generation: Bisbiguanides (Chlorhexidine)
3rd generation: Delmopinol
HISTORY :

4. COMPOSITION :
Cationic bisbiguanide
Formula : C22H30Cl2N10
pH : 5.5 to 7
Solubility in water : 0.0008 mg/ml (20°c)
1,6 – bis(4-chlorophenylbiguanido)hexane
STRUCTURE :
2 - four chlorophenyl rings
2 - biguanide groups
1 – central hexamethylene

5. AVAILABLE FORMS:
WATER SOLUBLE :-
1. Digluconate
2. Acetate
SPARINGLY SOLUBLE :-
3. Hydrochloride salts
CHX PRODUCTS:
 Mouth Wash (aqueous/alcohol solutions – 0.2%
and 1.2% conc.)
 Skin Cleansers
 Gauze Dressings
 Surgical Scrub
 Spray
 Rubbing agent
 Gel
 Local delivery agent
 Chewing Gum

6. CHLORHEXIDINE IN PERIODONTICS
The first enemy of the Periodontium is Dental plaque !
PLAQUE CONTROL
Mechanical plaque control
Chemical plaque control
 CHX is the 2nd generation chemical plaque control agent.
 CHX kills the harmful microorganisms that causes periodontal problems
 CHX interferes with Plaque formation.

7. MECHANISM OF
ACTION :
 1. Disruption of cell
membrane !
 Because of its cationic
nature CHX attaches to the negatively
charged sites in a bacterial cell wall
and interferes with osmosis thereby
disrupting the cell wall
 The agent is BACTERIOSTATIC at low
concentrations and
 BACTERICIDAL at high concentrations.

8. 2. CHX gets attached to the salivary proteins and desquamated
epithelial cells
Blocks acidic groups on salivary glycoprotein
Reduces glycoprotein absorption on tooth surface
Prevents pellicle formation
PELLICLE

9. 3. Prolonged antiseptic release
Bacteriostatic action that lasts for more than 12 hours
Prevents the absorption of bacterial cell wall on the tooth surface
Prevents plaque formation
4. Competes with calcium ions
Blocks agglutination of plaque
Prevents binding of mature plaque

10. PIN-CUSHION EFFECT
 The dicationic CHX molecule, attaches to the tooth surface by one cation, to the
bacteria attempting to colonize the tooth surface with the other. This Is called the
Pin-Cushion effect.
 This prolongs the CHX action
 Its long bacteriostatic action lasting for about 12 hours in the oral cavity after a
single rinse .
 Hence CHX is well known for its substantivity.

11. CHX MOUTHWASH
• Aqueous solutions of 0.2% CHX , used as 10ml rinse
• Other available conc. :- 0.1% , 0.12% , as 15ml rinses
• Efficacy is equal when used in equivalent doses
Dosage and administration:
o Recommended use is twice daily oral rinsing for 30 sec after tooth
brushing
o Usual dosage is 15ml of undiluted CHX rinse
o Patient should be instructed not to rinse with water or brush teeth
immediately after CHX oral rinse
o Care should be taken to avoid ingestion of the rinse.

12. CHX GEL
 Available as 1%, 0.2% and 0.12% gels
 Delivered in tooth brushes and trays
 Tray delivery has been found to be effective for handicapped
individuals
 CHX gel is found to be effective in patients having xerostomia
 Chlor-fluro gel is prepared by the combination of 0.2%
chlorhexidine gluconate and 0.003% sodium fluoride
 Contraindicated in those who cannot expectorate

13. CHX SPRAYS
 Available as 0.1% and 0.2% sprays
 Same proportions as mouth rinses produces same results
 Useful in physically challenged
 Localized effects can be achieved in required areas
CHX TOOTHPASTE
CHX VARNISH
CHX CHEWING GUM
 Available as 1% paste with or without fluorides
 Highly effective compared to other forms
 Used for prophylaxis against root caries
 Contains 5mg of chlorhexidine diacetate

14. LOCAL DRUG DELIVERY OF CHLORHEXIDINE
 Periochip is a small chip (4mm x 5mm x 0.35mm)
 Composed of biodegradable hydrolysed gelatin matrix, cross linked with
glutaraldehyde and also containing glycerine and water into, which 2.5mg of
chlorhexidine gluconate (36%) has been incorporated.
 Maintains drug conc. In GCF for at least 7 days
 Used mainly as an adjunct to SRP for reduction of pocket depth
 1 chip can be inserted in a pocket 5mm deep.

15. CLINICAL USES OF CHLORHEXIDINE
1. As an adjunct to oral hygiene and professional prophylaxis
CHX provides adequate plaque control following professional prophylaxis
which is essential for successful treatment and prevention of recurrence.
2. Preoperative rinsing and irrigation
• Uses preoperatively for ultra sonic and high speed instrumentation
• Reduce bacterial load and contamination of operating area
• In susceptible patients, CHX irrigation as an adjunct to systemic antibiotic prophylaxis
around gingival margin reduces the incidence of bacteremia

16. 3. Post oral surgery
 Reduces bacterial load and plaque formation at times when mechanical cleaning may
be difficult or is not indicated
 Periodontal dressings can be replaced by CHX rinsing as it provides improved healing
 But 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 effectives also depends upon the time over which the non surgical treatment is
performed
 Also for patients with intermaxillary fixation

17. 4. Medically compromised individuals predisposed to oral infections
 Those receiving chemo and/or radiotherapy, bone marrow transplants
 Immuno-compromised those including blood dyscrasias are susceptible to oral
infections, most commonly, candida infections
 CHX is highly effective against oral infections when combined with specific anti-
candida agents such as Nystatin and Amphotericin-B
 In terminally ill patients, CHX sprays can be used effectively for maintanence of
better oral hygiene

18. 5. High-risk caries patients
 CHX rinses and gels reduce Streptococcus mutans
 It has a synergistic effect with fluoride
6. Recurrent oral ulceration
 CHX gels and rinses reduce incidence, duration and severity of recurrent minor
aphthous ulcers by reduction in contamination of ulcers thereby, reducing natural
history
 CHX has a low therapeutic potential. It shows no effect in major aphthous ulcers

19. 7. 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
8. Denture stomatitis
 CHX gels can be applied to the fitting surfaces of the dentures – slow and incomplete
resolution of the condition
 Can be used along with specific anticandidal drugs
 Dentures can be sterilized by soaking in chlorhexidine solutions

20. SIDE EFFECTS OF CHLORHEXIDINE :
1. CHX Staining
4 mechanisms have been proposed to explain CHX staining:
 Degradation of CHX:
Releases parachloro aniline
 Maillard reactions:
Non-enzymatic browning reactions catalysed by CHX

21.  Protein denaturation produced by CHX
with the interaction of exposed sulphide 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 sulphide salts

22. 2. Taste perturbation
the salt taste is preferentially affected to leave the food and drinks with a rather
bland paste.
3. Oral mucosal erosion
- Idiosyncratic reaction and conc. dependent
Dilution of the 0.2% formulation to 0.1%, but rinsing with the whole volume to maintain
dose usually alleviates the problem

23. 4. Enhanced supra gingival calculus formation
This may be due to the precipitation of salivary 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.
5. Unilateral or bilateral parotid swelling:
Very rare occurrence

24. HANDLE WITH CARE :
 Long term oral use can cause a slight shift in the oral flora towards less-sensitive
organisms but this is rapidly reversible
 Ingestion of 1 or 2 ounces of CHX oral rinse by a small child may cause signs and
symptoms of gastric distress, nausea and intoxication
 Neurosensory deafness can occur if CHX is introduced into the middle ear.