Should Chlorhexidine Remain the “Gold Standard” In Today’s Modern Hygiene?

Chlorhexidine gluconate (CHX) is well known and frequently referred to as the “gold standard” in dentistry due to its antimicrobial and antiseptic properties utilized in conjunction with and following a wide variety of dental procedures.

After several decades of use, it would seem that CHX has stood the test of time and therefore should remain the gold standard. However, as ongoing research and advancements are made in dentistry, it is vital for dental providers to continually educate themselves on both traditional and alternative treatments in order to uphold and advance the standard of patient care. Ethical considerations including the risks and benefits associated with widespread use, despite the lack of supporting evidence for it, should be made when providing patient care. The purpose of this article is to highlight key points of the science related to the indicated use, risks, and benefits of CHX so you as a dental provider can advance and be confident in the standard of care and quality of the information provided to your own patients.

Indicated use

Research suggests that CHX is indicated as an effective, short-term, adjunctive treatment for gingivitis.¹ However, it is commonplace to see CHX used as a blanket recommendation despite its limited, indicated use as an adjunctive treatment for gingivitis.² Researchers concluded that daily application of CHX may be successful in preventing gingivitis, with the proviso that the agent is applied in a manner that allows it to reach all affected tissues.³

Another consideration to make when evaluating its overall effectiveness in the treatment of gingivitis is its limited recommended use time of only 2 to 4 weeks.¹ Additionally, there is a lack of evidence to support its effectiveness in managing or preventing acute necrotizing ulcerative gingivitis (ANUG), peri-implantitis, extraction-related infections, periodontal disease, and dental caries.¹ Furthermore, studies concluded that even as an adjunctive treatment, CHX mouthrinse was ineffective at decreasing moderate to severe periodontal disease.¹

Associated risks and side effects

Both dental professionals and patients are familiar with the more commonly known negative side effects associated with the use of CHX which include calculus formation, altered taste, staining, and xerostomia. Additionally, recent studies have been conducted regarding more serious side effects associated with CHX. An in vitro study evaluated the effects of CHX in various concentrations on gingival fibroblasts and found that the regenerative cells treated with the greatest concentration had the highest frequency of apoptosis (cell death).⁴,⁵

In addition to research highlighting the inhibitory effects of CHX on regenerative cells, research has suggested that CHX can be highly cytotoxic to cells. Another in vitro study demonstrated its cytotoxic nature when finding that CHX has the ability to significantly reduce the vitality of regenerative cells including fibroblasts, myoblasts, and osteoblasts.⁶

Relevance

Why is this relevant? Following dental procedures such as scaling and root planing or nonsurgical periodontal therapy, the aim is to promote healing rather than hinder it. Gingival fibroblasts are cells essential to wound healing. Hence, inhibition of these cells can delay the regeneration of tissues. Another study concluded that CHX affected cell survival, specifically in osteoblasts (bone-forming cells) through necrotic apoptosis and interference of mitochondrial function.⁷

Lastly, CHX has been shown to be inactivated in the presence of saliva, which may decrease the effectiveness of its use in the decontamination of the oral cavity.⁸ All of this data poses the question: Is it more harmful than beneficial to use CHX post-operatively? If so, shouldn’t a safer, more effective rinse hold the title of dentistry's “gold standard?” After all, it is 2024. While these findings are significant, it should be noted that further in vivo research is needed to comprehensively evaluate the inhibitory effect of CHX on human gingival fibroblasts.

Conclusion

The limited benefits that CHX offers should be considered alongside the negative side effects mentioned above prior to use with patients. Professional rinse alternatives to CHX, such as OraCare mouthrinse, which utilizes activated chlorine dioxide and xylitol, should also be considered when looking to provide patients with the most beneficial, adjunctive care.

Chlorine dioxide mouth rinses have been demonstrated to meet or exceed the antimicrobial properties of CHX.⁹ In a recent study, OraCare was evaluated for its effectiveness on gingival improvement, bleeding points, plaque accumulation and probing depths against brushing alone. Respectively, it showed a 604% in overall gingival improvement, 455% improvement in bleeding, 225% reduction in plaque, and an amazing 4,450% improvement in probing depths.

All in all, dental professionals should be well informed on both traditional and alternative rinses available while maintaining an investigative and progressive mindset. If we do this, then as dentistry evolves we can evolve with it. Because what seems to have been the “gold standard” for decades may not be the best choice to advance the standard of care in your practice.

References

1. Brookes ZLS, Bescos R, Belfield LA, Ali K, Roberts A. Current uses of chlorhexidine for management of oral disease: a narrative review. J Dent. 2020;103:103497. doi:10.1016/j.jdent.2020.103497
2. Sanz M, Herrera D, Kebschull M, et al. Treatment of stage I-III periodontitis-The EFP S3 level clinical practice guideline [published correction appears in J Clin Periodontol. 2021 Jan;48(1):163]. J Clin Periodontol. 2020;47 Suppl 22(Suppl 22):4-60. doi:10.1111/jcpe.13290
3. Löe H, Schiott CR. The effect of mouthrinses and topical application of chlorhexidine on the development of dental plaque and gingivitis in man. J Periodontal Res. 1970;5(2):79-83. doi:10.1111/j.1600-0765.1970.tb00696.x
4. Smith K, Copeland J, Nguyen S. (2020). Chlorhexidine: An Investigation of the Gold Standard on Wound Healing (Undergraduate Research Scholars Thesis). Caruth School of Dental Hygiene, Texas A&M University. doi:https://oaktrust.library.tamu.edu/bitstream/handle/1969.1/188419/SMITH-FINALTHESIS-2020.pdf
5. Wyganowska-Swiatkowska M, Kotwicka M, Urbaniak P, Nowak A, Skrzypczak-Jankun E, Jankun J. Clinical implications of the growth-suppressive effects of chlorhexidine at low and high concentrations on human gingival fibroblasts and changes in morphology. Int J Mol Med. 2016;37(6):1594-1600. doi:10.3892/ijmm.2016.2550
6. 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;3(4):165-172. Published 2018 Aug 10. doi:10.7150/jbji.26355
7. Giannelli M, Chellini F, Margheri M, Tonelli P, Tani A. Effect of chlorhexidine digluconate on different cell types: a molecular and ultrastructural investigation. Toxicol In Vitro. 2008;22(2):308-317. doi:10.1016/j.tiv.2007.09.012
8. Spijkervet, FKL, van Saene, JJM, van Saene, HKF, Panders, AK, Vermey, A & Fidler, V 1990, 'Chlorhexidine inactivation by saliva', Oral Surgery Oral Medicine Oral Pathology Oral Radiology and Endodontics, vol. 69, no. 4, pp. 444-449. https://doi.org/10.1016/0030-4220(90)90377-5
9. Downs RD, Banas JA, Zhu, M. An in vitro study comparing a two-part activated chlorine dioxide oral rinse to chlorhexidine. Perio-Implant Advisory. Published 2015 Jan 21. doi:https://www.perioimplantadvisory.com/clinical-tips/hygiene-techniques/article/16411500/an-in-vitro-study-comparing-a-twopart-activated-chlorine-dioxide-oral-rinse-to-chlorhexidine