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Chlorhexidine: The gold standard antiplaque agent


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Chlorhexidine is one of the most widely and commonly used antiplaque and antigingivitis agent. The properties and mechanism of action of chlorhexidine must be understood in order to be put into maximum use. Chlorhexidine was used as a broad spectrum antiseptic since the 1950's. Its antibacterial action is due to the disruption of the bacterial cell membrane by the chlorhexidine molecules, increasing the permeability and resulting in cell lysis. It can be either bacteriostatic or bactericidal depending on the dose. It is available in different formulations. However it does have some side effects like permanent staining of teeth and dysgeusia. This article discusses the various clinical applications, properties and adverse effects of chlorhexidine.
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Chlorhexidine: The Gold Standard Antiplaque Agent
Shruti Balagopal1, Radhika Arjunkumar2
1Student,Saveetha Dental College, Chennai
2Senior Lecturer,Department of Periodontics
Saveetha Dental College, Chennai
Chlorhexidine is one of the most widely and commonly used antiplaque and antigingivitis agent. The properties and mechanism of action of
chlorhexidine must be understood in order to be put into maximum use. Chlorhexidine was used as a broad spectrum antiseptic since the
1950’s. Its antibacterial action is due to the disruption of the bacterial cell membrane by the chlorhexidine molecules, increasing the
permeability and resulting in cell lysis. It can be either bacteriostatic or bactericidal depending on the dose. It is available in different
formulations. However it does have some side effects like permanent staining of teeth and dysgeusia. This article discusses the various
clinical applications, properties and adverse effects of chlorhexidine.
Chlorhexidine, mouthrinse, chemical plaque control
Chlorhexidine is a gold standard against which other
antiplaque and antigingivitis agents are measured.
Understanding the properties and limitations of the molecule
can ensure that the efficacy of the agent is maximized and the
side effects are minimized allowing it to rightly remain the
gold standard.
Dental plaque
Dental plaque clinically is a structured resilient, grayish-
yellow substance that tenaciously adheres to the intraoral
hard surfaces including removable and fixed restorations [1].
Plaque control
It is the removal of microbial plaque and the prevention of its
accumulation on the tooth and adjacent gingival tissues to
prevent calculus formation. Plaque control can be of two
Mechanical plaque control
Chemical plaque control
Mechanical plaque control
Dental plaque is one of the most important etiological factors
in the onset of periodontal disease. Dental plaque mineralizes
to form dental calculus. Calculus formation is significantly
reduced by proper plaque control. Bacterial plaque can be
removed effectively by mechanical means. It is safe and
effective. The various methods include:
Interdental cleaning aids
Dental floss
Interdental brush and swab
Chemical plaque control
Antimicrobial agents: Chemicals that have a bacteriostatic or
bacteriocidal effect in vitro that alone cannot be extrapolated
to a proven efficacy in vivo against plaque.
Plaque reducing/inhibitory agents: Chemicals that have only
been shown to reduce the quantity and/or affect quality of
plaque which may or may not be sufficient to influence
gingivitis and/or caries.
Antiplaque agents: Chemicals that have an effect on plaque
sufficient to benefit gingivitis and/or caries.
Antigingivitis agents: Chemicals which reduce gingival
inflammation without necessarily influencing bacterial plaque
(includes anti-inflammatory agents).
Chemical plaque control agents [2]
The various chemical plaque control agents are listed in
Table 1.
Commercial mouthwashes can be classified into based on
their substantivity, range of antibacterial activity against
various plaque bacteria, possible anti inflammatory effect,
acceptable taste, ability to promote fresh mouth sensation.
They can also be classified as group A,B and C as follows,
Group A agents- antiplaque
Chlorhexidine, acidified sodium chlorate, salifluor and
Group B agents-plaque inhibitory
cetyl pyridinium chloride,
essential oil and triclosan rinses
used as adjuncts to mechanical cleaning
Group C agents-Have a low to moderate activity and
are used for cosmetic purposes like breath freshening
Sanguinarine , oxygenating agents, saturated pyrimidine,
Shruti Balagopal et al /J. Pharm. Sci. & Res. Vol.5(12), 2013, 270 - 274
Table 1- Chemical plaque control agents
Bisbiguanide antiseptics
Bisbiguanide compounds are a group of chemical plaque
control agents and comprises of the following agents
From a therapeutic point of view, the most obvious benefit of
using mouth rinses is the potential to reduce plaque and
gingivitis and particularly in youngsters where mechanical
plaque control is not optimal in maintaining gingival health.
The ADA council for scientific affairs has proposed a
program for acceptance of plaque control agents. These
include that the patients be evaluated in placebo control trials
of 6 months or longer and demonstrate significantly improved
gingival health compared with controls [3].
To date the ADA has accepted 2 agents for treatment of
gingivitis which include prescription solution of
chlorhexidine digluconate oral rinse and non prescription
essential oil rinse.
Chlorhexidine was developed by Imperial Chemical
Industries in England during 1940’s.It was marketed as a
general antiseptic in the year 1950. In 1957 chlorhexidine
was introduced for human use in Britain as an antiseptic for
skin. Later it was widely used in medicine and surgery.
Plaque inhibition first investigated by Schroeder in 1969[4]. A
definitive study for caries inhibition by inhibition of dental
plaque was done by Loe and Schiott 1972[5].
Chlorhexidine is available in various forms such as
digluconate, acetate and hydrochloride salts which are
sparingly soluble in water.
Chlorhexidine is a symmetrical molecule.It has four
chlorophenyl rings and two biguanide groups connected by a
central hexamethylene bridge. (figure 1)
Figure 1- Structure of chlorhexidine
Chlorhexidine is an antimicrobial agent. It acts on the inner
cytoplasmic membrane hence it is a membrane active type of
substance. It is dicationic at pH levels above 3.5. It prevents
plaque accumulation, hence it is a antiplaque and
antigingivitis agent[6] and reduces the adherence of
Porphyromonas gingivalis to epithelial cells[7]. It can be
bacteriostatic or bactericidal depending on the dose. It acts
against a wide array of bacteria including Gram positive and
Gram negative bacteria, dermatophytes and lipolytic viruses.
It also acts against fungi, yeasts and some viruses including
Hepatitis B virus and Human Immunodeficiency Virus. It
acts against Streptococcus mutants making it anticariogenic
in nature. Studies have also shown that chlorhexidine has the
ability to neutralize pathogenic agents such as Streptococcus
aureus, Porphyromans gingivalis and Prevotella intermedia.[8]
Another most important unique property of chlorhexidine is
its substantivity. Substantivity refers to the oral retentiveness.
It depends upon various factors such as concentration, pH,
temperature and time of contact of the solution with oral
Mechanism of action of chlorhexidine:
The mechanism of action of chlorhexidine is outlined in
table 2.
Enzymes Protease, Lipase, Nuclease, Dextranase, Mutanase, Glucoseoxidase, Amyloglucosidase
Bisbiguanides Chlorhexidine, Alexidene, Octenidine
Quaternary Ammonium
Compounds Cetyl pyridinium chloride, Benzalconium Chloride
Phenolic compounds Thymol, 4-Hexylresorcinol, 2-Phenylphenol Eucalyptol, Listerene
Fluorides Sodium fluoride, Sodium monofluorophosphate Stannous fluoride, Amine fluoride
Metal ions Copper, Zinc, Tin
Oxygenating agents Peroxides
Other Antiseptics Iodine, Povidone iodine, Chloramine-T Sodium hypochlorite, Hexetidine, Triclosan
Salifluor, Delmopinol
Shruti Balagopal et al /J. Pharm. Sci. & Res. Vol.5(12), 2013, 270 - 274
Table 2- Mechanism of action of chlorhexidine
Chlorhexidine mouth rinses are available in the form of 0.2%
and 0.12%.There is equal efficacy for 0.2%and 0.12% rinses
when used at appropriate similar doses [10]. The time of
rinsing is 30 or 60 seconds depending on the adsorption rate
of antiseptics to the oral surfaces (50% of chlorhexidine binds
to receptors within 15 seconds) but this does vary from
individual to individual. The plaque inhibiting effect of a
0.2%chlorhexidine with rinsing times of 15, 30 and 60
seconds following a 72 hour non brushing period showed no
difference [11]. The ideal regimen is twice daily (morning and
night) which will have a substantivity for 12 hours.
The addition of fluoride to chlorhexidine is considered
questionable [12]. The concentration of 0.06% and sodium
fluoride 0.2% and 0.055% of stannous fluoride was
considered compatible with fluoride [13]. The chlorhexidine
monofluorophosphate complexes was considered
incompatible without fluorides [14].
The different available concentrations of chlorhexidine gel
are 1%, 0.2%, 0.12%. They are delivered in trays and
toothbrushes. Chlorhexidine gel, that is applied once a day
has therapeutic effects, like reducing oral malodour and
also reduces chlorhexidine staining [15].
0.12% of chlorhexidine with 1 parts per million of fluoride
has antiplaque effects similar to chlorhexidine mouthwash.
However there were difficulties in incorporating
chlorhexidine into gels and toothpastes.1% chlorhexidine
used as slurries and rinsed twice per day for one minute
causes significant reduction in the plaque and gingival scores
but also causes stains. Chlorhexidine in dentifrices gained
little attention due to its possible interaction with anionic
ingredients contained in toothpaste and competition for oral
retention sites [16].
0.1% and0.2% sprays have similar plaque inhibition
properties of 0.2% mouthwash. It is well received by
physically and mentally handicapped patients [17].
Chlorhexidine varnishes are used for prophylaxis against root
caries [18].
Sugar free chewing gum
Chlorhexidine remains unbound in this form. It contains
20mg of chlorhexidine diacetate. It is advised to chew 2
The bacterial cell wall is negatively charged and contains sulphates and phosphates
Dicationic positively charged chlorhexidine is attracted to the negatively charged bacterial cell wall with specific and strong
adsorption to phosphate containing compounds
Alters the integrity of the bacterial cell membrane and chlorhexidine is attracted to the inner cell membrane
Chlorhexidine binds to the phospholipids in the inner membrane and there is leakage of low molecular weight compounds
like potassium ions
By increasing the concentration of chlorhexidine there is progressive damage to the membrane
There is coagulation and precipitation of the cytoplasm by the formation of phosphate complexes which include adenosine
triphosphate and nucleic acids
Cytoplasm of the cells are chemically precipitated
Bactericidal stage which is irreversible
Shruti Balagopal et al /J. Pharm. Sci. & Res. Vol.5(12), 2013, 270 - 274
pieces twice per day for 10 minutes. This procedure is said to
cause less stains. It is a good method of using chlorhexidine
for a long period of time [19].
It is used as an adjunct to oral hygiene and professional
prophylaxis. It is used post oral surgery in periodontal
surgery or root planing. Studies have shown that the daily use
of mouthrinse combined with toothbrushing resulted in
reduced interproximal plaque when compared with
toothbrushing and daily flossing [20]. Chlorhexidine is of
importance in the maintainance protocol in immediate
function implants as there is a correlation between plaque and
bleeding index revealed a good result for 0.2% chlorhexidine
gel for daily implant self care at 6 months [21]. It is used in
patients with intermaxillary fixation and in patients who are
under high risk of caries. For those patients who are
physically and mentally handicapped chlorhexidine sprays
can be used [22]. It is used in medically compromised patients
who are predisposed to oral candidiasis. Chlorhexidine is
used to limit the bacteremia and operatory contamination by
oral bacteria and as an adjunct to antibiotic prophylaxis.
Other uses of chlorhexidine include sub gingival irrigation,
management of denture stomatitis, hypersensitivity and for
oral malodour. Full mouth disinfection has been introduced
with scaling and root planing and the application of
chlorhexidine into periodontal pockets with daily use of
chlorhexidine rinses at home for 2 months [23]. Chlorhexidine
formulations have well proven short to medium term
application as adjuncts and even replacements for mechanical
cleaning but it is still controversial [24]. Wound healing is
enhanced when chlorhexidine rinses are used before
extractions and after scaling and root planing or periodontal
surgery [25]. Chlorhexidine is shown to induce changes to
human gingival fibroblast collagen production and non
collagen protein production [26]. There is 65% reduction in
collagen production and a 75% reduction in non collagen
protein production.
Halita is the name of a mouth rinse containing 0.05% of
chlorhexidine, 0.05% cetyl pyridinium chloride and 0.14% of
zinc lactate. It is used in the management of halitosis [27, 28].
Zinc is added as it has the ability to convert volatile sulfur
compounds and it also acts synergistically with
chlorhexidine. Other clinical benefits include its use as a root
canal irrigant [29] and in atraumatic restorative treatment
where chlorhexidine containing glass ionomer cement [30].
Chlorhexidine is also used for surgical skin preparation for
the patient and the surgeon. Chlorhexidine is used as a local
drug delivery system in the form of a bio-degradable chip to
be used in the subgingival environment [31]. There is
controlled delivery of chlorhexidine to the periodontal
pocket. A slow sub-gingival release of 2.5mg of
chlorhexidine is found to have an average drug concentration
greater than 125 microgram per milliliter for 7 to 10 days.
The concentration of the drug remains above the minimum
inhibitory concentration for more than 99% of the
subgingival micro-organisms from the periodontal pockets.
The results of several clinical trials have shown that the use
of the chlorhexidine chip in conjunction with scaling and root
planing is effective in reducing periodontitis, clinical
attachment loss and bleeding on probing over a period of 6 to
9 months. The use of the controlled release of chlorhexidine
delivery system during maintenance therapy allows greater
improvement in clinical signs of periodontitis. In subgingival
exudates, the serum proteins may effectively compete with
the bacteria for the chlorhexidine, thus reducing the
availability of the drug. This might account for the occasional
lack of clinical effectiveness when the agent is administered
subgingivally [32].
Toxicology and side effects [33]
The side effects of chlorhexidine include brown
discolouration of the teeth, restorative materials and dorsum
of tongue. There is taste perturbation. There can be oral
mucosal erosion which is an idiosyncratic reaction and is
dose dependent. The bitter taste is difficult to mask.
Chlorhexidine staining
There is degradation of the chlorhexidine molecule to release
parachloroaniline. Non enzymatic browning reactions take
place called catalysis of Maillard. Protein denaturation and
metal sulfide formation occurs and there is precipitation of
anionic dietry chromogens [34].
Metabolism of chlorhexidine
The chlorhexidine that is swallowed undergoes minimal
metabolic changes. It has a half life of 4 days and it is
excreted in faeces.
Safety of chlorhexidine
Chlorhexidine is poorly absorbed in the gut and displays very
low toxicity. It does not cause any teratogenic alterations.
There is no evidence of formation of carcinogenic substances.
After the use of chlorhexidine mouthwash the intake of tea,
coffee and red wine must be avoided. The usage is restricted
in cases of anterior composite restorations and glass ionomer
restorations. There should be a 30 minute lapse between the
usage of a dentifrice and chlorhexidine mouth wash [35]. It is
so advised because the toothpastes contain detergents which
are predominantly anionic agents. Chlorhexidine molecule
being dicationic tends to bind with the anionic agents leading
to a reduction in the substantivity of chlorhexidine
Comparative studies
Increasing the rinsing frequency of cetyl pyridinium chloride
to four times a day has been suggested to produce efficacy
equivalent to that of chlorhexidine [8]. Listerine has a
moderate plaque inhibitory effect poor oral retention and
some antigingivitis effects [36]. Substantivity of hexitidine
is one to three hours and has some plaque inhibitory effects
[37]. The effect of three commercial mouth rinses on cultured
human gingival fibroblast, an in vitro study revealed that
chlorhexidine, listerine and povidone iodine are capable of
inducing a dose dependant reduction in cellular proliferation
of fibroblasts [38].
Shruti Balagopal et al /J. Pharm. Sci. & Res. Vol.5(12), 2013, 270 - 274
Chronic periodontitis is always preceded by chronic
gingivitis; chemicals that inhibit plaque may be expected to
be of value in both the prevention and management of
periodontal disease in some individuals. Thus, the use of a
chemical plaque-inhibitory mouthwash as an adjunct to tooth
brushing may have a major effect on improving the oral
health of the individual. Chlorhexidine is one chemical
plaque control agent which has various clinical applications
in dentistry especially in Periodontics . Chlorhexidine in its
various formulations has come to stay and it is appropriate to
call it the gold standard chemical plaque control agent.
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... Perawatan mekanis periodontitis dilakukan dengan melakukan scaling and root planning, sedangkan perawatan kimiawi dapat dilakukan dengan antibiotic maupun obat kumur (Newman et al, 2019). Clorhexidine gluconate 0,2% merupakan gold standar untuk obat kumur yang digunakan dalam perawatan periodontitis sebagai antiplak dan antigingivitis (Balagopal dan Arjunkumar, 2013). Penggunaan clorhexine gluconate digunakan untuk mengontrol pertumbuhan bakteri plak gigi namun pada penggunaan jangka panjang dapat menyebbakan beberapa efek samping seperti staning pada gigi, terganggunya indera perasa, mulut kering, dan reaksi alergi. ...
... Pada penelitian ini, diameter zona hambat kontrol positif chlorhexidine gluconate 0,2% sebesar 23,67 mm sedangkan control negative DMSO 1% sebesar 0,00 mm, masingmasing menjadi diameter terbesar dan terkecil diantara kelompok uji. Chlorhexidine gluconate merupakan agen antimikrobia terbaik dalam perawatan gingivitis dan periodontitis (Balagopal dan Arjunkumar, 2013). Chlorhexidine gluconate memiliki kemampuan untuk berikatan erat dengan dinding sel bakteri Gram negative, merubah integritas membrane sel bakteri, dan berikatan dengan fosfolipid membrane sel bakteri sehingga menyebabkan terjadinya presipitasi sitoplasma bakteri yang akhirnya menyebabkan bakteri mati (Balagopal dan Arjunkumar, 2013). ...
... Chlorhexidine gluconate merupakan agen antimikrobia terbaik dalam perawatan gingivitis dan periodontitis (Balagopal dan Arjunkumar, 2013). Chlorhexidine gluconate memiliki kemampuan untuk berikatan erat dengan dinding sel bakteri Gram negative, merubah integritas membrane sel bakteri, dan berikatan dengan fosfolipid membrane sel bakteri sehingga menyebabkan terjadinya presipitasi sitoplasma bakteri yang akhirnya menyebabkan bakteri mati (Balagopal dan Arjunkumar, 2013). DMSO 1% digunakan sebagai control negative karena tidak memiliki kemampuan dalam menghambat pertumbuhan bakteri. ...
Periodontitis is the most common dental and oral disease found in society and can cause tooth loss. One of the bacteria that causes periodontitis is Aggregatibacter actinomycetemcomitans. Periodontitis treatment is carried out by mechanical therapy (scaling and root planning) accompanied by chemical therapy (antibiotics and mouthwash). Prolonged use of chemical therapy can cause resistance, impaired taste and discolored teeth. As an alternative, herbal ingredients that have antibacterial properties can be used. Begonia multangula Blume stalks are used in several areas as a medicinal plant and have antibacterial activity. The purpose of this study was to determine the antibacterial activity of Begonia multangula Blume stalk extract on the growth of A. actinomycetemcomitans in vitro. The study was conducted in an experimental laboratory with A. actinomycetemcomitans ATCC 43718 as a sample. Begonia multangula Blume stalks were extracted using the maceration method and 5 concentration series were made (3.12%, 6.25%, 12.5%, 25% and 50%). The antibacterial test was carried out by the paper disc diffusion method with a positive control of 2% Chlorhexidine gluconate and a negative control of 1% DMSO. The diameter of the inhibition zone was then statistically analyzed. The results showed that the antibacterial activity of Begonia multangula Blume stem extract increased with increasing concentration with the highest activity at 50% concentration with an inhibition zone of 20.33 mm (p<0.05). The conclusion of this research is that the ethanol extract of Begonia multangula Blume stalk has antibacterial activity against A. actinomycetemcomitans.
... Chlorhexidine gel can be used as an adjunct for scaling and root planing and is more effective than scaling and root planing alone in the treatment of periodontitis [16]. The use of chlorhexidine has long-term side effects, such as extrinsic tooth staining and calculus formation [17,18]. Previous systematic reviews have demonstrated significant beneficial effects on scaling and root planing treatments with additional local antimicrobials, such as chlorhexidine chips and gels, monocycline microspheres, metronidazole gel, and tetracycline fibers compared to scaling and root planing alone in patients with periodontitis [13,19,20]. ...
... 10,13, [8] Administration of local antimicrobials after SRP has been shown to be safe and effective and is considered the best approach to treatment of periodontitis [21]. Chlorhexidine is the gold standard for anti-plaque and anti-gingivitis agents [17]. Chlorhexidine as a local antimicrobial for periodontitis treatment consists of 2 forms, namely gel and chip [21]. ...
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Periodontal pockets are characteristic of periodontitis. Scaling and root planing is the gold standard for periodontitis treatment. Additional local antimicrobials are recommended in patients with a probing depth of ≥ 5 mm. This study aims to determine the effectiveness of chlorhexidine compared to other local antimicrobials in periodontitis. Searches were conducted using the Preferred Reporting Items for Systematic Reviews and Meta Analysis (PRISMA) guidelines. Meta-analysis was performed on studies that met inclusion criteria after risk of bias assessment. Meta-analysis between chlorhexidine chips and other antimicrobials showed a mean difference in probing depth after one month of 0.58 mm (p < 0.00001) whereas after three months the mean difference in probing depth was 0.50 mm (p = 0.001), index plaque 0.01 (p = 0.94) and gingival index − 0.11 mm (p = 0.02). Between chlorhexidine gel and other antimicrobials showed a mean difference in probing depth of 0.40 mm (p = 0.30), plaque index of 0.20 mm (p = 0.0008) and gingival index of -0.04 mm (p = 0.83) after one month. Chlorhexidine chips were more effective on the gingival index than other antimicrobials after three months. The other antimicrobials were more effective than chlorhexidine chips on probing depth after one and three months, and than chlorhexidine gels on plaque index after one month.
... To augment antifungals, antimicrobial mouthwashes are frequently used to control oral candidiasis, such as chlorhexidine (CHX). This antimicrobial agent acts against bacteria [25], fungi, and hyphae [25][26][27]. For C. albicans oral isolates in the planktonic state, CHX is able to act as a fungicidal agent [28], causing damage to microbial cell membranes/walls [29]. ...
... However, when tested on biofilms, CHX has a limited effect due to the difficulty of reaching the deeper layers [30]. Staining of oral tissues and rehabilitative materials, taste disturbances [27], as well as reports of anaphylaxis [31] are among the main disadvantages of CHX. This antimicrobial at 0.2 and 2% is also highly cytotoxic to human gingival fibroblasts [32] and human endothelial cells [33]. ...
... Effective disinfection of dental impressions is an indispensable requirement for the safety of dental personnel and patients 2 . Chlorhexidine, which is a chemical disinfectant considered as the gold standard 3 . It has several adverse effects that are often unpleasant for the patients, such as creation of dental pigments, taste changes, mucosal irritation, dryness and injuries, squamous changes of the gums, allergies and even the occurrence of anaphylactic shock, acute respiratory distress syndrome, adverse effects on the fetus, cytotoxic effects and negative systemic effects if ingested, precipitating the gingiva to form a supragingival mass due to changes in acidity of the mouth and also increased accumulation of bacteria after its treatment [4][5][6] . ...
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Background: Dentists, dental equipments and dental laboratories are exposed to different types of pathogenic microorganisms. Chlorhexidine, which is a chemical disinfectant considered as the gold standard, whereas Aloevera in the form of herbal remedy have shown promising anti-microbial property. Aim: The purpose of the present study was to compare anti-bacterial effectiveness of the chlorhexidine and herbal aloevera gel on alginate impression made from diabetic dentulous patients. Materials and methods: In this study 30 samples of alginate impression were collected from diabetic dentulous patients. Each sample was divided in to 3 parts: one treated with 2 % Chlorhexidine, second treated with aloevera gel extract and third part is remain untreated. Result: The data obtained from the above study demonstrates that the efficacy of aloevera is comparable to chlorhexidine (a gold standard) as a disinfectant for microbial growth on alginate impression. Conclusion: Efficacy of aloevera, the herbal disinfectant is comparable to chlorhexidine, the chemical disinfectant on alginate impression made from diabetic dentulous patients.
... This difference can be explained by the unique characteristics and diatonic nature of CHX, which enables its rapid, strong, and long-term bonding to surface proteins in Gram-negative bacteria, which maintains its antimicrobial and bacterial agglutinating effects for at least 12 hours in fluid environments like the oral cavity. 48 On the other hand, differences in the effective concentration for both Qi extract and CHX, applied in this study, can explain such a significant discrepancy in their results. It is not unlikely that some changes in the water/ethanol proportion or applying other solvents like methanol or acetone would result in lower values of MIC and MBC for the Qi extract. ...
Background: Aggregatibacter actinomycetemcomitans (Aa) plays a vital role in some destructive forms of periodontitis. While mechanical and chemical plaque control is the first step in periodontitis treatment, side effects of adjunctive chemical agents such as chlorhexidine (CHX) mouthwash have led to the application of natural alternatives with minimal side effects. Therefore, this study evaluated the antibacterial effect of the hydroalcoholic extract of Quercus infectoria (Qi) galls on Aa in vitro. Methods: The hydroalcoholic extract of Qi was obtained by the maceration method, and Aa bacterial strain was cultured. The inhibition zone diameter was measured through the agar well diffusion method. Also, the minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) values were determined by the broth microdilution method. All the experiments were repeated three times. 0.2% CHX was used as a control. Results: The inhibition zone diameter of Aa increased with increasing concentration of Qi extract. While MIC and MBC values for CHX were 0.0039 and 0.0078 mg/mL, respectively, both MIC and MBC values of the Qi extract for this bacterium were similar, i.e., 2.5 mg/mL, which was significantly higherd. Conclusion: Since other in vivo studies have confirmed the other properties of this extract and its safety in terms of cytotoxicity and mutagenicity, hydroalcoholic extract of Qi may be used in mouthwashes or local delivery systems to affect periodontal biofilm.
... CHX is a popular antimicrobial agent in dentistry that effectively eliminates microbes. It is the gold standard for the destruction of microbial biofilms [22]. However, it has some disadvantages, including taste impairment and discoloration of teeth and mucous membranes [23]. ...
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Objectives: The aim of the present study was to determine the effects of antimicrobial photodynamic therapy (aPDT) using the blue diode laser (BDL) with different output powers and the photosensitizers riboflavin and curcumin on reducing the number of Streptococcus mutans around orthodontic brackets. Materials and methods: A total of 36 orthodontic brackets were contaminated with S. mutans and randomly assigned to 12 groups as follows: control, riboflavin alone, riboflavin + BDL with an output power of 200, 300, 400, or 500 mW, and curcumin alone, curcumin + BDL with an output power of 200, 300, 400, or 500 mW, and 0.2% chlorhexidine (CHX-positive control). Orthodontic brackets were irradiated with a BDL (wavelength 445 nm) at a power density of 0.4-1.0 W/cm2 for 30 s. All orthodontic brackets were examined under a stereomicroscope at 10× magnification. Mean colony-forming units (CFUs)/mL were measured before and after treatment. A one-way analysis of variance with Tukey's post hoc test was performed to compare CFU/mL between groups. Results: CHX and curcumin plus BDL with an output power of 500 mW had the highest reduction in S. mutans colony numbers (p < 0.001). The curcumin groups were more effective than the riboflavin groups. Riboflavin alone and riboflavin + BDL with an output power of 200 mW showed no significant difference from the control group (p = 0.99 and 0.74, respectively). Conclusion: Our results suggest that aPDT using curcumin as a photosensitizer plus BDL with an output power of 500 mW and a power density of 1.0 W/cm2 at a wavelength of 445 nm can effectively reduce colonies of S. mutans around stainless steel brackets.
... Natural essential oils have garnered attention as potential substitutes for chlorhexidine in dentistry due to their biocompatibility and pharmacological benefits [4]. Mouthwash containing chlorhexidine has been reported to possess a strong antibacterial effect and is considered the gold standard of antiplaque agents [5]. However, the continuous use of chlorhexidine has been associated with side effects, such as tooth staining and drug resistance [6,7]. ...
Objectives: We aimed to solubilize Curcuma xanthorrhiza oil (CXO) using nanoemulsification and evaluate its inhibitory effects against biofilm formation. Methods: The components of CXO were evaluated through high-performance liquid chromatography (HPLC) analysis. Healthy human saliva was inoculated onto hydroxyapatite discs to form microcosm biofilms for four days and treated six times with each antimicrobial agent: distilled water (DW), CXO emulsion (EM), CXO nanoemulsion (NE), and positive controls (Listerine, chlorhexidine). Biofilm fluorescence imaging was performed using quantitative light-induced fluorescence, and cell viability and dry-weight measurements were obtained. We compared the bacterial cell and extracellular polysaccharide (EPS) biovolume and thickness using confocal laser scanning microscopy (CLSM). Results: HPLC analysis revealed that CXO was composed of approximately 47% xanthorrhizol. Compared with DW, NE exhibited significantly lower red fluorescence intensity and area (42% and 37%, p < 0.001 and p < 0.001, respectively), and reduced total and aciduric bacterial cell viability (7.3% and 3.9%, p < 0.001, p = 0.01, respectively). Furthermore, the bacterial cell and EPS biovolume and thickness in NE decreased by 40-80% compared to DW, similar to chlorhexidine. Conversely, EM showed a significant difference only in cell viability against total bacteria when compared with DW (p = 0.003), with EPS biovolume and thickness exhibiting higher values than DW. Conclusions: Nanoemulsification successfully solubilized CXO and demonstrated superior anti-biofilm effects compared to the emulsion form. Clinical significance: These findings suggest the potential use of NE as a novel antimicrobial agent for preventing oral diseases.
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Context Dental caries is prevalent in spite of widespread use of mechanical and chemical plaque control methods. Streptococcus mutans is said to have a strong background in initiation of dental caries. Hence, exceptional methods are required which would be effective against dental caries. Current era is taking people back to traditional or herbal medicine, which is said to have comparatively better healing effects than synthetic drugs in the market. Aim Determine and analyse the minimum zone of inhibition of Curcuma amada against Streptococcus mutans. Settings and Design An In vitro Study. Methods, Statistical Analysis Used The well diffusion method using blood agar plates was used to evaluate the antibacterial activity of 5%, 10% and 25% concentration of C. Amada extract against Streptococcus mutans in comparison with 0.2% chlorhexidine. Results were statistically analysed using independent sample t-test or Mann–Whitney U test to compare mean or median zone of inhibition between two groups. Thus, the zone of inhibition (in mm) was analysed using the mean of all the readings obtained and the level of significance at <0.05 was considered statistically significant at 5% of level of significance. Results Maximum zone of inhibition was found to be with C. amada compared to corresponding concentration of 0.2% chlorhexidine. Thus, inhibitory effect of C. amada is significantly better than 5%, 10% and 25% chlorhexidine mouthwash. The inhibitory effect increases as the concentration increases. Conclusions The antibacterial activity of C. amada against Streptococcus mutans raises the possibility of incorporating it in various dental therapeutic agents.
Introduction This study evaluated a herbal mouthwash containing lemon verbena versus chlorhexidine as a gold standard for treating plaque-induced gingivitis. Materials and methods Sixty individuals diagnosed with generalised gingivitis were recruited from Mashhad Dental School referral patients. Plaque index, gingival index (GI), and bleeding on probing (BOP) were measured at baseline (T0). Patients were randomly divided into three groups of 20 and given a mouthwash containing either lemon verbena 1%, chlorhexidine 0.2%, or a placebo following scaling and patient health education. Patients were instructed to use the mouthwash twice daily for 30 seconds for 2 weeks. The measured indices were assessed at three time points (baseline, 2 weeks, and 1 month), and changes across groups over time were analysed using one-way ANOVA and Kruskal-Wallis tests. Results At T1 and T2, GI and BOP were significantly lower in the experimental groups than in the placebo group (P0.001). At T1, GI in the lemon verbena group was not significantly different from the chlorhexidine group; this correlation was reported to be significant at T2 and was lowered further in the chlorhexidine group. At T1 and T2, BOP in the lemon verbena group did not differ significantly from the chlorhexidine group. There was no statistically significant difference in the plaque index between any groups at T1 (P = 0.149) and T2 (P = 0.060). Conclusions Lemon verbena mouthwash, comparable to chlorhexidine, seems to be effective in treating gingivitis with no adverse side effects, making it a viable alternative to chlorhexidine mouthwash.
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OP4: The pivotal role of Pejvakin (DFNB59) protein in hearing loss in humans Santhosh Kumar Rajamani* Department of Otorhinolaryngology, MAEER MIT Pune’s MIMER Medical College, and Dr. BSTR Hospital, Talegaon D, 410507, Pune, Maharashtra, INDIA Keywords: cochlear nerve, inner ear, DFNB59, pejvakin, deafness, hair cells, apoptosis Objective The protein pejvakin, also known as DFNB59, is largely expressed in the inner ear, and other organs like testis (highest concentration), liver, brain, lungs, eyes, kidneys, and intestinal tissues. and is essential for hearing [1]. Pejvakin belongs to the gasdermin family of proteins that mediate pyroapoptosis in vertebrates. Gasdermin family comprises conserved affecter N-terminal domain that causes oligomerization, to form channels or pores in plasma membrane [2]. The functional proteins of Gasdermin family have immunoregulatory, cellular growth, and host immune defence [3]. Gasdermin family of protein seem homologous with respect to pore forming N terminal affecter end, this applies to pejvakin protein also [4]. There are many unanswered questions in the pathway, interaction, cellular mechanism of this protein [5]. Methods This presentation evaluates the role of pejvakin (DFNB59) protein in the development of post-lingual deafness in the light of extant evidence and uses this protein as a case-study protein in molecular mechanisms that lead to deafness in human beings. Results My presentation explicates the behavior of ciliary rootlet protein pejvakin (DFNB59) with homology to gasdermin family in the light of available genetic, molecular, biochemical, and computational evidence. REFERENCES [1] Berardino F. and Bruno G. (2021). Is auditory neuropathy an appropriate term? A systematic literature review on its aetiology and pathogenesis, Acta Otorhinolaryngologica Italica, 41, 6, 496–506. [2] Domínguez-Ruiz M. et al. (2022). Novel Pathogenic Variants in PJVK, the Gene Encoding Pejvakin, in Subjects with Autosomal Recessive Non-Syndromic Hearing Impairment and Auditory Neuropathy Spectrum Disorder, Genes, 13, 1. [3] Harris S.L. et al. (2017). Conditional deletion of pejvakin in adult outer hair cells causes progressive hearing loss in mice, Neuroscience, 344, 380–393. [4] Hashemzadeh Chaleshtori M. et al. (2007). Novel mutations in the pejvakin gene are associated with autosomal recessive nonsyndromic hearing loss in Iranian families, Clinical Genetics, 72, 3, 261–263. [5] Kazmierczak M. et al. (2017). Pejvakin, a Candidate Stereociliary Rootlet Protein, Regulates Hair Cell Function in a Cell-Autonomous Manner, The Journal of Neuroscience, 37, 13, 3447–3464.
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Aim: To examine the effect of three commercial mouth rinses (Hexidine 0.2%, Listerine Cool Mint, Betadine 1%) upon cultured human gingival fibroblast proliferation. Materials and Methods: Human gingival fibroblasts were cultured and incubated in Dulbecco′s Minimum Eagle′s Medium containing Chlorhexidine, Listerine, Povidone-Iodine at varying concentrations (1%, 2%, 5%, 10%, 20% and 100% of the given solution) at 37°C for 1, 5 and 15 min. Control cells received an equal volume of Dulbecco′s Minimum Eagle′s Medium without adding mouth rinses, for similar duration of exposure at 37°C. Following incubation the media were removed, cells were washed twice with medium, supplemented with 10% Fetal Bovine Serum, and fibroblasts in the test and control group were allowed to recover in the same media for 24 h. Results: In all the three groups, the proliferation inhibition was dependent on the concentration of solublized mouth rinses in the cell culture but independent of the duration of exposure to all three mouth rinses. The results showed that all three solutions were toxic to cultured human gingival fibroblasts, Chlorhexidine being the most cytotoxic. It was seen that at dilute concentrations (1% and 2% of given solutions) Listerine was more cytotoxic than Chlorhexidine and Povidone-Iodine. Conclusion: These results suggest that Chlorhexidine, Listerine and Povidone-Iodine are capable of inducing a dose-dependent reduction in cellular proliferation of fibroblasts. The results presented are interesting, but to know the clinical significance, further studies are needed.
Background. In this article, the authors present evidence-based clinical recommendations regarding the use of nonfluoride caries-preventive agents. The recommendations were developed by an expert panel convened by the American Dental Association (ADA) Council on Scientific Affairs. The panel addressed several questions regarding the efficacy of nonfluoride agents in reducing the incidence of caries and arresting or reversing the progression of caries. Types of Studies Reviewed. A panel of experts convened by the ADA Council on Scientific Affairs, in collaboration with ADA Division of Science staff, conducted a MEDLINE search to identify all randomized and nonrandomized clinical studies regarding the use of nonfluoride caries-preventive agents. Results. The panel reviewed evidence from 50 randomized controlled trials and 15 nonrandomized studies to assess the efficacy of various nonfluoride caries-preventive agents. Clinical Implications. The panel concluded that certain nonfluoride agents may provide some benefit as adjunctive therapies in children and adults at higher risk of developing caries. These recommendations are presented as a resource for dentists to consider in the clinical decision-making process. As part of the evidence-based approach to care, these clinical recommendations should be integrated with the practitioner's professional judgment and the patient's needs and preferences. (The full report can be accessed at "".)
The effects on dental plaque, caries, molar surface dissolution rate and fluoride content of daily topical applications of 0.016 M solutions of chlorhexidine acetate (ChlAc), chlorhexidine hydrofluoride (ChlHF), chlorhexidine hydrochloride (ChlHCl) and of sodium fluoride (NaF) were tested in factorial arrangement in a short term rat caries test performed on 6 groups of 12 Osborne Mendel rats fed the high sucrose diet 2000a during a 20 day experimental period. Plaque formation was strongly inhibited by the readily soluble chlorhexidine compounds but not by NaF. Fluoride did not affect the plaque inhibiting properties of chlorhexidine. Smooth surface caries was strongly depressed by ChlAc, ChlHF and NaF but not by ChlHCl. Fissure caries was inhibited by both NaF and ChlAc and their effects were additive. While ChlHCl was ineffective, ChlHF was highly cariostatic. Molar surface dissolution rate and fluoride uptake were significantly influenced by chlorhexidine.
abstract – The purpose of this study was to test the hypothesis that a frequent intake of sucrose does not produce caries if the teeth are regularly treated with an antibacterial agent. Twenty-four students with clean teeth and normal gingivae were assigned to one of the following three groups: (1) eight individuals ceased all active oral hygiene measures and rinsed 9 times daily with 50% sucrose, (2) eight students refrained from all active oral hygiene procedures, rinsed 9 times daily with sucrose and twice daily with 10 ml 0.2% chlorhexidine gluconate, (3) the third group consisted of two subgroups each comprising 4 students. One subgroup ceased all oral hygiene procedures and rinsed twice daily with 0.2% chlorhexidine gluconate. The other was instructed to practice meticulous tooth brushing twice daily. The experiment lasted for 22 days. The group who rinsed with sucrose showed heavy plaque accumulation, those who rinsed with sucrose + chlorhexidine showed a drastic reduction in the formation of plaque. In the subgroup rinsing with chlorhexidine only and in that performing good oral hygiene, plaque was non-existent. The gingival state essentially paralleled the plaque formation. The sucrose group showed a definite increase in Caries Index. No significant changes occurred in the group rinsing with sucrose + chlorhexidine, with chlorhexidine only, or in the group performing good oral hygiene. It is concluded that prevention of plaque formation inhibits the development of gingivitis and dental caries, even with frequent rinses of sucrose.
To clinically evaluate the perioperative use of 0.2% chlorhexidine gluconate for the prevention of alveolar osteitis, to assess the patient compliance to chlorhexidine and to prepare a comprehensive treatment plan to prevent alveolar osteitis after removal of an impacted third molar extraction. A prospective study was done on 50 patients with bilaterally impacted lower third molars which were indicated for extraction. Extraction of impacted mandibular third molar on one side was done without using any mouthrinse. While extracting the third molar on the other side, patients were instructed to use chlorhexidine 0.2% mouth rinse for 8 days, 1 day preceding and 7 days following the surgery. They were instructed to use chlorhexidine 0.2% (Rexidine) mouth rinse for 30 s twice a day (before breakfast and after dinner) with 15 ml of the rinse with 1:1 dilution with clean water. All the patients were evaluated for pain, presence or absence of clot and condition of the alveolar bone for the diagnosis of dry socket. Incidence of dry sockets was 8%, when patients did not use 0.2% chlorhexidine gluconate perioperatively which is statistically significant. It appeared that the incidence of dry socket can be reduced significantly by using 0.2% chlorhexidne gluconate mouth rinse perioperatively (twice daily, 1 day before and 7 days after surgical extraction.
In this article, the authors present evidence-based clinical recommendations regarding the use of nonfluoride caries preventive agents. The recommendations were developed by an expert panel convened by the American Dental Association (ADA)Council on Scientific Affairs. The panel addressed several questions regarding the efficacy of nonfluoride agents in reducing the incidence of caries and arresting or reversing the progression of caries. A panel of experts convened by the ADA Council on Scientific Affairs, in collaboration with ADA Division of Science staff, conducted a MEDLINE search to identify all randomized and nonrandomized clinical studies regarding the use of non fluoride caries-preventive agents. The panel reviewed evidence from 50 randomized controlled trials and 15 nonrandomized studies to assess the efficacy of various nonfluoride caries-preventive agents. The panel concluded that certain nonfluoride agents may provide some benefit as adjunctive therapies in children and adults at higher risk of developing caries. These recommendations are presented as a resource for dentists to consider in the clinical decision-making process. As part of the evidence based approach to care, these clinical recommendations should be integrated with the practitioner’s professional judgment and the patient’s needs and preferences.
The oral retention of chlorhexidine, cetylpyridinium chloride and hexadecyltrimethylammonium bromide (a component of cetrimide) was measured by means of 14C-labelled compounds in 7 subjects after 10-ml 2.2 mM mouth rinses for 1 min. The oral retention of chlorhexidine was 32 ± 6 per cent, of cetylpyridinium chloride 65 ± 5 per cent and of hexadecyltrimethylammonium bromide 70 ± 7 per cent of the administered dose. The salivary concentration was measured after similar mouth rinses in 3 subjects and calculated according to the 14C-activity of saliva samples from 0.5 to 24 h after the rinsing. Although the concentrations of the quaternary ammonium compounds were usually higher than those of chlorhexidine shortly after rinsing, their concentrations were significantly lower (p < 0.001) than those of chlorhexidine from 4 h and onwards. The plaque-inhibiting effect was assessed in subjects who rinsed with 2.2 mM test solutions twice daily for 3 days, using sucrose rinses to provoke plaque formation. The plaque-inhibiting effect of the quaternary ammonium compounds was also tested when used in a mouth rinse four times daily. A moderate degree of plaque inhibition was obtained when the quaternary ammonium compounds were used twice daily. When the frequency was increased to four times daily, the plaque-inhibiting effect of the quaternary ammonium compounds seemed to approach that of chlorhexidine.
The extent and severity of periodontal attachment loss are described for a random sample of 690 dentate community-dwelling adults, aged 65 or over, residing in five counties in North Carolina. In addition, risk indicators for serious levels of loss of attachment and pocket depth in this population are presented. Pocket depths and recession were measured on all teeth by trained examines during household visits. Blacks had an average of 78% of their sites with attachment loss and the average level of loss in those sites was approximately 4 mm, as compared to 65% and 3.1 min for whites. Because the extent and severity scores in this population were much higher than in younger groups, a serious condition in this group was defined as having 4+ sites of loss of attachment of 5+ mm with one or more of those sites having a pocket of 4+ mm. Bivariate analyses identified a large number of explanatory variables that were associated with increased likelihood of having the more serious periodontal condition. The logistic regression model for blacks includes the following important explanatory variables and associated odds ratios: use to tobacco (2.9), colony counts of B. gingivalis greater than 2% (2.4) and B. intermedius greater than 2% (1.9), last visit to the dentist greater than 3 years (2.3), and gums bleeding in the last 2 weeks (3.9). The model for whites indicated that tobacco use (6.2), presence of B. gingivalis (2.4) and the combined variable of having not been to the dentist in the last 3 years and having a high BANA score (16.8) were important explanatory variables.(ABSTRACT TRUNCATED AT 250 WORDS)