Really understanding oral hygiene solutions
UncategorisedPosted by: Dental Design 5th May 2023
Chlorhexidine (CHX) has been used in dentistry since the 1950s, when it was introduced as a broad-spectrum biocide to protect against both gram-positive and gram-negative bacteria.[i] It has also been proven effective fighting aerobes, yeasts, fungi and some viruses. Despite its benefits, CHX is associated with an array of negative side effects, which is partly why it was only ever intended for short-term use. It is essential to understand these potential effects when seeking the most appropriate solutions for patients. The means continually educating both yourself as a dental professional, and your patients as the user of products containing CHX.
Discolouration
The most obvious side effect of CHX is the staining it causes to teeth, though it can also discolour the soft tissues. One study[ii] found a significant increase in extrinsic staining among users of a CHX mouth rinse at 4-6 weeks, 7-12 weeks and 6 months. Another[iii] stated that the stains caused were resistant to polishing and could only be removed through scaling.
Interestingly, research by Zanatta et al suggested that both discolouration and calculus formation impact patients to different degrees, depending on the presence or adequate removal of plaque prior to treatment.[iv]This highlights the importance of careful biofilm disruption before commencing periodontal therapy with a CHX solution to reduce the risk of negative side effects.
Cytotoxicity
Perhaps more worrying to many dental professionals is the cytotoxicity of CHX. Research[v] has demonstrated a significant cytotoxic effect on cell survival in vitro. Exposure to 0.12% CHX for 3 minutes was seriously cytotoxic to ligament fibroblasts and 0.2% CHX led to immediate cell fixation into tissue cell culture surfaces, as well as having a cytotoxic impact on osteoblasts and myoblasts. Of note is that reduced cell migration and cell survival were identified in CHX concentrations as low as 0.002%.
Hypersensitivity
The prevalence of CHX allergy is unknown, but it is predicted to be on the rise. A narrative review in the British Journal of Anaesthesia[vi] found that 50 CHX-induced perioperative hypersensitivity reactions were recorded between 1994 and 2004 in the UK, while 104 cases were reported in 2009-2013. Another study[vii] on CHX hypersensitivity among dental students discovered that 8.6% of participants had CHX sensitisation. This was despite 57% having no history of allergies and less than 20% reporting exposure to CHX, which indicates unknown exposure and risk of adverse reactions in the future.
Impact on saliva
Bescos et al[viii] reported that CHX mouthwash changes the oral microbiome significantly. In particular, the substance was found to increase the acidity of conditions in the mouth, lowering the salivary pH. Lactate and glucose concentrations were higher in the saliva after 7-days use of CHX mouthwash and less nitrate was turned into nitrite. The study postulated that more research is needed to accurately determine the full impact of CHX on the oral cavity.
Other adverse effects reported in the literature include glandular swelling, a burning sensation in the mouth, ulceration or erosion, taste disturbance and discolouration of the soft and hard tissues.[ix]
Know your options
As is true in all areas of dentistry, it is crucial that you know exactly what you are using or recommending to patients and how these solutions could be benefiting or putting them at risk. In some situations, the risks may be negligible, but in others, you might be more comfortable finding safer or more effective alternatives.
When it comes to CHX, there are other options available on the market today. Hypochlorous solutions, for example, provide all the microbial benefits of CHX, without any of the negative side effects like staining, cytotoxicity or hypersensitivity. However, it is not as simple as finding just any hypochlorous-based product – it is still essential to know exactly what you are offering patients.
Clinisept+ Dental Mouthwash is a totally unique, next generation hypochlorous solution that is backed by extensive science and clinical research. Its high-purity, high-stability formula is proven to deliver superior microbial control through oxidation instead of toxicity. Because Clinisept+ is not cytotoxic, it delivers the perfect environment for optimum tissue healing, which is why it is used by many of the UK’s top implant dentists. It also has a neutral pH and contains no alcohol, causes no discolouration and is anti-inflammatory and hypoallergenic for complete peace of mind.
Greater choice of products is a luxury that we should never take for granted, but with this comes greater responsibility to select the safest, most appropriate solution. Dental professionals have access to various oral aids that are designed to treat gingival disease and minimise the risk of infection in patients – but these are not all created equal. Be sure to do your research to better understand the products you use and always look for better options that pose the least risk to patients wherever possible.
Find out more at www.cliniseptplus.com, or contact 01455 247797 or
[i] Horner C, Mawer D, Wilcox M. Reduced susceptibility to chlorhexidine in staphylococci: is it increasing and does it matter? J Antimicrob Chemother. 2012;67(11):2547-2559. https://doi.org/10.1093/jac/dks284
[ii] James P, Worthington HV, Parnell C, Harding M, Lamont T, Cheung A, Whelton H, Riley P. Chlorhexidine mouthrinse as an adjunctive treatment for gingival health. Cochrane Database of Systematic Reviews 2017, Issue 3. Art. No.: CD008676. DOI: 10.1002/14651858.CD008676.pub2. Accessed 10 January 2023.
[iii] Eley, B. Antibacterial agents in the control of supragingival plaque — a review. Br Dent J 186, 286–296 (1999). https://doi.org/10.1038/sj.bdj.4800090
[iv] Zanatta FB, Antoniazzi RP, Rösing CK. Staining and calculus formation after 0.12% chlorhexidine rinses in plaque-free and plaque covered surfaces: a randomized trial. J Appl Oral Sci. 2010 Sep-Oct;18(5):515-21. doi: 10.1590/s1678-77572010000500015. PMID: 21085810; PMCID: PMC4246385.
[v] Liu JX, Werner J, Kirsch T, Zuckerman JD, Virk MS. Cytotoxicity evaluation of chlorhexidine gluconate on human fibroblasts, myoblasts, and osteoblasts. J Bone Jt Infect. 2018 Aug 10;3(4):165-172. doi: 10.7150/jbji.26355. PMID: 30155401; PMCID: PMC6098817.
[vi] Rose MA, Garcez T, Savic S, Garvey LH. Chlorhexidine allergy in the perioperative setting: a narrative review. British Journal of Anaesthesia. July 2019l 123(1); E95-103. DOI:https://doi.org/10.1016/j.bja.2019.01.033
[vii] Khazin S M, Abdullah D, Liew A K C, Harun N A, Abdullah N, Chong B S. IgE-mediated hypersensitivity to chlorhexidine among first-year dental students. Allergo J Int 2019; 28: 204-208.
[viii] Bescos, R., Ashworth, A., Cutler, C. et al. Effects of Chlorhexidine mouthwash on the oral microbiome. Sci Rep 10, 5254 (2020). https://doi.org/10.1038/s41598-020-61912-4
[ix] Pałka Ł, Nowakowska-Toporowska A, Dalewski B. Is Chlorhexidine in Dentistry an Ally or a Foe? A Narrative Review. Healthcare (Basel). 2022 Apr 20;10(5):764. doi: 10.3390/healthcare10050764. PMID: 35627901; PMCID: PMC9141996.
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