CONTENTS

1. Introduction

2. History

3. Structure

4. Chlorhexidine – based products

5. Mechanism of action

6. Chlorhexidine Staining

7. Toxicology

8. Clinical Uses

9. Conclusion

10.Reference
INTRODUCTION

Chlorhexidine is a
bisbiguanide formulation with
cationic
properties. The molecule is
symmetric with two
chlorophenyle rings and two
bigunide groups connected by
a
central hexamethylene chain.
It is a strong base and is most
stable in the form of salts.
The most common
preparation is
the digluconate salt because of
its water solubility
Chlorhexidine is a
bisbiguanide formulation with
cationic
properties. The molecule is
symmetric with two
chlorophenyle rings and two
bigunide groups connected by
a
central hexamethylene chain.
It is a strong base and is most
stable in the form of salts.
The most common
preparation is
the digluconate salt because of
its water solubility
Chlorhexidine is a
bisbiguanide formulation with
cationic
properties. The molecule is
symmetric with two
chlorophenyle rings and two
bigunide groups connected by
a
central hexamethylene chain.
It is a strong base and is most
stable in the form of salts.
The most common
preparation is
the digluconate salt because of
its water solubility
Chlorhexidine is a
bisbiguanide formulation with
cationic
properties. The molecule is
symmetric with two
chlorophenyle rings and two
bigunide groups connected by
a
central hexamethylene chain.
It is a strong base and is most
stable in the form of salts.
The most common
preparation is
the digluconate salt because of
its water solubility
Chlorhexidine is a
bisbiguanide formulation with
cationic
properties. The molecule is
symmetric with two
chlorophenyle rings and two
bigunide groups connected by
a
central hexamethylene chain.
It is a strong base and is most
stable in the form of salts.
The most common
preparation is
the digluconate salt because of
its water solubility
Chlorhexidine is a
bisbiguanide formulation with
cationic
properties. The molecule is
symmetric with two
chlorophenyle rings and two
bigunide groups connected by
a
central hexamethylene chain.
It is a strong base and is most
stable in the form of salts.
The most common
preparation is
the digluconate salt because of
its water solubility
Chlorhexidine is a
bisbiguanide formulation with
cationic
properties. The molecule is
symmetric with two
chlorophenyle rings and two
bigunide groups connected by
a
central hexamethylene chain.
It is a strong base and is most
stable in the form of salts.
The most common
preparation is
the digluconate salt because of
its water solubility
Chlorhexidine is a bisbiguanide formulation with cationic properties . The
molecule is symmetric with two chlorophenyle rings and two bigunide groups
connected by a central hexamethylene chain . It is a strong base and is most
stable in the form of salts . The most common preparation is the digluconate salt
because of its water solubility.1

Chlorhexidine is a bisbiguanide
formulation with cationic
properties. The molecule is symmetric
with two
chlorophenyle rings and two bigunide
groups connected by a
central hexamethylene chain. It is a
strong base and is most
stable in the form of salts. The most
common preparation is
the digluconate salt because of its water
solubility
Chlorhexidine is an ideal broad-spectrum antimicrobial. It is effective against
Gram-positive bacteria, Gram-negative bacteria and fungi. These organisms are
commonly associated with Healthcare-Associated Infections (HAIs).With its low
toxicity level, chlorhexidine offers a safe side effect profile. For nearly 60 years,
chlorhexidine has been used by hospitals and clinics as a disinfectant and
antiseptic for topical and hard-surface applications. Chlorhexidine has become an
integral part of the strategy to prevent the transmission of disease and
nosocomial infections. Chlorhexidine is used to kill bacteria that cause infections.
It is found in many medicines that are applied directly to the affected area of the
body. It is an antiseptic treatment. It is used to treat and prevent infections. In
general this drug is used where infections of the skin, mouth or throat are
present or may arise. The treatment and prevention of infections of minor cuts,
grazes, burns and scalds, athlete’s foot, blisters, stings and insect bites, spots,
chapped or rough skin and minor infections of the mouth or throat. It is also used
for cleaning the skin before injections and small operations. 2

The available formulations of chlorhexidine are gels, chips, sprays, varnishes, and
mouthwashes. It is commonly preferred among dentists. The clinical effect of
chlorhexidine is likely due to both its substantive and antibacterial properties
Chlorhexidine has a wide variety of usefulness in oral health care. It is used in the
management of oral hygiene, dental plaque, dental caries, gingivitis,
periodontitis, peri-implantitis, irrigating agent, pre-procedural mouth rinse, and
management of oral mucosal diseases. The presence of bacteria in dental plaque
or oral biofilm produces host inflammatory response of gingiva and
periodontium resulting in gingivitis and periodontitis respectively. Chlorhexidine
is used as a mouthwash against plaque-producing bacteria. It should always be
used along with mechanical plaque control measures such as tooth brushing and
interdental aids, as an adjunct, as suggested by the European Federation of
Periodontology (EFP). Reduction in clinical signs of gingivitis and periodontitis has
been shown in studies with the use of 0.2% CHX mouthwash for 4-6 weeks .
When chlorhexidine is used as a mouth wash, it should be used 30 minutes to 2
hours after tooth brushing as it could interact with the anionic compounds of the
toothpaste and it could nullify the effect of fluoride that is present in toothpaste .
The use of chlorhexidine mouth rinse (0.2%) could potentially reduce plaque
formation and eventually results in a low incidence of caries. Chlorhexidine is a
commonly used antiseptic mouthwash due to its antimicrobial effects..3

HISTORY
HISTORY OF MOUTH RINSE
 The first reference to mouth rinsing as a formal practice is credited to Chinese medicine,
about 2700 B.C.E. Recommendation was rinsing with the urine of a child. Mouth rinsing as
an adjunct to mechanical cleansing became popular with the upper classes in the Roman
period. Pliny recommended salty water used in an uneven number of Mouthfuls.
Hippocrates advocated a mixture of salt, alum and vinegar. Other included a mixture of
honey, oil and beer and a combination of dill, anise seed, myrrh and pure white wine.
“Therapeutic rinsing” was especially popular among the Europeans, and persisted until the
early 18th century. Mouth rinsing also had a religious connection. The Talmud contains
instructions for rinsing the mouth between meals to remove food remnants and prevent
admixing of meat and milk products, a violation of the dietary laws. Mechanical tooth
cleaning and mouth rinsing were established practices by the 16th century. 4
 The Zene Artzney (Medicines for the Teeth), published in Germany in 1530, contained a
section on “How to save the teeth’. The recommendations included washing the mouth
with burnt alum mixed with vinegar or myrrh boiled in wine. The final suggestion was
“always after eating, wash the mouth with wine or beer, in order to wash away all that
might adhere to the teeth and make them decay, produce bad odor, and destroy them”.
W.D. Miller, in support of his Chemo parasitic theory of tooth decay, pointed out - There
are places around every dentition which will remain untouched by even the most thorough
application of an antiseptic, or the antiseptic will reach them in so diluted a condition that
it possesses little or no action.4

Mouth washes has been grouped into 3 categories 4

1. Group A Mouth washes : With good substantivity and antibacterial spectrum and good
anti-plaque effects. Agents with these properties are the bisguanides (the best of which is
chlorhexidine), salifluor and delmopinol.
2. Group B Mouth washes : With little or no substantivity but with a good antibacterial
spectrum. Therefore, they have plaque inhibitory effects. These include Cetyl pyridinium
chloride, Essential oil/ phenolic mouthwash, Listerine, Triclosan. They cannot be used to
replace tooth brushing but can be used as adjuvants to mechanical cleaning.
3. Group C Mouthwashes : With antibacterial, varying plaque inhibitory effects from
moderate to low or no. These include Hexetidine (Oraldene), Povidone iodine, Oxygenating
agents, Sanguinarine. These have limited or no adjuvant effects when combined with
mechanical cleaning and therefore cannot be recommended for this purpose.

HISTORY OF CHLORHEXIDINE
In 1947, a complex study to synthesize new antimalarial agents led to the development of the
polybiguanides. These compounds showed significant antimicrobial potential. Davies et al
(1954) demonstrated that this compound had bacteriostatic activity, especially against Gram-
positive bacteria (linked to the central hexamethylene unit and the terminal benzene ring) and
bactericidal activity (depending on the concentration). This compound did not modify the
action of penicillin, streptomycin,chloramphenicol, oxytetracyline. Experimental studies in
albino mice revealed a low degree of toxicity at 10 days after the subcutaneous,
intraperitoneal, intravenous or oral administration of a single dose of Chlorhexidine, as well as
after a year of continuous oral administration. Chlorhexidine was developed in the 1940s by
Imperial Chemical Industries, England, and marketed in 1954 as an antiseptic for skin wounds.
(As Hibitane) . Later, the antiseptic was more widely used in medicine and surgery including
obstetrics, gynecology, urology and presurgical skin preparation for both patient and surgeon.
Use in dentistry was initially for presurgical disinfection of the mouth and in endodontics.
Plaque inhibition by chlorhexidine was first investigated in 1969 (Schroeder 1969). The
definitive study was performed by Loe and Schiott (1970).Study showed that rinsing for 60
seconds twice per day with 10 ml of a 0.2% (20 mg dose) chlorhexidine gluconate solution in
the absence of normal tooth cleaning, inhibited plaque regrowth and the development of
gingivitis.4
STRUCTURE
Chemical structure Chlorhexidine is an amphipathic molecule with hydrophilic and
hydrophobic groups. Synthesized from proguanil and belongs to the biguanide family, a group
of compounds with antimalarial activity. Chlorhexidine is a bisbiguanide antiseptic; being a
symmetrical molecule consisting of two chlorophenyl rings and two biguanide groups
connected by a central hexamethylene bridge.The compound is a strong base and dicationic at
pH levels above 3.5, with two positive charges on either side of a hexamethylene bridge.
Chlorhexidine is available in three formsDigluconate,Acetate, Hydrochloride salts(as base
molecule is insoluble in water). Most studies and most oral formulations and products have
used the digluconate salt, which is manufactured as a 20% volume of solute / volume of
solution concentrate. Digluconate a acetate salts are water-soluble but hydrochloride is very
sparingly soluble in water.4

Figure 1 : chemical structure of chlorhexidine

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Chlorhexidine is available in three forms :

1. Digluconate - Most commonly used , and Water soluble

2. Acetate - Water soluble .

3. Hydrochloride salts - sparingly water soluble . 5

According to Ferraz et al, 2

chlorhexidine gluco-
nate had lower surface
tension in comparison to so-
dium hypochlorite and EDTA.
The use of chlorhexi-
dine associated with a gel
vehicle provides dentin
walls free of waste produced
by instrumentation as
a result of the mechanical
properties of gel
According to Ferraz et al, 2
chlorhexidine gluco-
nate had lower surface
tension in comparison to so-
dium hypochlorite and EDTA.
The use of chlorhexi-
dine associated with a gel
vehicle provides dentin
 walls free of waste produced
by instrumentation as
a result of the mechanical
properties of gel
Chlorhexidine is insoluble in water and is formulated with either gluconic or
acetic acid to form water soluble digluconate or diacetate salts . Chlorhexidine
solutions are colourless , odourless and have an extremely bitter taste . When
used topically , the N - chlorinated derivative of chlorhexidine binds covalently to
proteins in the skin and mucosa and results in a persisting antimicrobial effect
with limited systemic absorption , even after an oral ingestion " .6

According to Ferraz et al chlorhexidine gluconate had lower surface tension in

comparison to sodium hypochlorite and EDTA . The use of chlorhexidine
associated with a gel vehicle provides dentin walls free of waste produced by
intrumentation as a result of the mechanical properties of gel .7

CHLORHEXIDINE – BASED PRODUCTS

Chlorhexidine is active against a broad range of microbes . It dis rupts the

cell membrane and causes precipitation of the cytoplasm , resulting in cell death . No
adverse alterations in the oral microbial flora or overgrowth of opportunistic
microorganisms have been observed. A restorable delivery system has been tested
for the sub gingival placement of chlorhexidinegluconate with positive clinical results
.7

Subgingival Chlorhexidine in Chip Form

 PerioChip is a small chip ( 4.0 X 5.0 x 0.35 mm ) that is com posed of a

biodegradable hydrolyzedgelatin matrix . It is cross linked with glutaraldehyde , and
it also contains glycerin and water into which 2.5 mg of chlorhexidin egluconate
has been incorporated per chip . The chip is stored at 20 ° to 25 ° C ( 68 ° to 77 ° F ) ,
with excursions permitted to 15 ° to 30 ° C ( 59 ° to 86 ° F ) . The chlorhexidine chip
is placed into the pocket directly from the foil container using a forceps . This
delivery system i leases chlorhexidine and maintains drug concentrations in the
 GCF of more than 100 µg /mL for at least 7 days ; these concentrations are well
above the tolerance of most oral bacteria . Since the chip biodegrades within 7-10
days , a second appointment for re moval is not needed . However , dental floss
should be avoided for 10 days to avoid dislodging it .7

 PerioCol - CG is a small, 10 - mg chip ( 4 X 5 X 0.25-0.32 mm ) designed as a

collagen matrix into which chlorhexidine gluconate ( 2.5 mg ) is incorporated from
a 20 % chlorhexidine solution that is its active ingredient . The chip is designed for
insertion into the periodontal pocket and resorbs after 30 days, but its coronal
edge degrades within 10 days . It releases chlorhexidine in vitro at rate of
approximately 40 % to 45 % in the first 24 hours, followed by a linear release for 7
to 8 days , and it has a shelf - life of 2 years .7

Subgingival Chlorhexidine in Gel Form

 Chlo - Site is a xanthan gel , consisting of a saccharide polymer as a three -

dimensional mesh containing 1.5 % chlorhexidine in 0.5 mL of gel , which is injected
into the periodontal pocket . The gel product is sterilized by gamma radiation at
2.5 Mrad and is individually packed for delivery in 0.25 - ml prefilled syringes fitted
with a blunt side - exit needle. The gel contains two types of chlorhexidine : a slow -
release chlorhexi dine digluconate ( 0.5 % ) and a rapid - release chlorhexidine dihy
drochloride ( 1.0 % ) . The gel is retained within the pocket and is not easily
dislodged by the gingival crevicular fluid or saliva . The gel disappears from the
pocket in 10 to 30 days and is reported to achieve chlorhexidine concentration in
gingival crevicular fluid of more than 100 µg / ml foran average of 6 to 9 days and
to maintain an effective concentration for at least 15 days .8

Mouth rinses
Aqueous alcohol solutions of 0.2% chlorhexidine were first made available for
mouth rinse products for twice daily use in Europe in the 1970s. The studies
revealed equal efficacy for 0.2% and 0.12% rinses when used at appropriate
similar doses ( Segreto et al. 1986).More recently alcohol free chlorhexidine
mouth rinses have been available .This possess equivalent effects of inhibiting
plaque and gingivitis compared to alcohol containing but with better taste
acceptability.
Various mouth rinses
Peridex oral rinse (0.12%) 3M, Periogard (0.12%) Colgate, Hexide (0.2%) Deys
medical, Rexidin (0.2%) Indico remedies ltd., Hexiklin (0.2%) Simpson Brawn
pharma, Hexiclo (0.2%) Sunways India Pvt Ltd, Hexidine (0.2%) Icpa Health
Products Ltd, Clohex (0.2%) Dr Reddy's Laboratories Ltd, Haa mouth wash (0.2%)
Cadila Pharmaceuticals Ltd.

Gel
A 1% chlorhexidine gel product is available and can be delivered on a toothbrush
or in trays. The distribution of the gel by toothbrush around the mouth appears
to be poor (Saxen et al. 1976). In trays the chlorhexidine gel was found to be
particularly effective against plaque and gingivitis in handicapped individuals
(Francis et al 1987). The acceptability of this tray delivery system to the
recipients and the careers was found to be poor. More recently, 0.2% and 0.12%
chlorhexidine gels have become available.

Sprays
0.1% and 0.2% chlorhexidine in sprays are commercially available in some
countries. Studies with the 0.2% spray have revealed that small doses of
approximately 1-2 mg delivered to all tooth surfaces produces similar plaque
inhibition to a rinse with 0.2% mouth rinses (Kalaga et al 1989) Sprays appear
useful for the physically and mentally handicapped.(Francis et al 1987, Kalaga et
al 1989) .

Toothpaste
Chlorhexidine is difficult to formulate into toothpaste. Chlorhexidine products
based on toothpaste and sprays produces similar tooth staining to mouth rinses
and gels; taste disturbance, mucosal erosion and parotid swellings tend to be less
or have never been reported.

Varnishes
Chlorhexidine varnishes have been used mainly for prophylaxis against root
caries rather than an antiplaque depot for chlorhexidine in the mouth.
MECHANISM OF ACTION

The bacterial cell wall is negatively charged and contain sulphates and
phosphates.

Dicationic positively charged chlorhexidine is attracted to the negativity charged

bacterial cell wall with specific and strong absorption to phosphate containing
compounds.

After the integrity of the bacterial cell membrane and chlorhexidine is attracted
to the inner cell membrane.

By increasing the concentration of chlorhexidine there is progressive damage to

the membrane.

Chlorhexidine binds to the phospholipids in the inner membrane and there is

leakage of low molecular weight compound like potassium ions.

Cytoplasm of the cell are chemically precipitated.

There is coagulation and precipitation of the cytoplasm by the formulation of

phosphate complex which include adenosine tryphosphate and nucleic acid.

Bactericidal stage which is irreversible.9

Antibacterial action
Antibacterial n
actio
Antibacterialaction
The positive charges of chlorhexidine molecule are present over the nitrogen
atoms on the sides of the hexamethylene bridge.At low concentration,
chlorhexidine damages the cellular transport of the bacterial cell by creating
pores in the cellular membrane.In higher concentration, chlorhexidine
penetrates the bacterial cell and causes bacteriolysis.10

Anti-plaque effect
The substantivity of chlorhexidine made it a more suitable antimicrobial agent
for the inhibition of plaque.The chlorhexidine affects the pellicle formation by
blocking the acidic groups on the salivary glycoproteins. There is a reduction in
the protein adsorption to the tooth surface. Chlorhexidine binds to the bacterial
surface and thus reduces the formation of plaque by precipitating the
agglutination factors in saliva and displaces the calcium.10
Bactericidal effect

When the concentration increases , chlorhexidine causes greater damage to the

membrane The leakage of low - molecular weight components causes the
coagulation and precipitation of the cytoplasm by the formation of phosphated
complexes . This bactericidal stage is irreversible .10

CHLORHEXIDINE STAINING

The mechanisms proposed for chlorhexidine staining:

1. Degradation of the chlorhexidine molecule to release parachloraniline

2. Catalysis of Maillard reactions

3. Protein denaturation with metal sulfide formation

4. Precipitation of anionic dietary chromogens.

Degradation of chlorhexidine to release parachloraniline appears not to occur on

storage or as a result of metabolic processes. Also, alexidine, a related
bisbiguanide, does not have parachloraniline groups, yet causes staining identical
to that of chlorhexidine. Non-enzymatic browning reactions (Maillard reactions)
catalysed by chlorhexidine are a theoretical possibility (Eriksen et al
1985).Maillard reaction is step in the formation of advanced glycation end
products. Protein denaturation produced by chlorhexidine with the interaction of
exposed sulfide radicals with metal ions is also theoretically possible but there is
no direct evidence Again, the theory does not take into account similar staining
by other antiseptics and metal ions. Precipitation of anionic dietary chromogens
by cationic antiseptics, including chlorhexidine and polyvalent metal ions as an
explanation for the phenomenon of staining by these substances, is supported by
a number of well-controlled laboratory and clinical studies.6 Cationic group can
also attach dietary factors such as gallic acid derivatives (polyphenols) found in
some foods and many beverages including tea and coffee and tannins from wines
to the molecule and hence to the tooth surface.4

Gold standard
Superior antiplaque effect - in terms of its superior degree of persistence at the
tooth surface. Superior persistence of antibacterial effect (both bactericidal and
bacteriostatic) at the tooth surface. One charged end of the chlorhexidine
molecule binding to the tooth surface and the other remaining available to
initiate the interaction with the bacterial membrane as the microorganism
approaches the tooth surface – a “Pin-Cushion’’ effect.4

TOXICOLOGY AND SAFETY

The cationic nature of chlorhexidine minimizes absorption through the skin and
mucosa, including from the gastrointestinal tract. Primary route of excretion is through
faeces. Systemic toxicity from topical application or ingestion is not reported. (poorly
absorbed by GIT, oral LD is 1800mg/kg ). Even in intravenous infusion in animals,
chlorhexidine is well tolerated. (Intravenous LD is 22mg/kg). No tetragenic alterations
have been found.2 Neurosensory deafness can occur if chlorhexidine is introduced into
the middle ear and the antiseptic should not be placed in the outer ear in case the
eardrum is perforated. In oral use as a mouth rinse, chlorhexidine has been reported to
have a number of local side effects (Flotra et al. 1971). 4

1. Brown discoloration of the teeth and some restorative materials and the dorsum of
the tongue (Dose dependent).

2. Taste perturbation (Concentration dependent).

3. Oral mucosal erosion.

4. Unilateral or bilateral parotid swelling. This is an extremely rare occurrence and an

explanation is not available.
 5. Enhanced supragingival calculus formation. This effect may be due to the
precipitation of salivary proteins on to the tooth surface, thereby increasing pellicle
thickness and/or precipitation of inorganic salts on to the pellicle layer. 4

Chlorhexidine also has a bitter taste, which is difficult to mask completely.6 for these
reasons; the prolonged use of chlorhexidine should be avoided. It is useful for short
periods of up to 2 weeks.4

CLINICAL USES
Despite the excellent plaque inhibitory properties of chlorhexidine, widespread and
prolonged use of the agent is limited by local side effects. Moreover, because of the
cationic nature of the chlorhexidine and therefore its poor penetrability, the antiseptic
is of limited value in the therapy of established oral conditions including gingivitis, and
is much more valuable in the preventive mode. A number of clinical uses, some well
researched, have been recommended for chlorhexidine.11

AS AN ADJUNCT TO ORAL HYGIENE AND PROFESSIONAL PROPHYLAXIS

Oral hygiene instruction is a key factor in the treatment plan for patients with
periodontal disease and as part of the maintenance program following
treatment. Adequate plaque control by periodontal patients is therefore
essential to successful treatment and the prevention of re-occurrence of the
disease. Chlorhexidine should therefore increase the improvement in gingival
health through plaque control, particularly following a professional prophylaxis
to remove existing supra and immediately subgingival plaque. There is, however,
a potential disadvantage of using such an effective chemical plaque control agent
at this stage of the periodontal treatment plan. Thus, following oral hygiene
instruction, it is normal, usually by the use of indices, to quantify the
improvement in plaque control by patients so instructed and, in particular, the
improvement at specific sites which previously had been missed by individual
patients. By virtue of the excellent plaque control effects of chlorhexidine, the
response to oral hygiene instruction cannot be accurately assessed since the
antiseptic will overshadow any deficiencies in mechanical cleaning. Indeed, as
the original research demonstrated, patients could maintain close to zero levels
of plaque following a professional prophylaxis without using any form of
mechanicaloral hygiene.11
POST-ORAL SURGERY INCLUDING PERIODONTAL SURGERY OR ROOT PLANNING
Chlorhexidine may be used postoperatively since it offers the advantage of
reducing the bacterial load in the oral cavity and preventing plaque formation at
a time when mechanical cleaning may be difficult because of discomfort. In
periodontal surgery, periodontal dressings have largely been replaced by the use
of chlorhexidine preparations, in particular mouthrinses, since healing is
improved and discomfort reduced (Newman & Addy 1978, 1982). Regimens vary
but chlorhexidine should be used immediately post treatment and for periods of
time until the patient can reinstitute normal oral hygiene. Depending on
theappointment schedule, chlorhexidine could be usedthroughout the treatment
phase and for periods of weeks after completion of the treatment plan. If
dressings are used, chlorhexidine is of limited value to the postoperative site
since it does not penetrate beneath
the periodontal dressings (Pluss et al. 1975). The idea of full mouth disinfection
using chlorhexidine both supra and subgingivally has recently been assessed by
one group of researchers (Quirynen et al. 1995). In the event, few adjunctive
benefits could be shown and it appeared that the more dominant factor was the
time over which the non-surgical treatment plan was completed.Thus, root
planing performed totally within 24 hours was more effective than root planing
completed over more conventional periods of several weeks.11

FOR PATIENT WITH JAW FIXATION

Oral hygiene is particularly difficult when jaws are immobilized by such methods
as intermaxillary fixation. Chlorhexidine has been shown to reduce markedly
the bacterial load, which tends to increase during jaw immobilization, and
improve plaque control (Nash & Addy 1979).11

FOR ORAL HYGIENE AND GINGIVAL HEALTH BENEFITS IN THE MENTALLY AND
PHYSICALLY HANDICAPPED

Chlorhexidine has been found particularly useful in institutionalized mentally and

physically handicapped groups, improving both oral hygiene and gingival
health (Storhaug 1977). Spray delivery of 0.2% solutions was found particularly
useful and acceptable to patients and care workers (Francis et al. 1987a,b, Kalaga
et al. 1989b).11
MEDICALLY COMPROMISED INDIVIDUALS PREDISPOSED TO ORAL INFECTIONS

A number of medical conditions predispose individuals to oral infections, notably

candidiasis. Chlorhexidine is effective as an anticandidal agent but is most useful
when combined with specific anticandidal drugs, such as nystatin or amphoteracin B
(Simon etti et al. 1988). Indications for chlorhexidine use combined with
anticandidal drugs have been for the prevention of oral and systemic infections in
the immunocompromised, including those with blood dyscrasias, those receiving
chemotherapy and/or radiotherapy and notably bone marrow transplant patients
( Ferretti et al. 1987, 1988, Toth et al. 1990). The value of chlorhexidine appears
greatest when initiated before oral or systemic complications arise. A chlorhexidine
spray was also found to produce symptomatic/ psychological oral care benefits in
the terminally ill (Dobbins et al.1992).11

HIGH RISK CARIES PATIENT

Chlorhexidine rinses or gels can reduce considerably the streptococcus mutans

counts in individuals who are caries prone. Additionally, and interestingly, chlor
hexidine appears synergistic with fluoride and combining chlorhexidine and
fluoride rinses appears beneficial to such at risk individuals (Dolles & Gjermo
1980, Lindquist et al. 1989).11

RECURRENT ORAL ULCERATION

Several studies have shown that chlorhexidine mouthrinses and chlorhexidine

gels reduce the incidence, duration and severity of recurrent minor aphthous
ulceration (Addy et al. 1974, 1976, Hunter & Addy 1987). The mechanism of
action is unclear but may relate to a reduction in contamination of ulcers
by oral bacteria, thereby reducing the natural history of the ulceration. Regimens
have included three times daily use of chlorhexidine products for several weeks.
Interestingly, one study showed that triclosan rinses reduce the incidence of
recurrent mouth ulcers (Skaare et al. 1996). There have been no controlled studies of
chlorhexidine in the management of major aphthous ulceration or other oral erosive
or ulcerative conditions, although anecdotally chlorhexidine appears ineffective.
Again, this may reflect the low therapeutic potential of this and other antiseptics.
Removal and fixed orthodontic appliance wearers Plaque control in the early stages
of orthodontic appliance therapy may be compromised and chlorhexidine
can be prescribed for the first 4-8 weeks. Additionally, chlorhexidine has been
shown to reduce the number and severity of traumatic ulcers during the first 4
weeks of fixed orthodontic therapy (Shaw et al. 1984).11

IN DENTURE STOMATITIS

Chlorhexidine has been recommended in the treatment of candidal associated

infections; however, in practice even applying chlorhexidine gel to the fitting
surfaces of denture produces, in many cases, slow and incomplete resolution of
the condition. Again, chlorhexidine is less effective in the therapeutic mode and
it is more advantageous to treat denture stomatitis with specific anticandidal
drugs and then employ chlorhexidine to prevent recurrence. The denture itself
can be usefully sterilized from candida by soaking in chlorhexidine solutions
(Olsen et al. 1975a,b).11
IMMEDIATE PRE-OPERATIVE CHLORHEXIDINE RINSING AND IRRIGANT

This technique can be used immediately prior to operative treatment,

particularly when ultrasonic polishing or high-speed instruments are to be used.
Such preoperative rinsing markedly reduces the bacterial load and contamination
of the operative area andoperator and staff (Worral et al. 1987). Additionally, in
susceptible patients, irrigation of chlorhexidine around the gingival margin
reduces the incidence of bacteremia (MacFarlane et al. 1984). However, this
should be seen only as an adjunct to appropriate systemic antimicrobial
prophylaxis.11

SUBGINGIVAL IRRIGATION

Numerous antimicrobial agents have been used as subgingival irrigants in the

management and treatment of periodontal diseases (for reviews see
Wennstrom 1992, 1997). Alone, irrigation with antimicrobial agents produces
effects little different from using saline and of short duration, suggesting that the
action is a washing-out effect. Irrigation combined with root planing appears to
provide no adjunctive benefits.11

Clinical Applications Of Chlorhexidine:-

 As an adjunct to oral hygiene and professional prophylaxis .
 Post oral surgery in periodontal surgery or root planing.
 Patients with intermaxillary fixation and in patients who are under high risk
of caries . [ Nash and Addy 1979 ]
 Physically and mentally handicapped chlorhexidine sprays can be used
 Medically compromised patients who are predisposed to oral candidiasis
 Used to limit the bacteremia and operatory contamination by oral bacteria
and as aa adjunct to antibiotic prophylaxis
 Sub gingival irrigation
 Final irrigation before root canal obturation . management of denture
stomat
 Hypersensitivity , tooth decay , recurrent oral ulceration [ Addy 1974,1976 ]
 Patients undergoing athodontic treatment . [ Shaw et al 1984 ]
 Oral malodour [ Halita is the name of a mouth rinse containing 0.05 % of
chlorhexidine , 0.05 % cetyl pyridinium chloride and 0.14 % of zinc lactate ]
 For surgical skin preparation
 As a local drug delivery system in the form of a bio - degradable chip to be
used in the subgingival environment [ periochip - 2.5mg of chlorhexidine is
 found to have an average drug concentration greater than 125 microgram
per milliliter for 7 to 10 days 12

USE IN OTHER BRANCHES

Chlorhexidine can be applied clinically as antimicrobial agent during all phases of
root canal preparation, including the disinfection of operatory field ; during
enlargement of the canals orifices; removal of necrotic tissues before performing
the root canal length determination; in the chemomechanical preparation prior
to the foraminalpatency and enlargement; as an intracanal medicament alone or
combined with others for modelling the main gutta percha cone; in the removal
of gutta percha cones during retreatment and in the disinfection of prosthetic
spaces . Chlorhexidine has been recommended as an alternative to
NaOCl,especially in cases of open apex,root resorption,foramen enlargement and
root perforation,due to its biocompatibility ,or in cases ofallergy related to
bleaching solutions. The main feature is canals medicated with chlorhexidinedo
not affect negatively the ability of root fillings to prevent fluid penetration into
the root canal system through the apical foramen.13

Table 1
Adjunctive uses of chlorhexidine products in the treatment of stage I-III
periodontitis.14

Purpose of Interventions Evidence Based Recommentations

Improve clinical outcome of subgingival Chlorhexidine mouthwash may be used for a
instrumentation limited period of time, in periodontitis therapy, as
an adjunct to mechanical debridement in specific
cases.

Locally administered sustained-release

chlorhexidine may be considered for use as an
adjunct to subgingival instrumentation in patients
with periodontitis.

Control of gingival inflammation in patients If antiseptic dentifrice formulation is to be

with periodontitis receiving supportive
periodontal care
used adjunctively, products containing
chlorhexidine, triclosan-copolymer, and
stannous fluoride-sodium
hexametaphosphate are suggested.
 If antiseptic mouthwash is to be used
adjunctively, mouthwash containing
chlorhexidine, essential oils, or
cetylpyridinium chloride is suggested.

Side Effects : Brown discolouration of the teeth , restorative materials and yellow discoloration
oftongue . * The mechanisms proposed for CHX staining can be debated ( Eriksen et al . 1985 ,
Addy & Moran 1995 , Watts & Addy 2001 ) but have been proposed as : 1. Degradation ofthe
chlorhexidine molecule to release parachloraniline . [ ( Addy and Roberts 1981 )

USE OF CHLORHEXIDINE IN COVID-19 PATIENTS (OROPHARYNGEAL)

As SARS-COV-2 is an enveloped viruses, chlorhexidine has been shown

to be effective against SAR-COV-2 . The data shows a significant
elimination of SARS-COV-2 with application in oral cavity and
pharynx.In an effort to deliver chlorhexidine to the posterior
oropharynx more effectively, a spray application was used to apply
chlorhexidine to the posterior Oropharynx directly.

The use of chlorhexidine as an Oropharyngeal rinse may serve two

purposes.

1. To prevent the viral spread from a covid-19 patient to others.

2. To prevent the SARS-COV-2 infection in the case of virus.

Prevention of a virus spread from SARS-COV-2 to others

Using chlorhexidine twice a day as follows

I. Spray 1 ml to the...... and rinse the throat thoroughly with 15 ml

for at least 30 seconds and use a spray application to spray the
posterior throat three times (1.5ml).
II. Continued process until virus naturally clearing from body
approximately takes to 3 weeks.
CONCLUSION

Numerous authors have demonstrated the immediate antibacterial effect of

CHX, and its substantivity in saliva for a minimum of 7 hours after a single
mouthrinse. However, few authors have studied the in situ antibacterial activity
of CHX on the salivary flora, analysing the influence of intrinsic factors associated
with the antiseptic and extrinsic factors, all of which can affect its antibacterial
activity. Nor have many papers been published using CLSM in association with
bacterial viability techniques to determine the effects of CHX on in situ
undisturbed PL-biofilm, and in the studies carried out the results have not been
uniform.
Consequently, a more extensive application of advanced
microbiological and/or microscopy techniques in combination with CLSM is
required in future research in order to increase our understanding of the
antibacterial effects of CHX and other antimicrobial agents on PL-biofilm
structure. These effects should then be compared with the effects observed in
other oral ecosystems (such as salivary flora) and the influence of intrinsic and
extrinsic factors on the effectiveness of the antiseptic should be analysed.

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