This document provides a history of oral hygiene practices and the development of mouthwashes. It focuses on chlorhexidine, detailing its discovery in the 1940s, structure, mechanism of action, properties, uses, toxicity, side effects, and alternatives. Chlorhexidine is highlighted as the gold standard for chemical plaque control due to its bacteriostatic and bactericidal properties against a broad spectrum of microorganisms. Its mechanism of action involves preventing pellicle formation and bacterial adhesion to teeth. It has high substantivity allowing effects to last over 12 hours.

1. RESOURCE FACULTY:
DR. SHIVALAL SHARMA
DR. KHUSHBOO GOEL
DR. SAJEEB SHRESTHA
KASHMIRA POKHREL-483

2. HISTORY
Chlorhexidine
 Introduction
 Structure
 Ingredients
 MOA
 Properties
 Uses
 Toxicity
 Side effects
 Contraindications
Other mouth washes
CONTENTS

3. HISTORY…..
 The Egyptians used many products to freshen
their breath. They chewed sodium carbonate
or rinsed their mouth with honey and water to
which goose fat, frankincense, cumin, and
ocher had been added.
 A.D. 1: The Romans used to buy bottled
Portuguese urine to purge bacteria from the
mouth.

4.  A.D. 23:people used to swish tortoise blood
around in their mouth at least three times a
year to prevent toothaches
 A.D. 40 – 90: Greek surgeon and physician,
Pedanius Dioscorides, suggested the mixture
of the juice and leaves of olives, milk, gum
myrrh, pomegranate, vinegar and wine could
help fight bad breath

5.  12th Century: German philosopher and
mystic, Saint Hildegard von Bingen, suggests
that swishing pure, cold water around in the
mouth can help remove tarter and plaque
 16th Century: Medieval oral hygiene practices
centered around a mint and vinegar rinsing
solution was believed to rid the mouth of bad
breath and germs.

6.  19th Century: Mouthwashes as we know them
today, developed in the late 1800s. Instead of rinses
containing urine, alcohol was added to help fight
germs and bacteria while stabilizing the
formula. One of the most popular mouthwashes on
the market today for its germ-killing qualities
 Today: Sodium hexametephosphate and hydrogen
peroxide are found in more abundant quantities in
mouthwashes to help lift and prevent future stains
on the surfaces of teeth and more companies are
coming out with solutions that won’t irate sensitive
mouths.

7. CHLORHEXIDINE
 It was developed in 1940s by Imperial
Chemical Industries, England & marketed
in1954 as an antiseptic for skin wounds.
 Chlorhexidine (CHX) is mainly available in
three forms: Digluconate, Acetate &
Hydrochloride salts.
 Use in Dentistry was initially for presurgical
disinfection of mouth & in endodontics.

8.  Plaque inhibition by CHX was first
investigated in 1969 by Schroeder but the
definitive study was performed by Loe &
Schiott in 1970.

9.  CHLORHEXIDINE is a GOLD STANDARD IN
CHEMICAL PLAQUE CONTROL with
bacteriostatic and bactericidal properties.
 Broad spectrum anti-microbial drug

10. Structure of chlorhexidine..
 Chlorhexidine is a symmetrical molecule
consisting four chlorophenyl rings and two
bisguanide groups connected by a central
hexamethlene ring
 The compound is strongly base & dicationic
at ph levels above 3.5 with positive charges
on either side of hexamethylene bridge.
 It is the “dicationic nature” of chlorhexidine
making it extremely intractive with anions

11. Ingredients
 Chlorhexidine
 Alcohol
 Glycerine
 Sodium saccharin
 PEG-40 sorbitan diisostearate
 Flavoring agent
 Purified water

12. cationic CHX molecule+ negatively charged
bacterial cell wall
Instant adsorption of CHX to Phosphate
containing compounds
CHX binds with the phospholipids in the inner
cell membrane causing cell wall integrity
Leakage of the lesser molecular weight
components viz. potassium ions(bacteriostatic)

13. Intracellular
coagulation
Slows down leakage of
intracellular
components
Cytoplasmic
coagulation
Irreversible cell

14. MOA
CHX mainly inhibits plaque by 3 mechanism:
1) It prevents pellicle formation by blocking the
acidic groups on the salivary
glycoproteins ,hence reducing the glycoprotein
adsorption on the tooth surface.
2) Prevents the adsorption of bacterial cell wall
onto the tooth surface by binding to the bacteria.
3) Prevents binding of the mature plaque by
precipitating the agglutination factors in the
saliva and displacing the calcium from the

15. Properties
 It is effective against an array of
microorganisms, including gram positive &
gram negative organisms, fungi, yeast &
viruses.
 Chlorhexidine exhibits both antiplaque and anti
bacterial properties.
 Chlorhexidine shows different concentration
effects at different concentration
- Bacteriostatic at low concentration

16.  Substantivity - the prolonged adherence of the
antiseptic to the oral surfaces(mucosa & teeth)
& it’s slow release at effective doses that
guarantees the persistence of its microbial
activity.
 Approximately 30% i.e. 5.5-6.9 mg from a 10 ml
solution of 0.2% CHX will be bound to the oral
surface.
 The CHX molecules bound to the salivary
proteins will be released in excess of 12 hrs in

17. How to use?
Dose: 10ml of 0.2% CHX in 1:1 dilution
 Frequency:
- Twice daily oral rinsing for 30 second in the
morning and evening after 30 minutes of tooth
brushing.
Instructions
 Do not rinse with water or other mouthwashes,
brush teeth or eat immediately after using CHX
mouthwash.

18. Uses
1. As an adjunct to oral hygiene and professional
prophylaxis
- Improved plaque control
- Improved gingival health
2. Post oral surgery including periodontal surgery or root
planing
- Reduces bacterial loading oral cavity
- Improves healing and discomfort is reduced
3. For patients with jaw fixation
- Reduce markedly bacterial load which tends to increase

19. 4. For oral hygiene and gingival health benefits in the
mentally and physically handicapped
- Improve oral hygiene & gingival health of mentally &
physically handicapped
- Spray delivery of 0.2%
5. Medically compromised individuals predisposed to
oral infections
- Mainly candidiasis, used in combination with
anticandidal agents
- Improves oral and systemic infections
- Those with blood dyscrasias, under chemotherapy
radiotherapy.

20. 6. High-risk caries patients
- CHX considerably reduces streptococcus mutans
counts
- Synergistic with sodium fluoride
7. Recurrent oral infections
- Reduces incidence, duration and severity of recurrent
apthous ulcer by reduction in contamination of ulcer by
oral bacteria
8. Removal & fixed orthodontic appliance wearers
- Plaque control in early stages of therapy for the first 4-
8 weeks
- Also reduce the number & severity of traumatic ulcers

21. 9. In denture stomatitis
- Candidal associated infection
10. Immediate preoperative chlorhexidine rinsing
and irrigation
- Used immediately prior operative t/t when
ultrasonic or high speed instruments are used
- Reduces bacterial load and contamination of
operative area and operator and staff as well
- Reduces incidence of bacteremia
11. Subgingival irrigation

22. Toxicity and safety
 Minimum absorption through skin & mucosa,
including GI tract.
 Systemic toxicity from topical application or
ingestion is not reported.
 No evidence of teratogenicity in animal model.
 Hypersensitivity reaction including anaphylaxis
have been reported.
 Neurosensory deafness can occur if CHX is
introduced in middle ear.

23. Side effects
 Brown discoloration of the teeth and
some restorative materials and the
dorsum of the tongue (staining):
 Mechanism:
1. Degradation of chlorhexidine molecules
to release parachloraniline.
2. Catalysis of Maillard reactions.
3. Protein denaturation with metal sulfide
formation.
4. Precipitation of anionic dietary
chromogens

24.  An alteration of taste perception.
 Oral mucosal erosion which appears to be
idiosyncratic reaction and conc
dependent.
 Unilateral or bilateral parotid swelling.
 Enhanced supragingival calculus
formation which maybe due to the
precipitation of salivary proteins on to the
surface, thereby increasing pellicle
thickness &/or precipitation of inorganic

25. Contraindications
 It is contraindicated in patients who are known
to be hypersensitive to CHX gluconate or other
formula ingredients

26. Other mouthwashes
 Triclosan
 Delmopinol
 Listerine
 Povidone iodine
 Metallic ions
 Quaternary ammonium compounds
 Sanguinarine

27. Triclosan
 Phenol derivative
 It is synthetic, non-ionic, and is used as topical
antimicrobial agent.
 Broad spectrum of activity against both gram
positive & negative bacteria. Also includes
mycobacterium spores, and candida species.
 MOA:
- Acts on the microbial cytoplasmic membrane,
including leakage of cellular constituents & thereby
causing bacteriolysis.
- Can delay plaque maturation & also inhibit formation
of prostaglandins &leukotrienes which are key
mediators of inflammation via inhibition of both
cyclo-oxygenase & lipo-oxygenase pathways.

28. Delmopinol
 Morpholinoethanol derivative
 Inhibits plaque growth and reduces gingivitis.
 Low substantivity.
 Indicated as pre brushing mouth rinse.
 MOA:
It interferes with plaque formation & reduces
bacterial adhesion easy removal of plaque by
mechanical procedure.
Adverse effects:
- Transient numbness of tongue & tongue
staining.
- Taste disturbance
- Mucosal soreness & erosion

29. Listerine
 Listerine was created by Dr. Joseph
Lawrence and Jordan Lambert and named in
honour of Dr. Joseph Lister, the pioneer of
antiseptic surgery.
 Consists of essential oils, salicylate.
 It is used for reducing supragingival plaque &
gingivitis and halitosis.

30. Povidone Iodine
 No significant plaque inhibitory activity
when used as a 1 %. Mouthwash.
 Unsatisfactory in long term use because
significant amount of this compound is
absorbed by the oral cavity.
 Certain studies shows it can reduce
inflammation and progression of
periodontal disease.
 Low substantivity.

31. Metallic ions
 Some metal ions have a plaque inhibitory
capacity.
 Salts of zinc & copper are most commonly
used
 MOA:
- Acts by reducing the glycolytic activity in
microorganisms and delays bacterial
growth.

32. QUATERNARY AMMONIUM
COMPOUNDS
 They are cationic antiseptic & surface
active agents.
 Are more active against gram +ve than –ve
organisms.
 MOA: The positively charged molecule
reacts with the negatively charged cell
membrane phosphates disrupts
the cell wall structure of the microorganism
 E.g. Benzylconium chloride,
cetylpyridinium chloride etc.

33. SANGUINARINE
 It is a benzophenanthridine alkaloid, which
is derived from the plant Sanguinaria
Canadensis.
 They are effective against a wide variety of
gram negative organisms.
 It exhibits good retentive properties with
dental plaque when used as a mouth rinse.

34. Substantivity highest in:
A.Chlorhexidine
B.Triclosan
C.Sanguinarine
D.Delmopinol
mcq

35. Chlorhexidine staining is due to:
1.Degradation of chlorhexidine molecules to
release parachloraniline.
2.Catalysis of Maillard reactions.
3.Protein denaturation with metal sulfide
formation.
4. all of the above
mcq

36. Which of the following is phenol derivative?
1. Chlorhexidine
2. triclosan
3. Povidone-iodine
4. listerine
mcq

37. Refrences
 Clinical Periodontology & Implant Dentistry –
Jan Lindhe
 Essentials of Preventive and Community
Dentistry – Soben Peter
 Internet sources