Based on the association of bacterial plaque with the initiation of chronic gingivitis and progression of chronic periodontitis, chemical antiplaque agents have been employed both in prevention of periodontal disease and its treatment. In supragingival plaque control regimens, chlorhexidine has not been superceded as a chemical anti-plaque agent, although other compounds have been shown to be useful. The local side-effects of chlorhexidine and other cationic antiseptics, however, limit their long-term use for prevention. Extrinsic tooth staining in particular remains the greatest problem. Short-term anti-plaque uses for chlorhexidine include as an adjunct to mechanical cleaning in the initial oral hygiene phase of treatment, in situations where mechanical oral hygiene is difficult, including postsurgery, intermaxillary fixation, fixed orthodontic therapy, physically and mentally handicapped individuals, systemic diseases with oral manifestations such as leukaemia. More recent interest in chlorhexidine has resulted from the delivery of compounds subgingivally in the treatment of chronic periodontitis. Such methods have extended the use of chlorhexidine into areas inaccessible to the action of antimicrobial drugs delivered locally by conventional means, such as tooth brushing or mouth rinsing. Available evidence suggests that chlorhexidine may not be as effective as some antimicrobial drugs whose activity is more specific for those organisms considered particularly pathogenic to the periodontal tissues.

Chlorhexidine compared with other locally delivered antimicrobials. A short review.

In addition to its plaque-inhibiting effect, chlorhexidine possesses other properties beneficial for use in dentistry. These effects are outlined, and specific recommendations are given regarding chlorhexidine's use by general practitioners. The side effects of long-term use, such as staining, and the availability of chlorhexidine also are discussed.

A review of the literature on use of chlorhexidine in dentistry

Evidence suggests that brushing with a toothpaste may slow plaque reformation over 24 h. This study measured the effect of toothpaste alone on plaque regrowth over a 96 h period and compared the effect with water and the known antiplaque agent chlorhexidine. At 9 a.m. at the beginning of 7,4-day no oral hygiene periods, 10 volunteers were scaled and polished. Al 5 p.m. subjects brushed their own teeth with water until plaque free. Each subject rinsed for I min with 10 ml of a randomly allocated rinse. Rinsing was repeated at 10 a.m. and 10 p.m. on subsequent days. The rinses were water, chlorhexidine 0.2% or 3 g/10 ml slurries of toothpastes containing (1) monofluorophosphate(MFP), (2) monofluorophosphate + sodium fluoride (MFP+NaF) (3) monofluorophosphate + zinc citrate (MFP+ZCT) (4) stannous fluoride (SnF2) (5) sodium fluoride (NaF). At 16, 24, 48 and 72 h plaque on the buccal surface of the upper and lower premolars, canines and incisors was scored by the Gingival Margin Plaque Index (GMPI) and gram films of plaque samples made. At 96 h plaque was recorded diagraromatically and areas of coverage measured visually (Debris Index) and by planimetry. Progressive plaque formation to a Gingival Margin Plaque Index of 100% at 72 h was observed for toothpaste and water rinses. For chlorhexidine the Gingival Margin Plaque Index at 72 h was 6%, At 96 h plaque areas were significantly less with toothpaste rinses compared with water. Chlorhexidine very significantly reduced plaque areas compared with toothpaste and water. The bacteriological assessment of smears revealed essentially similar plaque development during toothpaste and water rinses and was consistent with previous reports. However, with chlorhexidine the densities of organisms in the smears were greatly reduced. It was concluded that the small effect of toothpaste rinses on plaque accumulation compared with chlorhexidine would not alone represent a true antiplaque effect resulting in therapeutic benefit.

Effect of toothpaste rinses compared with chlorhexidine on plaque formation during a 4-day period.

A 3-month clinical trial was conducted to compare the effects of two concentrations of a chlorhexidine mouthrinse on gingivitis and plaque accumulation. Six hundred (600) adults were divided into three treatment groups matched for age, sex, and initial gingivitis severity. Following a thorough examination and prophylaxis at baseline, subjects were given a mouthrinse containing either 0.12% or 0.20% chlorhexidine gluconate or a placebo mouthrinse. Subjects were evaluated after 6 weeks and 3 months of mouthrinse use. After 3 months, both chlorhexidine groups showed significantly less gingivitis and plaque than the placebo group. The group using the 0.12% chlorhexidine gluconate mouthrinse demonstrated 27–27 % less gingivitis occurrence and 28–28% less gingivitis severity than the placebo group. The 0.12% chlorhexidine gluconate group also had 48–48% less gingival bleeding and 36% less plaque than the placebo group. There were no significant advantages for the 0.20% mouthrinse over the 0.12% mouthrinse. It is therefore concluded that a 0.12% chlorhexidine gluconate mouthrinse offers the same clinical benefits as a 0.20% chlorhexidine gluconate mouthrinse.

A comparison of mouthrinses containing two concentrations of chlorhexidine

The aim of the present study was to evaluate the effect of two chlorhexidine rinsing solutions (0.12% and 0.2%) on plaque and gin- gival bleeding. Ten dental students participated in this double-blind, cross-over study, rinsing twice a day, for one minute, with each one of the tested solutions for fourteen days. A wash-out period of one week between treatments was observed. In order to assess gingival bleeding, the van der Weijden et al. 1 (1994) index was used. The plaque indexes used were those of Quigley, Hein 2 (1962) and Silness, Loe 3 (1964). In the pre-experimental period, subjects received oral hygiene instructions and dental prophylaxis. The results revealed no significant differences between both concentrations in relation to plaque and gingival bleeding. Mean values (± standard deviation) of the Quigley & Hein index were 0.25 ± 0.16 for the 0.12% solution and 0.23 ± 0.26 for the 0.2% solu- tion (p = 0.4838). Mean values (± standard deviation) of the Silness-Loe index were 0.12 ± 0.10 for the 0.12% solution and 0.11 ± 0.11 for the 0.2% solution (p = 0.7592). The bleeding index mean values at the end of the study were not different for both concentrations with mean values (± standard deviation) of 14.93% ± 6.68% and 13.95 ± 9.24% for the 0.12% and 0.2% solutions, respectively. Although an increase in gingival bleeding was observed, both concentrations were able to control dental plaque.

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Comparative analysis of the effect of two chlorhexidine mouthrinses on plaque accumulation and gingival bleeding

This study showed that 0.15, 0.10, and 0.05% chlorhexidine gluconate solutions used on the toothbrush subsequent to scaling were for at least 45 days able to maintain plaque and gingivitis scores lower than those obtained 14 days after scaling and oral hygiene instruction. Discolorations of teeth and fillings were the only side effects observed.

Lena M. Bay

Papers

Effect of Toothbrushing with Different Concentrations of Chlorhexidine on the Development of Dental Plaque and Gingivitis