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Chlorhexidine

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Ivan Obadiah

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).

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

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Chlorhexidine

  • 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.