RESOURCE FACULTY:DR. SHIVALAL SHARMADR. KHUSHBOO GOELDR. SAJEEB SHRESTHA

KASHMIRA POKHREL-483

CHLORHEXIDINE AND OTHER

MOUTHWASHES

HISTORYChlorhexidine

Introduction Structure Ingredients MOA Properties Uses Toxicity Side effects Contraindications

Other mouth washes

CONTENTS

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.

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

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.

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.

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.

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

CHLORHEXIDINE is a GOLD STANDARD IN CHEMICAL PLAQUE CONTROL with bacteriostatic and bactericidal properties.

Broad spectrum anti-microbial drug

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

Ingredients

Chlorhexidine Alcohol Glycerine Sodium saccharin PEG-40 sorbitan diisostearate Flavoring agent Purified water

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)

Mechanism of actionBacteriostatic and bactericidal

Intracellular coagulation

Slows down leakage of intracellular components

Cytoplasmic coagulation

Irreversible cell damage [bactericidal]

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 plaque matrix.

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- Bactericidal at high concentration

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 active form.

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.

Avoid intake of tea,coffee and alcohol during use.

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 during jaw immobilization- Improve plaque control

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.

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

during first 4 week of fixed therapy.

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

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.

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

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 salts on pellicle layer.

Contraindications

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

Other mouthwashes

Triclosan Delmopinol Listerine Povidone iodine Metallic ions Quaternary ammonium compounds Sanguinarine

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.

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

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.

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.

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.

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.

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.

Substantivity highest in:A.ChlorhexidineB.Triclosan C.SanguinarineD.Delmopinol

mcq

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

Which of the following is phenol derivative? 1. Chlorhexidine2. triclosan 3. Povidone-iodine4. listerine

mcq

Refrences

Clinical Periodontology & Implant Dentistry – Jan Lindhe

Essentials of Preventive and Community Dentistry – Soben Peter

Internet sources

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