CHLORHEXIDINE

Presented by
Dr. Sayak Gupta
INTRODUCTION
•The elimination of microorganisms from infected root canal
systems is a complicated task involving the use of various
instrumentation techniques, irrigation regimens and intracanal
medicaments.

•Mechanical instrumentation alone does not result in a bacteria-free

root canal system and when the complex anatomy of the root canal
system (Hess 1925) is considered.

•Clinical evidence has shown that mechanical instrumentation leaves

significant portions of the root canal walls untouched (Peters et al.
2001) and complete elimination of bacteria by instrumentation alone
is unlikely to occur.
•It is assumed, but not demonstrated, that any pulp tissue left in the
root canals can serve as a nutrient source for any remaining
microorganisms.

•Tissue remnants also impede the antimicrobial effects of root canal

irrigants and medicaments. Therefore, some form of irrigation and
disinfection is necessary to remove residual tissue and to kill
microorganisms.

•Chemical treatment of the root canal can be arbitrarily divided into

irrigants, canal rinses and inter-appointment medicaments.
•One of the most commonly preferred antiseptic in recent days in
dental field is Chlorhexidine.

•It possess antimicrobial action which reduces plaque, gingival

inflammation and bleeding.

•It is generally known for its bio-compatibility and substantivity ,

which is available as mouthwash, gel, aerosol, sprays and disks.

•Chlorhexidine is considered to be safe compound with minimal

and transitory local and systemic effects.
•Chlorhexidine is a chemical auxillary substance which is used for
successful disinfection and to clean the root canal during endodontic
treatment procedure.

• Chlorhexidine has been used in endodontics as an irrigating

substance or
an intracanal medicament due to its bio-compatiblity, substantivity,
lubricating property and rheological actions.

•Studies suggest that 0.12% chlorhexidine used in mouthwash are

able to reduce the signs of gingival inflammation, and that’s why it
is still considered to be the gold standard antiplaque and
antigingivitis agent and also a bisbiguanide antiseptic which
controls chemical plaque.
•CHX can be applied clinically as antimicrobial agent during all
phases of the root canal preparation, including

• the disinfection of the operatory field;

• during the enlargement of the canals orifices;

• Removal of necrotic tissues before performing the root canal

length determination;

• in the chemomechanical preparation prior to the foraminal

patency and enlargement;
• as an intracanal medicament alone or combined with
other substances (i.e. calcium hydroxide);

• in the disinfection of obturation cones;

• for modeling the main gutta-percha cone;

• in the removal of gutta-percha cones during

retreatment;

• in the disinfection of prosthetic space.

HISTORY
•Chlorhexidine was developed by imperial chemical industries in
England

during 1940’s .

•It was marketed as a general antiseptic in 1950.

•In 1957, Chlorhexidine was introduced for human use in Britain as

a skin antiseptic.

•The property of plaque inhibition of chlorhexidine was first

investigated by Schroeder in 1969.

• A definitive study for caries inhibition of dental plaque was done

by Loe and Schiott in 1972
CHEMISTRY

BISBIGUANIDE antiseptic

Symmetrical molecule

4 CHLOROPHENYL rings and 2 BIGUANIDE groups

Connected by a Central HEXAMETHYLENE bridge

2 POSITIVE CHARGES on either side of the hexamethylene

bridge
Strong BASE

DICATIONIC at pH levels >3.5

Extremely INTERACTIVE with anions due to its dicationic

nature.
MODE OF
ACTION
ON THE TOOTH SURFACE:

CHX gets attached to the salivary proteins and

desquamated epithelial cells

Blocks acidic groups on salivary glycoproteins

Reduces glycoprotein adsorption on tooth surface

Prevents pellicle formation

  Prolonged antiseptic release

Bacteriostatic action that lasts for more than 12

hours

Prevents the adsorption of bacterial cell wall on

to the tooth surface

Prevents plaque formation

 Competes with calcium ions

Blocks agglutination of plaque

Prevents binding of mature

plaque
ON THE BACTERIAL CELL MEMBRAN
E:
AT LOW CONCENTRATIONS:

CHX adheres to bacterial cell membrane

Binds to phospholipids in the inner cell membrane Leakage of

lesser molecular weight components

Sub lethal stage – reversible bacteriostatic action

AT HIGH CONCENTRATIONS:

The action continues

Intracellular coagulation

Leakage of intracellular components slow down

Cytoplasmic coagulation

Cell death (Bactericidal action)

CONCENTRATION
Include
• 0.12%,
• 0.2%,
• and 2%

Commercially available oral rinse typically contains 0.12% CHX

gluconate.

0.12% CHX has been found to be ineffective for endodontic use

whereas concentrations above it have been successfully used

Sassone (2003)
Luciana M( Aust Endo J 2008)

Available in both gel and liquid formulations

PRESENTATION
FORM
•CHX is an almost colorless to pale straw-colored substance
or slightly opalescent, odorless or almost odorless
substance.

•The 20% (w/w) CHX salt is the most commonly used.

•Solutions prepared from all salts have an extremely bitter

taste that must be masked in formulations intended for oral
use.

•The most commonly used concentrations in commercially

available CHX mouth rinses are 0.12 and 0.20%.
The 2% concentration, used in Endodontics, can be prepared
by pharmacies, under prescription.

For endodontic purposes, CHX can be used in a liquid or in a

gel presentation.

CHX gel consists of a gel base (1% natrosol, a

hydroxyethylcellulose, pH 6-9) and chlorhexidine gluconate,
in a optimal pH range of 5.5 to 7.0

Natrosol gel is a biocompatible carbon polymer that is a

water soluble substance, and therefore can be easily removed
from the root canal with a final flush of distilled water.
Studies have shown that the antimicrobial activity of CHX
liquid is equal or superior to that of CHX gel when the direct
contact was used as a methodology.

In other studies, using the agar diffusion test, 2% CHX gel

was superior to 2% CHX liquid.

Ferraz et al. showed that 2% CHX gel has several advantages

over 2% CHX solution, in spite of having similar
antimicrobial, substantivity and biocompatibility properties.

The CHX gel lubricates the root canal walls, which reduces the
friction between the file and the dentin surface, facilitating the
instrumentation and decreasing the risks of instrument
breakage inside the canal.
CHX gel improves the elimination of organic tissues, which
compensates for its incapacity to dissolve them.

Another advantage of CHX gel is the reduction of smear

layer formation, which does not occur with the liquid form.

CHX gel maintains almost all the dentinal tubules open

because
its viscosity keeps the debris in suspension (rheological
action), reducing smear layer formation.
STORAGE

A shelf life of at least 1 year can be expected, provided that

packaging is adequate, in a dark, refrigerated bottle.

Regarding the gel formulation, it may keep its pH and

satisfactory antimicrobial activity for approximately 10
months after the fabrication date.
ANTIMICROBIAL ACTIVITY

CHX is bactericidal and effective against Gram-positive and

Gram-negative bacteria, facultative and strict anaerobes yeasts
and fungi, particularly Candida albicans.

It shows comparatively greater efficacy towards gm positive

bacteria.

Retains its activity in the presence of blood and organic

matters.

In the liquid presentation, CHX kills microorganisms in 30 s or

less, while in the gel formulation it takes from 22s (2% CHX
gel) to 2h (0.2% CHX gel).
Several in vitro works using a broth dilution test have shown
that 2.0% CHX and 5.25% NaOCl have similar antimicrobial
performance against all tested microorganisms, while others
have shown the superiority of 2% CHX gel or liquid over 5.25%
NaOCl using the agar diffusion method.

A recent clinical study has shown that canals that received a

final rinse with a 2% CHX solution were significantly more
often free of cultivable microorganisms than controls irrigated
with NaOCl alone.
At physiologic pH CHX is a large dicationic molecule, with the
positive charge distrubuted over the nitrogen atoms on either
side of the heamatoxylin bridge.

The bacterial cell is characteristically negatively charged.

Low concentrations- bacteriostatic

High concentrations- bactericidal

CHX penetrates the cellwall andcauses precipitation or

coagulation of cytoplasm probably caused by cross linking.
cationic-anionic electrostatic attraction…

-
-
-
-
Adsorption to the surface of bacteria due to the cationic-
anionic electrostatic attraction…

-
… making the membrane permeable
this results in micro leakage of intracellular
components leading to cell death
SUBSTANTIVITY
Clinically CHX’s substantivity seems to be another advantage
over NaOCl, sustaining the antimicrobial activity over a
period of 48 hours or 72 hrs after treatment.
Their cationic properties also allow them to bind
electrostatically to surfaces.
They are gradually released from the surface, as the
concentration of chlorhexidine in the environment
decreases.

The reversible reaction of uptake and release of CHX

results in a substantive antibacterial activity.
CHX AND BIOFILMS
A biofilm can be defined as communities of microorganisms
attached to a surface, embedded in an extracellular matrix of
polysaccharides.

Several studies using a single-species biofilm model and

apical dentin biofilm have reported that higher concentration
of NaOCl (varying from 2.25% to 6%) and CHX solution
(2%) were effective against microorganisms.

Although CHX is effective against bacterial biofilms, NaOCl

is the only irrigation solution with the capacity of disrupting
biofilms.
ENDOTOXIN REDUCTION

It has been reported that CHX does not inactivate

lipopolysaccharide (LPS), which is a structural component of
the Gram-negative bacteria’s outer cell envelope.

Signoretti et al showed that Chlorhexidine improved the

properties of reducing the endotoxin content in root canals in
vitro.
CHX AND CORONAL MICROLEAKAGE

Canals medicated with CHX alone or in combination with

CH retard the entrance of microorganisms through the
coronal portion of the tooth into the root canal system, due to
its wide antimicrobial activity and substantivity.

Regarding coronal microleakage during the intracoronal

bleaching, it was found that CHX used as a vehicle for
sodium perborate enhanced its antimicrobial activity and did
not affect adversely dentin microhardness.
CHX AND APICAL FLUID PENETRATION

Canals irrigated or medicated with CHX do not affect

negatively the ability of root fillings to prevent fluid
penetration into the root canal system through the apical
foramen.
TISSUE DISSOLUTION CAPACITY

The tissue dissolution capacity of a substance depends mainly

on three factors: the frequency of shaking, the amount of
organic matter in relation to the amount of irrigant in the
canal system and the surface area of tissue that is available
for contact with the irrigant.

Chlorhexidine gluconate has been recommended as a root

canal irrigant because of its broad spectrum antimicrobial
action, substantivity and low toxicity.

It does not promote a superficial necrosis.

INTERACTION WITH ENDODONTIC
IRRIGANTS
NaOCl + CHX :

Formation of an orange-brown precipitate, resulting in a

chemical smear layer that covers the dentinal tubules and
may interfere with the seal of the root filling.

Vianna and Gomes found that the association of NaOCl

and CHX did not improve the antimicrobial activity of
CHX alone.
After chemomechanical preparation with NaOCl, the use
of CHX as a final irrigant or as an intracanal medicament
would require the removal of NaOCl from the canal.

Do Prado et al. found that with regard to the use of

NaOCl with CHX, 10 mL of distilled water in association
or not with 17% EDTA and 10% citric acid was not
enough to inhibit the formation of the chemical smear
layer.
EDTA + CHX :

Immediate formation of a white milky

precipitate, related to the acid-base
reactions resulting in a chemical smear
layer that covers the dentinal tubules.

Precipitate involves the chemical

degradation of chlorhexidine (Rasimick
et al)
CHX + H2O2 :

Combination was introduced by Helling et

al.

When combined do not counter act one

another at specific conc (synergistic axn).
H2O2 Smear layer removal Greater antibacterial
effect at deeper
layers
CHX Allow penetration of
CHX into the Kills most of the
dentinal tubules bacteria in the area
adjacent to the
lumen.
CHX, Metalloproteinases and Collagen Fibrils

2% CHX gel, whether combined or not with 17% EDTA, is

an auxiliary chemical substance that does not interfere with
the collagen present in the organic matrix of root dentin, and
maintains the quality of the dentin substrate for posterior
obturation or restoration of the tooth with resin-based
materials.

CHX has also shown the capacity to preserve the durability

of the hybrid layer and bond strength in vitro and in vivo,
probably to do its effectiveness as a MMP inhibitor, resulting
in lower degradation of hybrid layer and sub-hybrid layer
collagen fibrils.
CHX AND DENTIN BONDING

Chlorhexidine application prior to acid-etching has no

adverse effects on immediate composite- adhesive bonds
in coronal pulp chamber, dentin, enamel or with resin-
reinforced glass-ionomer cements.

Erdemir et al. reported that endodontic irrigation with

Chlorhexidine solution significantly increased bond
strength to root dentin.
CHX AS INTRACANAL MEDICAMENT

When used as an intracanal medicament, CHX is more

effective than CH against E. faecalis infection in dentinal
tubules.

CHX gel as intracanal medicament is recommended for

a short period of time (3-5 days)

Also recommended in cases of exudation, as it retains its

antimicrobial activity in the presence of blood and other
organic matters.
Studies have also shown that CH pastes added with
CHX gel, alone or with ZnO, have greater antimicrobial
activity than those prepared with distilled water or
saline.

To achieve its best antimicrobial activity, it should stay

for a period of 15 to 30 days inside the root canal,
without being changed.
Diffusion into the Dentinal
Tubules
2% CHX containing medicaments is able to
diffuse into the dentin tubular structure and reach
the outer root surface, exerting antimicrobial
action.
Disinfection of Obturation
Cones (Gutta-Percha and
Resilon Cones)
2% CHX did not change gutta-percha cone properties
after exposure for up to 30 min, suggesting that this
substance is less harmful to the structure of guttapercha.

Cones disinfected with CHX presented smaller contact

angles
than NaOCl, favoring the interaction between the solid
surface (cone) and the liquid, in this case, the sealer.
Other Uses in the Endodontic Therapy
CHX has been recommended as an alternative to NaOCl,
especially in cases of open apex, root resorption, foramen
enlargement and root perforation, due to its biocompatibility.

CHX gel can also be used for modeling gutta-percha cones,

which improves their adaptation to the apical dentin wall.

The use of CHX is must in cases of retreatment.

THANK
YOU!