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Chlorhexidine mouthwash as an anticaries agent: A systematic review

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Chlorhexidine mouthwash as an anticaries agent:
A systematic review
Ana Sofia Estima Cunha Coelho, DMD, MSc 1/Anabela Baptista Pereira Paula, DMD, MSc 1/
Teresa Maria Palmeirão Carrilho, DMD, MSc 2/Mário Jorge Rebolho Fernandes da Silva, PhD 3/
Maria Filomena Rabaça Roque Botelho, PhD4/Eunice Virgínia Valdez Faria Bidarra Palmeirão Carrilho, PhD 4
Objective: To evaluate the effectiveness of chlorhexidine
mouthwashes on the reduction of cariogenic bacteria on
patients with moderate to high risk for dental caries. Data
Sources: A systematic review of the literature was performed
using Cochrane Library, Embase, PubMed, Scopus and Web of
Science. The search was limited to articles in English, Spanish,
and Portuguese, published until January 2017. The research
question was formulated following the PICO strategy. The risk of
bias was evaluated using the guidelines of the Cochrane
Handbook for Systematic Reviews of Interventions. Conclusion:
Key words: chlorhexidine, dental caries, Lactobacillus, mouthwashes, prevention, Streptococcus mutans
Chlorhexidine, 1,1’-hexamethylene bis (5-[4-chlorophe-
nyl] biguanide), is a cationic antiseptic used in different
medical fields due to its broad spectrum of antibac-
terial action. The compound is a strong base and is
available in the form of digluconate (the most com-
monly used), acetate, and hydrochloride.1
1 PhD Student, Teaching Fellow, Faculty of Medicine, University of Coimbra,
Coimbra, Portugal.
2
Research Student, Faculty of Medicine, University of Coimbra, Coimbra, Portugal.
3 Full Professor, Faculty of Dental Medicine, University of Oporto, Oporto, Portugal.
4 Full Professor, Faculty of Medicine, University of Coimbra; and Institute for Bio-
medical Imaging and Life Sciences, IBILI, Coimbra, Portugal.
Correspondence: Dr Ana Coelho, Área de Medicina Dentária, Av.
Bissaya Barreto, Bloco de Celas, 3000-075 Coimbra, Portugal. Email:
anasofiacoelho@gmail.com
VOLUME 48 • NUMBER 7 • JULY/AUGUST 2017
Q U I N T E S S E N C E I N T E R N AT I O N A L
GENERAL DENTISTRY
Ana Sofia Estima
Cunha Coelho
All the authors found statistically significant differences in
Streptococcus mutans levels during and after the use of a chlor-
hexidine mouthwash. Although the results are suggestive, there
is a clear need for the development of new studies with higher
quality and with longer follow-ups, in order to assess whether
the results translate into less development of dental caries and,
consequently, whether or not these products should be incorpor-
ated into prevention protocols. (Quintessence Int 2017;48:
585–591; doi: 10.3290/j.qi.a38353)
Since chlorhexidine is a cationic molecule, binding to
the bacterial wall is possible, and according to the con-
centration in which it is used there is a bacteriostatic or a
bacteriocidal action. At low concentrations, chlorhexidine
alters the bacterial osmotic balance, with the consequent
release of cytoplasmic components, which promotes its
bacteriostatic action. At high concentrations, the mol-
ecule promotes precipitation/coagulation of cytoplasmic
proteins. The bacteriocidal activity of chlorhexidine is
particularly effective against gram-positive bacteria. Fol-
lowing the use of a high-concentration chlorhexi-
dine-based product, an immediate bacteriocidal effect is
expected, followed by a prolonged bacteriostatic effect.1,2
The cationic nature of chlorhexidine also minimizes
its absorption, which, together with its substantivity,
585
Q U I N T E S S E N C E I N T E R N AT I O N A L
Coelho et al
allows a prolonged antibacterial action in the oral cav-
ity.3 The substantivity is associated with its binding to
the mucins of the acquired pellicle, where it inhibits
bacterial colonization, glycosyltransferases, bacterial
transport of sugars, and the production of organic
acids.4-6 The duration of chlorhexidine substantivity is
related to the time and concentration in which it is
used. The use of a mouthwash also allows a longer sub-
stantivity than the use of gels or sprays.7,8
The first clinical study evaluating the effects of
chlorhexidine was published in 1970 by Löe and
Schiott,9 who proved its efficacy as an antiplaque agent.
Since then, chlorhexidine products have been indi-
cated, mainly, for the treatment and maintenance of
periodontal diseases, and its use is associated with a
decrease in bacterial plaque and gingival bleeding and
inflammation, as well as in surgical postoperative care.
The analysis of the efficacy of chlorhexidine in these
situations is the most common aim found in clinical
studies using this product and it is often referred to as
the gold standard of antiplaque agents.10,11 The mech-
anisms of chlorhexidine action as an antiplaque agent
are related to the inhibition of formation of the
acquired pellicle (by binding to the acidic groups of
salivary glycoproteins), to its binding to extracellular
polysaccharides (which inhibits the ability of bacteria to
bind to the dental structure), and to the competition
with calcium ions in the dental biofilm.12
Concerning dental caries, there is controversy
regarding its prevention by chlorhexidine. The poten-
tial use of the product is mainly associated with
patients with high risk of caries, given its ability to
reduce the rate of formation of dental biofilm and its
antibacterial action against different Streptococcus spe-
cies, namely Streptococcus mutans.13-17
When a chlorhexidine mouthwash is indicated, the
Food and Drug Administration (FDA)18 suggests its use
in concentrations of 0.12% or 0.2% twice a day, for 30
seconds each time, and with 10 to 15 mL of product.
Although some side effects associated with long-
term use of chlorhexidine have been described, they
are all reversible. The most common effect is the
brownish pigmentation of hard and soft tissues of the
586
oral cavity, mainly of teeth (in the cervical third, inter-
proximal areas, pits, and fissures) and in the tongue,
more prevalent in patients with plaque that was not
previously removed or in the ones who include chro-
mogenic components in their diet. Effects such as dys-
geusia, mucosal dehydration, increased supragingival
calculus, and ulcerations are also described.12,19
The aim of this systematic review was to evaluate
the effectiveness of chlorhexidine mouthwashes on the
reduction of cariogenic bacteria on patients with mod-
erate to high risk for dental caries.
DATA SOURCES
A systematic review of the literature was performed
using Cochrane Library (www.cochranelibrary.com),
Embase (www.embase.com), PubMed (www.ncbi.nlm.
nih.gov/pubmed), Scopus (www.scopus.com), and Web
of Science (www.webofscience.com) (Table 1).
RESOURCES SELECTION
The search was limited to articles in English, Spanish,
and Portuguese, published until January 2017.
The research question was formulated following the
PICO (population, intervention, comparison, outcome)
strategy: “Is the use of a chlorhexidine mouthwash an
effective method in the prevention of dental caries in
patients with greater susceptibility to the disease when
compared to their non-use or use of a placebo?”
(Table 2).
After the elimination of the duplicate articles, the
titles and abstracts resulting from the research were
analyzed in order to identify potential studies to be
included in the systematic review. All titles, abstracts,
and full texts of the relevant studies were inde-
pendently examined by three reviewers. Review art-
icles, cell and animal studies, letters, clinical cases, and
comments were excluded. Additional studies were
searched through a manual review of the references of
the articles included.
The selection methodology of the articles included
in the systematic review is illustrated in Fig 1.
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Coelho et al

Table 1 Search strategy for each database

Database Search strategy

Cochrane chlorhexidine AND (caries OR streptococcus OR lactobacillus)
“chlorhexidine”/exp OR chlorhexidine OR eludril OR corsodyl OR parodontax OR chx AND (“dental caries”/exp OR caries OR
Embase
“streptococcus mutans”/exp OR mutans OR streptococcus OR “lactobacillus”/exp OR lactobacillus)
((((((chlorhexidine[MeSH Terms]) OR eludril) OR corsodyl) OR parodontax) OR chx)) AND ((((((((dental caries[MeSH Terms]) OR
PubMed
carious) OR decay) OR deminerali*) OR DMF* index) OR streptococc*) OR mutans) OR lactobacill*)
(TITLE-ABS-KEY(chlorhexidine OR corsodyl OR eludril OR parodontax) AND TITLE-ABS-KEY (caries OR “streptococcus mutans”
Scopus
OR mutans OR lactobacillus OR demineralization))
TOPIC: (chlorhexidine OR corsodyl OR eludril OR parodontax OR Chx) AND TOPIC: (caries OR carious OR decay OR streptococ-
Web of Science
cus OR mutans OR lactobacillus)

Table 2 PICO strategy used for the evaluation of the scientific evidence regarding the use of chlorhexidine
mouthwashes for the prevention of dental caries

Element Research
Individuals with moderate to high risk for dental caries. Exclusion criteria: groups with less than 10 elements; patients under-
Population (P)
going orthodontic treatment
Intervention (I) Use of chlorhexidine mouthwashes. Exclusion criteria: combined therapy with other products; split-mouth design studies
Comparison (C) No intervention or use of a placebo
Outcome (O) Dental caries and/or S mutans/Lactobacillus species levels

For each included study, descriptive and quantita-
tive information was collected, including authors and
year of publication, number of participants in each
group (test and control), type and duration of inter-
vention, evaluation methods, results, and conclusions.
The quality of the study methodology was evalu-
ated using the guidelines of the Cochrane Handbook
for Systematic Reviews of Interventions version 5.1.0.20
Three reviewers independently assessed the quality of
the studies.
REVIEW
The initial research resulted in a total of 4,637 articles,
of which 30 were selected for a full text analysis. No
additional studies were included through the evalu-
ation of the references lists of the selected articles.
Eight articles21-28 published between the years of 2003
and 2015 were considered for analysis (Table 3).
Two of the studies were conducted in children.26,28
Of the remaining six studies, five were conducted in
young adults (18–25 years old).21,22,24,25,27 Five articles
referring to the use of a 0.2% chlorhexidine mouth-
wash,21,22,24-26 and two articles referring to the use of
0.12% mouthwashes23,27,28 were included in the analysis.
Jayaprakash et al28 used three mouthwashes (0.02%,
0.06%, and 0.12%) in three independent test groups.
Srinagesh and Pushpanjali25 did not perform any type
of intervention in the control group and all the other
authors assigned water or a placebo mouthwash to the
elements of this group to be used after brushing.
Patients included in the analyzed studies performed
mouthwashes of 1021,22,26 or 15 mL23-25,27,28 of the
assigned mouthwash twice a day. All the studies pre-
sented different times of treatment and of evaluation.
All the authors reported results regarding the prev-
alence of S mutans in saliva. Netto et al23 also reported
results regarding the prevalence of Lactobacillus spe-

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Q U I N T E S S E N C E I N T E R N AT I O N A L
Coelho et al

Embase Cochrane PubMed Scopus Web of Science

510 424 961 1,417 1,325

Initial search:
4,637 unique articles

4,607 excluded articles for being duplicated

or after analysis of titles and abstracts

30 selected articles for full text reading

23 articles excluded for not meeting the

inclusion criteria

8 articles included in the systematic review

Fig 1 Flow diagram on the selection process of the studies included in the systematic review.

cies. None of the articles performed a follow-up long DISCUSSION

enough to allow the development evaluation of new
dental caries lesions.
A high risk of bias was attributed to two studies,24,25
resulting from the evaluation of at least two high-risk
parameters. Two studies22,23 were evaluated with low
risk of bias and the remaining four21,26-28 with risk of
uncertain bias, given the lack of data needed for the
evaluation of several parameters (Table 4).
All the authors found statistically significant differ-
ences in S mutans levels during and after the use of a
chlorhexidine mouthwash. Jothika et al,21 Gupta and
Gupta,22 and Srinagesh and Pushpanjali25 also reported
significant results 30 days after the end of the therapy.
Netto et al23 attributed a 0.12% chlorhexidine
mouthwash to the test group for 28 days and reported
statistically significant differences in Lactobacillus spe-
cies only in saliva collected 7 and 14 days after the insti-
tution of the therapy. In contrast, S mutans levels
remained statistically significant throughout the study
period, including day 45 (17 days posttreatment).
Eight studies that met the inclusion criteria and that
evaluated the efficacy of chlorhexidine mouthwashes
in patients with moderate to high risk of developing
dental caries were included in this systematic review.
Although all the articles included in the analysis
reported similar results (decrease in S mutans levels),
only two studies22,23 presented low risk of bias. There-
fore, careful analysis of the results is required. There is a
need to carry out new scientific studies aimed at the
evaluation of this topic, allowing the adoption of strict
inclusion criteria, random sequence generation, and
the blinding of participants, examiners, and evaluators.
Although the analysis of the results suggests that
the use of chlorhexidine mouthwashes results in a
decrease in the levels of S mutans, it would also be rele-
vant to evaluate the levels of Lactobacillus species,
since this plays an important role in the etiology of
dental caries. Only one study evaluated this param-
eter,23 and although differences in Lactobacillus species
levels lost statistical significance before the end of the
therapy, this consisted of a 0.12% chlorhexidine mouth-

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Coelho et al

Table 3 Use of chlorhexidine mouthwashes (systematic review)

Inclusion criteria
Study (n = T/C) Intervention Results Comments
Jothika 18–25 y T: 0.2% chlorhexidine. T: initial, 1.14; day 7, 2.48; day 14, 5.79; day A prophylaxis was performed prior to
et al21 old; > 1 × 104 C: distilled water. 10 mL 30, 10.38. C: initial, 1.9; day 7, 17.95; day 14, the collection of the first saliva sample.
CFU/mL S mutans twice-daily for 24 h 20.25; day 30, 70.33. Unit 104 CFU S mutans/ Citation: “Chlorhexidine mouthwash
in saliva; mL proved to be effective even on the 14th
n = 13/13 and 30th days with a reduced colony
count, showing its substantivity.” The
control group “showed a statistically
significant difference when compared
with [the chlorhexidine group] on 7th,
14th, and 30th days (P < .05).”
Gupta and 19–25 y old, T: 0.2% chlorhexidine. T: reduction of the initial number of CFUs Statistically significant results for the
Gupta22 DMFT 2–5 with at C: placebo. 10 mL by 83% on day 30 and 63% on day 60. C: two times of evaluation (P < .001). The
least one dental twice-daily for 30 days reduction of the initial number of CFUs by variation of the control group was not
caries; n = 30/30 3% on day 30 and increase of 7% on day 60. statistically significant (P = .201).
Netto et al23 18–55 y T: 0.12% chlorhexidine. S mutans. T: initial: 2.3 ± 0.5; day 7, 1.7 ± 0.6; Citation: “Analysis of covariance
old; > 1 × 105 C: placebo. 15 mL day 14, 1.8 ± 0.5; day 28, 1.7 ± 0.7; day 45, revealed significant treatment effects
CFU/mL S mutans twice-daily for 28 days 1.9 ± 0.5. C: initial, 2.2 ± 0.4; day 7, 2.2 ± 0.7; from baseline to 28 and 45 days (…) for
in saliva and at day 14, 1.9 ± 0.5; day 28, 2.6 ± 0.6; day 25, the salivary levels of mutans strepto-
least one cavi- 2.6 ± 0.7. Unit: 0–1, < 100,000 CFU/mL; cocci” (P < .05). Regarding
tated caries 2, > 100,000 to < 1,000,000 CFU/mL; Lactobacillus species: “chlorhexidine
lesion; n = 20/20 3, > 1,000,000 CFU/mL. was superior to placebo at 7-day and
Lactobacillus species. T: initial, 3.5 ± 0.9; day 14-day visit.”
7, 3.3 ± 1.1; day 14, 3.1 ± 0.8; day 28,
3.1 ± 0.8; day 45, 3.1 ± 0.8. C: initial,
2.7 ± 0.9; day 7, 2.9 ± 0.8; day 14, 2.7 ± 1.0;
day 28, 3.0 ± 0.9; day 45, 3.1 ± 1.0. Unit: 2,
1,000 CFU/mL; 3, 10,000 CFU/mL; 4, 100,000
CFU/mL; 5, 1,000,000 CFU/mL
Srinagesh 18–25 y old, at T: 0.2% chlorhexidine. T: initial, 193; 48 h, 158.3; day 7, 109.6. C: ini- Citation: “the chlorhexidine group
et al24 least 1 active C: water. 15 mL twice- tial, 182.1; 48 h, 177.8; day 7, 183.7 showed 16% and 45% reduction” in the
incipient lesion daily for 7 days CFUs/mL at 48 h and on day 7 … The
and/or 1 cavi- reduction in colony count was statisti-
tated caries cally significant between (…) chlor-
lesion; n = 20/20 hexidine and control group (P < .001).”
Srinagesh 19–25 y old, at T: 0.2% chlorhexidine. T: reduction of the initial CFU number of S Citation: “There was a significant
and least 1 active C: without intervention. mutans in 80% on day 15 and 65% on day decrease in the [S mutans] colony
Pushpanjali25 incipient lesion 15 mL twice-daily for 45. C: reduction of the initial number of count in (…) the chlorhexidine group
and/or 1 cavi- 15 days CFUs by 3% on day 15 and increase of 7% (80% and 65%) on day 15 and on day
tated caries on day 45. 45 (P < .0001).” Regarding the control
lesion; n = 19/20 group there was not a statistically sig-
nificant difference between the two
evaluation times (P = .116).
Jayaprakash 10–12 y old, at T: 0.02% chlorhexidine T1: initial, 1.23 ± 0.38; wk 1, 0.25 ± 0.14. T2: Citation: “One week after treatment
et al28 least 1 active (T1), 0.06% chlorhexi- initial, 1.79 ± 0.43; wk 1, 0.11 ± 0.04. T3: ini- schedule there was a significant reduc-
incipient dine (T2), or 0.12% tial, 1.58 ± 0.57; wk 1, 0.11 ± 0.09. C: initial, tion in the mutans streptococci counts
lesion, > 1 × 105 chlorhexidine (T3). C: 1.62 ± 0.61; wk 1, 1.13 ± 0.54. in the test groups than the control
CFU/mL S mutans placebo. 15 mL twice groups. Children using chlorhexidine
in saliva; daily, 30 min after 0.12 concentration showed maximum
n = (10/10/10)/10 brushing, for 1 wk reduction of mutans streptococci.”
Neeraja et 6–12 y old, DMFT T: 0.2% chlorhexidine. T: day 1, 15,460.00 ± 9,677.43; day 15, Citation: “Inhibition of S mutans in all
al26 3–4; n = 15/15 C: placebo. 10 mL 14,753.33 ± 11,207.07; day 30, the [groups] was significant at first day,
twice-daily for 14 days 8,660.00 ± 9,395.80; day 90, 15 days, and 30 days after mouth rinse
7,346.67 ± 9,871.96. C: day 1, therapy, but at 90 days the inhibition
4,520.00 ± 2,645.00; day 15, was significant only in chlorhexidine
4,053.33 ± 4,885.67; day 30, group.”
3,953.33 ± 2,370.01; day 90,
1,800.00 ± 967.32. Unit: difference between
initial and posttreatment means (S mutans).
continued on next page

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continuation from previous page

Inclusion criteria
Study (n = T/C) Intervention Results Comments
Kulkarni 18–25 y T: 0.12% chlorhexidine. T: initial, 2.426 ± 2.265; wk 2, 0.694 ± 1.020. There were no statistically significant
and old; > 1 × 105 C: placebo. 15 mL C: initial, 2.350 ± 2.446; wk 2, 2.290 ± 2.551. differences between groups at base-
Damle27 CFU/mL S mutans twice-daily, 30 min Unit: 105 CFU S mutans/mL line. Citation: “After 2 weeks of the
in saliva; after brushing, for 2 wk treatment schedule there was signifi-
n = 20/20 cant decrease in mutans streptococci
count (CFU/mL of saliva) in test groups
as compared to the control group
(P < .05).”
C, control group; CFU, colony forming unit; DMFT, decayed, missing, and filled teeth; T, test group.

Table 4 Risk of bias in the studies included in the systematic review (present authors’ judgments)

Blinding of
Random Allocation participants Blinding of Incomplete
sequence conceal- and outcome outcome Selective
Study generation ment personnel assessment data reporting Other bias Risk of bias
Jothika et al21 Unclear Unclear Low Low Unclear Low Unclear Unclear
Gupta and Gupta22 Low Low Low Low Low Low Low Low
Netto et al23 Low Low Low Low Low Low Low Low
Srinagesh et al24 Unclear High High Low Low Low Low High
Srinagesh and
Low High High Low Low Low High High
Pushpanjali25
Jayaprakash et al28 Unclear Unclear Unclear Low Unclear Low Unclear Unclear
26
Neeraja et al Unclear Unclear Low Low Unclear Low Low Unclear
Kulkarni and Damle27 Unclear Unclear Low Low Low Low Low Unclear

wash. No studies were found that fulfilled the inclusion
criteria of the present analysis, assessed the levels of
Lactobacillus species, and used 0.2% chlorhexidine
mouthwash, which could lead to different results.
Jothika et al21 reported levels of S mutans in the saliva
of patients at moderate risk for developing dental caries
significantly lower than those found prior to the use of a
0.2% chlorhexidine mouthwash and those found in the
control group, 30 days after the end of the therapy. Sim-
ilarly, Gupta and Gupta22 found, 30 days after the use of
a 0.2% mouthwash for 30 days, a reduction of 63% in S
mutans levels. Reporting identical results, Srinagesh and
Pushpanjali25 found a reduction of 65% 30 days after the
use of the same mouthwash for 15 days. Inhibition of S
mutans proliferation/metabolism after the end of the
chlorhexidine therapy may be related to its substantivity
as well as to its bacteriocidal and bacteriostatic capacity.
Some authors report the existence of chemical reac-
tions between the toothpaste components (in particu-
lar sodium lauryl sulfate and sodium monofluorophos-
phate) and chlorhexidine, with the consequent
inhibition of chlorhexidine, and it is suggested that it
should be used only 30 minutes after brushing.29,30 Only
Kulkarni and Damle27 implemented this rule. However,
recent studies do not find an association between the
efficacy of chlorhexidine and the type of dentifrice or
the time toothbrushing should be performed.31-33
The most recent previous review on the topic was a
Cochrane systematic review34 that evaluated the anti-
cariogenic effects of chlorhexidine varnishes and chlor-
hexidine gel in children and adolescents. Although this
review included trials with different inclusion criteria,
the authors also found little evidence supporting the
use of chlorhexidine as an anticaries agent.

590 VOLUME 48 • NUMBER 7 • JULY/AUGUST 2017


CONCLUSION
Given the risk of bias in the analyzed studies it is not
possible to conclude with certainty whether the use of
a chlorhexidine mouthwash by patients with moderate
to high risk of developing dental caries is effective in
preventing it.
Although the results are suggestive, there is a clear
need for the development of new studies with higher qual-
ity and with longer follow-ups, in order to assess whether
the results translate into less development of dental caries
and, consequently, whether or not these products should
be incorporated into prevention protocols.
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