Chlorhexidine Formulations Research Articles

Efficacy of Intra-Pocket Application of Two Antimicrobial Agents as an Adjunct to Mechanotherapy of Chronic Periodontitis (a Comparative Study)

Numerous studies have been performed to evaluate the effectiveness of the use of locally delivered antimicrobials as an adjunct to mechanotherapy in treatment of chronic periodontitis. Some studies were resulted in improved clinical outcomes and others were not. The aim of this study is evaluation of the efficacy and safety of subgingival application of a (10 mg metronidazole gel), (1% chlorhexidine collagen gel) and (CHLOSITE® GHIMAS, Italy) gel which is a combination of two chlorhexidine formulations: 0.5% chlorhexidine digluconate and 1.0% chlorhexidine dihydrochloride), as an adjunct to mechanical treatment (scaling and root planing) (SRP) of chronic periodontitis. A total of 120 sites from 15 patients with age range of (24-55 years), who had periodontal pockets measuring 5-9 mm and had been diagnosed as chronic periodontitis cases, were selected for the study. The 4-quadrant split-mouth design was used in this study. The pocket sites in each patient were randomly assigned to 4 groups (30 sites for each):(Group A) GA=(SRP) only.(Group B) GB=(SRP) + 10 mg metronidazole gel.(Group C) GC=(SRP) + 1% chlorhexidine collagen gel. (Group D) GD=(SRP) + CHLOSITE®Clinical parameters including (plaque index PI), (gingival index GI), (gingival bleeding index) GBI, (probing pocket depth PPD) & (clinical attachment level CAL) were measured and recorded at baseline before any treatment at (day 0) then the treatment was performed at the same day, The clinical parameters were also recorded at (day 30) & (day 90), in the selected sites of the four groups. The results of this study obviously showed a statistically significant reduction of all clinical parameters in all groups at (day 30 & day 90) from the base line (day 0). GD=(SRP) + CHLOSITE® revealed a reduction of the clinical parameters than groups (A, B and C) and the differences were highly statistically significant.

Application of Accelerated Predictive Stability Studies in Extemporaneously Compounded Formulations of Chlorhexidine to Assess the Shelf Life

Industrially fabricated medicines have a well-defined shelf life supported by rigorous studies before their approval for commercialization. However, the shelf life of extemporaneous compounding topical formulations prepared at hospitals tends to be shorter, especially when no data are available to prove a longer stability period. Also, the storage conditions are unknown in many circumstances. Accelerated Predictive Stability (APS) studies have been shown to be a useful tool to predict in a faster and more accurate manner the chemical stability of extemporaneously compounded formulations requiring a minimum amount of formulation, thereby reducing the chemical drug waste per study. Shelf life will be allocated based on scientific data without compromising drug efficacy or safety. In this work, the APS approach was applied to the commercially available Cristalmina® (CR) and an extemporaneously compounded formulation of chlorhexidine (DCHX). A different degradation kinetic was found between DCHX and CR (Avrami vs. zero-order kinetics, respectively). This can explain the different shelf life described by the International Council for Harmonisation of Technical Requirements Registration Pharmaceuticals Human Use (ICH) conditions between both formulations. A predicted stability for the DCHX solution was obtained from the extrapolation of the degradation rate in long-term conditions from the Arrhenius equation. The estimated degradation from the Arrhenius equation for DCHX at 5 °C, 25 °C, and 30 °C at 365 days was 3.1%, 17.4%, and 25.9%, respectively. The predicted shelf life, in which the DCHX content was above 90%, was 26.67 months under refrigerated conditions and 5.75 and 2.24 months at 25 and 30 °C, respectively. Currently, the Spanish National Formulary recommends a shelf life of no longer than 3 months at room temperature for DCHX solution. Based on the predicted APS and confirmed by experimental long-term studies, we have demonstrated that the shelf life of DCHX extemporaneously compounded formulations could be prolonged by up to 6 months.

A dentifrice containing salivary enzymes and xylitol exhibits superior antimicrobial activity in vitro against adherent Streptococcus mutans compared to a chlorhexidine dentifrice.

Human saliva contains natural antimicrobial enzymes. In this in vitro study, we evaluate the antimicrobial activity of a dentifrice containing a salivary enzyme complex (SEC) with xylitol versus a standard 0.12% chlorhexidine (CHX) dentifrice. Adherent cells of Streptococcus gordonii, Streptococcus mutans, Actinomyces naeslundii, Fusobacterium nucleatum subsp polymorphum and Corynebacterium matruchotii were exposed to SEC-xylitol and CHX dentifrices for 2 mins and viable CFUs were enumerated. Exposure to the SEC-xylitol dentifrice resulted in a significant reduction in bacterial viability, which was greater than that shown by the CHX dentifrice, against all organisms tested. The SEC-xylitol dentifrice also exhibited greater antimicrobial activity against all organsims in well diffusion assays compared to CHX. Dentifrice activity was also evaluated against a three species community of Streptococcus gordonii, Streptococcus mutans and Corynebacterium matruchotii using bacterial live/dead stain. The SEC-xylitol dentifrice was at least as effective as CHX in removal of the multispecies community. The combination of SEC and xylitol generates a highly effective antimicrobial dentifrice with greater anti-bacterial activity than a standard 0.12% CHX formulations. SEC and xylitol combinations are worthy of further investigation for routine use and in the management of gingivitis and periodontal disease.

Enablers and Barriers to Chlorhexidine Use in Umbilical Cord Care: Voices of Care Givers and Healthcare Providers in Selected Counties in Kenya

Neonatal sepsis contributes to increased rates of mortality among newborns during their first month of life. Chlorhexidine (CHX) has proven effective in the prevention of neonatal sepsis due to umbilical stump infection after birth. Despite shifting from dry cord care techniques to CHX use, there is still a high prevalence of improper cord care in low-resource settings in Kenya. This study sought to explore barriers and enablers to CHX use in Kwale, Vihiga and Machakos counties in Kenya. We adopted mixed methods cross-sectional survey with 582 women of reproductive age with a young child less than one year as respondents to the quantitative survey. Qualitative data entailed thirty (30) key informant interviews with healthcare workers and national policymakers. Six (6) focus group discussions with mothers, caregivers, community health volunteers (CHVs) and traditional birth attendants were conducted. An observation checklist was used to assess the availability of CHX services and supplies in fourteen (14) health facilities was conducted. Results indicated variation in umbilical cord care practices for newborns across counties. Of 582 caregivers, only 1.3% reported having ever used CHX. Majority mentioned using methylated spirits (41.6%), other antiseptics (23.3%) and salty water (11.3%). Other substances used for cord care included plain water, herbal extracts, cow dung, soil, and breast milk. Despite 100% awareness of CHX among health workers, only a third of caregivers (38.7%) had heard of CHX. About 76.9% of participants preferred the gel formulation and 8.9% did not know where to get the product. Drivers of CHX use included faster cord healing, infection control in hospitals, ease of use, cost implications, ease of access, influence from key decision makers and preferred CHX formulation. Barriers included minimal awareness among caregivers, cultural practices and taboos on cord care, inadequate capacity building of CHVs on CHX, unclear CHX user guidelines for caregivers, prolonged stockouts and inadequate knowledge of CHX in communities. Healthcare workers highlighted poor dissemination of CHX guidelines by the Ministry of Health, unavailability in the Kenya Medical Supplies Authority (KEMSA) and Mission for Essential Drugs and Supplies logistic management information system making it difficult to procure. There is a need for advocacy to promote the uptake of CHX in facilities and increase knowledge of communities on CHX as well as manage the supply chain to increase CHX availability

Changes in the force degradation of orthodontic elastomeric chains subjected to different formulations of chlorhexidine mouth rinse

Introduction: The aim of this study was to assess whether various formulations of chlorhexidine mouth rinses had an effect on force characteristics of the elastomeric chains. Methods: The sample consisted commercially available elastomeric chain of 3M Unitek with five commercially used chlorhexidine mouth rinses of different formulations. The e chain were stretched on artificial saliva .30 sec everyday exposure to different chlorhexidine formulation was tested by digital dynamometer and was statisticaly evaluated using ANOVA test. Conclusion: mouthwashes does not accelerate force degradation of elastomeric chains which could clinically affect their effectiveness. However, the results could be variable in the presence of other biological factors in the oral environment and their interactions between oral microorganisms with the host.

Differences in chlorhexidine mouthrinses formulations influence the quantitative and qualitative changes in in-vitro oral biofilms.

Chlorhexidine mouthrinses are marketed in different formulations. This study aimed at investigating qualitative and quantitative changes in in-vitro multispecies oral biofilms, induced by different chlorhexidine-containing mouthrinses. Earlier studies comparing chlorhexidine mouthrinses are either clinical studies or in-vitro studies assessing the antimicrobial efficacy of the mouthrinses. However, no clear investigations are available regarding ecological impact of different chlorhexidine formulations on in-vitro multispecies oral biofilms after rinsing with different chlorhexidine formulations. Nine commercially available chlorhexidine mouthrinses were selected. Multispecies oral communities (14species) were grown for 48h in a Biostat-B Twin bioreactor. After that, they were used to develop biofilms on the surface of hydroxyapatite disks in 24-well pates for 48h. Biofilms were then rinsed once or multiple times with the corresponding mouthrinse. Biofilms were collected before starting the rinsing experiment and every 24h for 3days and vitality quantitative PCR was performed. The experiment was repeated 3 independent times on 3 different days and the results were analyzed using a linear mixed model. The mouthrinses provoked different effects in terms of change in total viable bacterial load (VBL), ecology, and community structure of the multispecies biofilms. There was no relation between chlorhexidine concentrations, presence, or absence of cetylpyridinium chloride and/or alcohol, and the observed effects. Some tested chlorhexidine mouthrinses (MC, HG, HH, and HI) strongly lowered the total VBL (≈1007 Geq/ml), but disrupted biofilm symbiosis (≥40% of the biofilms communities are pathobionts). On the other hand, other tested chlorhexidine mouthrinses (MD, ME, and HF) had limited impact on total VBL (≥1010 Geq/ml), but improved the biofilm ecology and community structure (≤10% of the biofilms communities are pathobionts). Not all chlorhexidine mouthrinses have the same effect on oral biofilms. Their effect seems to be strongly product dependent and vary according to their compositions and formulations.

Activity of chlorhexidine formulations on oral microorganisms and periodontal ligament fibroblasts.

Given the importance of microorganisms in the pathogenesis of the two most prevalent oral diseases (i.e. caries and periodontitis), antiseptics are widely used. Among the antiseptics chlorhexidine (CHX) is still considered as gold standard. The purpose of this in-vitro-study was to determine the antimicrobial activity of new CHX digluconate containing formulations produced in Switzerland. Two test formulations, with 0.1% or 0.2% CHX (TestCHX0.1, TestCHX0.2) were compared with 0.1% and 0.2% CHX digluconate solutions (CHXph0.1, CHXph0.2) without additives and with a commercially available formulation containing 0.2% CHX digluconate (CHXcom0.2). The minimal inhibitory concentrations (MIC) of the CHX formulations were determined against bacteria associated with caries or periodontal disease. Then the anti-biofilm activities of CHX preparations were tested regarding inhibition of biofilm formation or against an existing biofilm. Further, the cytotoxicity of the CHX preparations against periodontal ligament (PDL) fibroblasts was measured. There were no or only minor differences of the MIC values between the CHX preparations. Except for 0.1% CHXph, all formulations blocked the formation of the biofilms. When analyzing the effect on an established “cariogenic” biofilm, the TestCHX0.2 was most active (- 3.5 log10 colony forming units (cfu); p<0.001 vs. control). The cfu counts of an established periodontal biofilm were most decreased by CHXcom0.2 (-3.9 log10), followed by TestCHX0.2 (-3.34 log10) and CHXph0.2 (-3.0 log10 cfu) (each p<0.001 vs. control). All CHX preparations reduced the viability of the PDL fibroblasts. Taken together, the Swiss made test mouth rinses have an equal or better antibacterial and anti-biofilm activity as the respective CHX solutions and can be recommended.

InVitro Comparison of the Acanthamoeba Cysticidal Activity of Povidone Iodine, Natamycin, and Chlorhexidine.

PurposeAcanthamoeba keratitis often is refractory to medical and surgical therapy, primarily because of the remarkable resilience of Acanthamoeba cysts. In this study, we directly compared the cysticidal activity and potency of several candidate medical therapies in vitro.DesignExperimental study.ParticipantsIn vitro Acanthamoeba specimens obtained from 9 patients with keratitis seen at the Francis I. Proctor Foundation from 2008 through 2012.MethodsThe minimum cysticidal concentration (MCC) of povidone iodine, natamycin, and chlorhexidine was investigated using an established assay technique. The relative potency of each agent was estimated starting with concentrations commonly used in clinical practice and determining the number of two-fold dilutions required to reach the MCC. Statistical comparisons of relative potency were performed using bootstrap simulations and permutation tests.Main Outcome MeasuresMinimum cysticidal concentration and the number of two-fold dilutions required to reach the MCC.ResultsThe MCC for chlorhexidine ranged from 3.1 to 25 μg/ml (median, 12.5 μg/ml; interquartile range [IQR], 6.25–12.5 μg/ml), the MCC for natamycin ranged from 390.6 to 3125 μg/ml (median, 390.6 μg/ml; IQR, 390.6–781.2 μg/ml), and the MCC for povidone iodine ranged from 0.3 to 78.1 μg/ml (median, 2.4 μg/ml; IQR, 0.6–9.8 μg/ml). Doses commonly used in clinical practice (povidone iodine 1%, natamycin 5%, and chlorhexidine 0.04%) were approximately 12, 7, and 5 two-fold dilutions higher than the drug’s corresponding median MCC, respectively (P < 0.001, comparing 3 drugs). Povidone iodine 1% had the highest potency of the 3 medications tested, requiring more dilutions than natamycin 5% (P < 0.001) and chlorhexidine 0.04% (P < 0.001) to reach the MCC.ConclusionsAll 3 medications demonstrated in vitro cysticidal activity in each of the 9 isolates. The potency of 1% povidone iodine was greater than standard formulations of natamycin or chlorhexidine. Although its clinical efficacy is yet to be determined, povidone iodine may be considered as a potential adjuvant treatment in cases of recalcitrant Acanthamoeba keratitis.

The assortment analysis of chlorhexidine-containing medicines and procurement data of state and municipal organizations

Chlorhexidine is an effective cationic antiseptic and disinfectant that has been used in medical practice for decades. It is generally recommended to use different concentrations of aqueous or alcoholic solutions of chlorhexidine for different therapeutic purposes.&#x0D; Objective. To determine the proportions of different chlorhexidine concentrations in medicines purchased by state and municipal organizations and to identify possible issue of chlorhexidine formulations utilization in the suboptimal or insufficient concentrations.&#x0D; Results. The vast majority of the chlorhexidine-containing medicines found in the State Register of Medicines of Ukraine are 0.05% solutions for external use, 0.05% gels for dental and urological use and vaginal suppositories (pessaries) with 16 mg of chlorhexidine in one dose. While the most common representatives of chlorhexidine-containing medicines abroad are solutions with a concentration of 4% and 2%, as well as mouthwashes with a concentration of 0.12%. The highest share - 96% - among the procurements of chlorhexidine-containing medicines by state and municipal organizations is 0.05% aqueous solution for external use. Instructions for medical use of 0.05% aqueous chlorhexidine solution for external use contain indications that are not supported by international documents: WHO Model List of Essential Medicines and British National Formulary.&#x0D; Conclusions. The obtained results suggest probable cases of irrational use of chlorhexidine medicines in medical practice in Ukraine. The consequences of such cases are not limited to the failure to achieve therapeutic goals or to the development of nosocomial infection, but includes also the selection of chlorhexidine-resistant strains of microorganisms.&#x0D; Key words: chlorhexidine; assortment analysis; medicinal procurements study; suboptimal concentration; rational pharmacotherapy

Erythritol-enriched powder and oral biofilm regrowth on dental implants: an in vitro study.

Background Peri-implant mucositis and peri-implantitis are the main biological complications associated with dental implants. Since most authors agree that bacteria play a major etiological role, the main aims of this study were to determine if a formulation of erythritol and chlorhexidine applied with an air polishing system inhibits biofilm regrowth over dental implants and to compare the decontamination capacity of this therapy with that of mechanical removal by saline and gauze.Material and Methods A multispecies biofilm (P. gingivalis, A. actinomycetemcomitans, F. nucleatum, A. naeslundii, V. parvula and S. oralis) was grown for 14 days on 52 dental implants in an artificial mouth. These implants were divided into three groups according to the applied treatment: 14 negative control (CON), 19 erythritol-chlorhexidine (ERY) and 19 gauze with saline (GAU) samples. Twelve dental implants from the ERY and GAU groups and 8 implants from the CON group were re-incubated for 7 additional days after treatment. The bacterial count was performed by quantitative polymerase chain reaction (qPCR) using propidium monoazide (PMA). A descriptive and bivariate analysis of the data was performed.Results The erythritol and chlorhexidine formulation significantly inhibited biofilm regrowth in comparison with the mechanical treatment (GAU), since a significant decrease in all the species was observed in the ERY group (except for Aggregatibacter actinomycetemcomitans). The antibiofilm and antibacterial capacity of the two active treatment groups (ERY and GAU) was similar for a 14 days multispecies in vitro biofilm, except for the lower count of A. naeslundii in the GAU group.Conclusions The use of erythritol powder with chlorhexidine applied with an air polishing system reduces biofilm regrowth over dental implants when compared with mechanical removal by saline and gauze. This effect might be beneficial for patients included in peri-implant maintenance programs. Key words:Dental implants, biofilms, peri-implantitis, erythritol, chlorhexidine.

Efficacy of ultrasonic mechanical instrumentation with and without chlorhexidine in treatment of chronic periodontitis

Aim: The aim of the present study was to evaluate the effects of ultrasonic mechanical instrumentation (UMI) along with the professional use of chlorhexidine (CHX) compared with UMI alone during periodontal supportive therapy in patients with chronic periodontitis. Material and Methods: A total of twenty patients were included in the study and were divided into test and control group. The test group (ten patients) was treated with a single session of UMI along with subgingival irrigation under cavitation with CHX 0.02%. A 0.2% CHX solution was used for professional tongue brushing and mouth rinsing. The control group (ten patients) received a similar single session of UMI along with subgingival irrigation and professional tongue brushing and mouth rinsing with a control formulation. Clinical and microbiological parameters were assessed pre-treatment at 3 and 6 weeks post­treatment. Results: Results showed that there was a significant reduction of supragingival plaque and gingival inflammation as well as a significant reduction of subgingival bacterial pathogens in both test and control groups. The additional use of CHX did not result in any additional clinical and microbiological benefit with respect to UMI alone. Conclusion: CHX formulations in conjunction with UMI seems to produce no additional benefits over UMI alone during supportive therapy in chronic periodontitis patients. Keywords: Chlorhexidine, Chronic Periodontitis, Piezoelectric Ultrasonic, Subgingival Microbiota.

Does Chlorhexidine Prevent Complications in Extractive, Periodontal, and Implant Surgery? A Systematic Review and Meta-analysis with Trial Sequential Analysis.

This systematic review aimed to assess the effect of chlorhexidine (CHX) in preventing complications after extractive, implant, and periodontal surgery. The PICO question set for this systematic review was: "Is the use of chlorhexidine formulations able to prevent complications (safety) in patients undergoing procedures of either oral surgery, dental implantology, or periodontology compared to treatment procedures in patients without a chlorhexidine prescription?" Once inclusion and exclusion criteria were established, a search was carried out independently by two researchers on PubMed/MEDLINE, Scopus, and Web of Science. The primary outcomes investigated were the rate of alveolar osteitis and bacteremia after surgical procedures in oral surgery. Meta-analysis and trial sequential analysis (TSA) were performed in order to evaluate the findings. After the selection, the 32 studies that fully met the eligibility criteria were considered in this systematic review. A meta-analysis was only possible for data obtained from studies related to extractive surgery. Meta-analysis and TSA showed a statistically significant decrease in the rate of alveolar osteitis after tooth extraction when CHX was employed compared with placebo treatments or treatments not using CHX (RR = 0.49; 95% CI: [0.40, 0.60], P < .001; I2 = 8%). Focusing on the rate of bacteremia, meta-analysis and TSA showed how the employment of CHX (RR = 0.87; 95% CI: [0.79, 0.96], P = .004; I2 = 4%) decreases the rate of bacteremia after extractive surgery. Data from the literature seem to lack in the evaluation of CHX use for the reduction of complications in periodontology and implant dentistry. This systematic review showed with a good power of evidence that CHX employment reduces alveolar osteitis and bacteremia rates after dental extractions.

Implications of chlorhexidine use in burn units for wound healing.

Chlorhexidine is known to be a potent antiseptic with evidence of a beneficial role in burn care. Nevertheless, several in vitro studies have reported cytotoxicity on cultured cells, while in vivo and clinical data seem to show more controversial results. In the frame of this work, we aimed to evaluate the use of chlorhexidine in burn units worldwide be sending a survey to professionals of the field. We associated survey results to those perspectives reported in the literature to update recommendations for the use of chlorhexidine in specific protocols for burn management. The survey results showed that there is no clear consensus on the use of chlorhexidine regarding the concentrations, the type of excipient and the cleansing after application. Literature searches showed evidence that the skin of premature infants appears to be more sensitive to chlorhexidine that adult skin, with more reported cases of adverse effects. It was also determined that aqueous formulations of chlorhexidine do not appear to be necessarily less efficient than with alcohol as an excipient, and that lower concentrations are as efficient as higher concentrations. In view of this study, we have adjusted our protocols for the use of aqueous formulations at low concentrations and investigated further the role of washing after application in order to standardize the indication of chlorhexidine and minimize the probability of adverse effects.

Effect of two different alcohol-free chlorhexidine formulations in mouthrinses on the immediate postoperative period for oral mucosal biopsies.

Oral biopsy is a common surgical practice. To date, few authors have described the healing of mucosal wounds following oral biopsy. The aim of the present single-center, prospective, randomized, controlled study is to evaluate the differences between two chlorhexidine (CHX) mouthrinses and a treatment-free approach in the immediate postoperative period following oral mucosal biopsy. 354 patients were included in this study and were randomly allocated to three groups: A) CHX 0.12% mouthrinse (twice daily, 10 mL rinse for 30 s), B) CHX 0.20% mouthrinse (twice daily, 10 mL rinse for 30 s), and C) no topical treatment. 118 patients were treated in group A and 115 in group B; 121 received no therapy in group C, reporting the greatest improvement in related symptoms. Outcome variables included the age, gender, site and size of lesions, visual analog score (VAS), Oral Health Impact Profile questionnaire (OHIP-14), and number of painkillers taken during the first week post-surgery. Use of a CHX 0.12% mouthrinse exhibited the poorest outcome. On the other hand, best clinical healing was found for patients treated with CHX 0.20%. These findings suggest that regardless of its concentration, CHX was found to be ineffective in reducing related symptoms, whereas CHX 0.20% can be recommended to facilitate enhanced healing.

Effectiveness of Different Commercial Chlorhexidine-Based Mouthwashes After Periodontal and Implant Surgery

The aim of the present study was to review the effectiveness, side effects, and patient acceptance of different concentrations and formulation of chlorhexidine-based mouthwashes used after periodontal and implant surgery. The PRISMA guideline was adopted in the search strategy using electronic databases PubMed and MEDLINE to identify randomized and case-control prospective studies on humans written in English language and published up to September 2017. A total of 10 articles were selected for a total of 344 patients. Because of the significant heterogeneity of the outcome measures, meta-analysis was not performed, and the data were summarized in a table. A positive relationship between the use of chlorhexidine and reduction of plaque was found, demonstrating the effectiveness of the substance in terms of antisepsis and decrease of inflammation after periodontal and implant surgery. Chlorhexidine is recognized as the primary agent for plaque control and the gold standard in preventing infection, although the presence of largely known side effects would affect patient compliance. Future research should be directed at finding chlorhexidine formulation with negligible adverse effects, without compromising or even increasing its effectiveness as the antiseptics and antiplaque agent.

Efficacy of chlorhexidine rinses after periodontal or implant surgery: a systematic review.

Biofilm management and infection control are essential after periodontal and implant surgery. In this context, chlorhexidine (CHX) mouth-rinses are frequently recommended post-surgically. Despite its common use and many studies in this field, a systematic evaluation of the benefits after periodontal or implant surgery is-surprisingly-still missing. To evaluate the benefits of chlorhexidine rinsing after periodontal or implant surgery in terms of plaque and inflammation reduction potential. Furthermore, to screen whether the concentration changes or additives in CHX solutions reduce side effects associated with its use. A systematic literature search was performed for clinical trials, which compared CHX rinsing after periodontal or implant surgery with rinsing using placebo, non-staining formulations, or solutions with reduced concentrations of the active compound. Four databases (Medline, PubMed, Embase, Cochrane) were searched up to June 2018. Two reviewers independently identified and screened the literature. From 691 titles identified, only eleven publications met the inclusion criteria and were finally included. Mainly early publications assessed the benefits of CHX over placebo rinsing, whereas more recent publications focused more on the evaluation of new formulations with regard to effectiveness and side effects. The use of CHX after surgery showed in general significant reduction in plaque (means of 29-86% after 1week) and bleeding (up to 73%) as compared to placebo. No consensus, however, was found regarding the most beneficial CHX formulation avoiding side effects. Chlorhexidine rinsing helps to reduce biofilm formation and gingival inflammation after surgery. However, no additional reduction of periodontal probing depth over any given placebo or control solution could be found irrespective of whether CHX was used or not. The use of additives such as antidiscoloration systems (ADS) or herbal extracts may reduce side effects while retaining efficacy. Within the limitations of this review, it can be concluded that CHX may represent a valuable chemo-preventive tool immediately after surgery, during the time period in which oral hygiene capacity is compromised. To reduce the side effects of CHX and maintain comparable clinical effects, rinsing with less concentrated formulations (e.g., 0.12%) showed the most promising results so far.

A randomized controlled clinical trial on the effectiveness of three different mouthrinses (chlorhexidine with or without alcohol and C31G), adjunct to periodontal surgery, in early wound healing.

The use of chlorhexidine (CHX) with or without alcohol has been recommended for a number of clinical applications. On the other hand, there is a plethora of widely subscribed antiseptics, such as agent C31G (alkyl dimethyl glycine/alkyl dimethyl amine oxide), which has not yet been evaluated postsurgically. The effectiveness of three different mouthrinses (CHX with and without alcohol, C31G) in plaque control and early wound healing was compared postoperatively. In this, randomized, double-blind, controlled clinical trial 42 patients were allocated to three groups assigned to 2weeks rinsing after non-regenerative periodontal flap surgery with or without osseous surgery with C31G (group A), alcohol-free CHX 0.12% (group B) or alcohol-based CHX 0.12% (group C). At days 7 and 14, plaque and early wound healing indices were recorded. At day 14, total bacterial counts were estimated utilizing real-time quantitative polymerase chain reaction (qPCR). Statistics included linear and generalized linear mixed models. At day 7, healing response was not significantly different among groups. At day 14, group A revealed the highest while group C demonstrated the lowest plaque index values (B vs A, odds ratio-OR = 0.18, p= 0.012; C vs A, OR = 0.01, p< 0.001; C vs B, OR = 0.06, p< 0.001). Group C demonstrated the lowest bacterial counts levels at day 14 (38.470 × 106, 48.190 × 106, and 3.020 × 106 for groups A, B, and C, respectively). At day 14, healing was significantly better in group C compared to B (p= 0.007). Group A showed no significant differences compared to other groups. (1) The presence of alcohol may increase the effectiveness of CHX in early wound healing, (2) C31G might be an alternative solution prescribed during early postoperative period after non-regenerative periodontal flap surgery. The present study found that active agent C31G displayed no significant differences to CHX formulations regarding periodontal wound healing improvement and might be used alternatively after non-regenerative periodontal flap surgery. In addition, an alcohol based 0.12% CHX mouthwash was more effective than an alcohol-free 0.12% CHX and C31G mouthrinse on plaque control in the absence of mechanical oral hygiene.

Comparison of Antibacterial Efficacy of Probiotic Mouthwash with Chlorhexidine Against Common Oral Pathogens: An In-Vitro Study

Background: The basic method in prevention of oral disorders and hygiene of an oral cavity is control of plaque growth and germ accumulation on teeth and gingivae. Mouthwashes are most common topical solutions against plaque formation. Although there are many antimicrobial agents in use, only a few have shown clinical effectiveness. Furthermore, their long-term use may lead to several side effects. Therefore, utilizing natural antimicrobial agents such as probiotics may be an effective way to overcome the problem. The purpose of the present investigation was to design a mouthwash formulation containing probiotic extract. Methods: Standard strains of 4 main oral pathogenic bacteria, Streptococcus mutans, Streptococcus salivarus, Actinomyces viscosus, and Actinomyces neoslandi were utilized to evaluate the product antimicrobial activity. Lactobacillus casei was cultured in standard medium and its antibacterial effectiveness was evaluated by the spot-test. Each pathogen suspension was inoculated separately on plates containing specific media. Lyophilized probiotic extract (LPE) was prepared in a specific temperature condition and poured in wells. After incubation, the samples growth inhibition zone was measured. Mouthwash formulations containing different concentrations of LPE, Glycerin, and Sorbitol were prepared and based to their physic-chemical properties as well as their long-term stability. The best formulation was chosen and flavorant and sweetener were added. Well-diffusion method was utilized and their mean diameters of growth inhibition was recorded and compared to that of chlorhexidine and a blank Glycerin-Sorbitol solution as positive and negative controls, respectively. Minimum inhibitory concentrations of each formulation were investigated by the macro-dilution method and the formulation with maximum antibacterial activity was determined. Results: Well-diffusion experiment showed that chlorhexidine mouthwash is stronger than 1% - 4% containing LPE formulations, while there was no significant difference between 5% LPE formulation and the positive control (P > 0.05). There was no growth in the inhibition zone. For negative control, MIC studies proved that 5% LPE and chlorhexidine formulations were similar and their maximum and minimum activities were A. neoslandi and S. salivarous, respectively. Conclusions: The findings in the present study proved that the 5% LPE formulation is as effective as the chlorhexidine solution and may be utilized as a natural safe mouthwash.

Use of nystatin and chlorhexidine in oral medicine: Properties, indications and pitfalls with focus on geriatric patients.

The aim of this work was to review the scientific literature on the properties, indications and pitfalls related to nystatin and chlorhexidine in oral medicine and also to compare these to other topical antifungal agents, considering the elderly population. Nystatin is a polyene antifungal widely used as a topical formulation to treat candidiasis, whereas chlorhexidine is a wide-spectrum antimicrobial, especially used against bacteria, but also effective in treating some fungal infections including those caused by Candida spp. These compounds have been prescribed for immunocompromised patients, hospitalized or not, some of them undergoing head and neck radiation therapy and/or chemotherapy, including elderly patients. Dental and medical literature concerning the use of nystatin and chlorhexidine in oral medicine were selected and reviewed. Nystatin and chlorhexidine are gold-standard antimicrobial mouthrinses respectively for Candida spp. and bacteria. Although recognized as effective in cotrolling oral infections, both nystatin and chlorhexidine are just complementary to systemic therapy in cases of systemic infections already established. The prescriber should also take into account that some commercial nystatin and chlorhexidine formulations contain compounds such as sugar and ethanol, which can be associated with side effects. Meanwhile, alternative formulations in which these compounds are absent are available and should be considered. Further studies investigating new drugs and interactions of drug combinations are necessary to improve the therapeutic management of oral infections.

Use of Chlorhexidine Preparations in Total Joint Arthroplasty.

Prosthetic joint infection (PJI) is a serious complication after total joint arthroplasty (TJA). Chlorhexidine is a widely used antiseptic because of its rapid and persistent action. It is well tolerated and available in different formulations at various concentrations. Chlorhexidine can be used for pre-operative skin cleansing, surgical site preparation, hand antisepsis of the surgical team and intra-articular irrigation of infected joints. The optimal intra-articular concentration of chlorhexidine gluconate in irrigation solution is 2%, to provide a persistent decrease in biofilm formation, though cytotoxicity might be an issue. Although chlorhexidine is relatively cheap, routine use of chlorhexidine without evidence of clear benefits can lead to unnecessary costs, adverse effects and even emergence of resistance. This review focuses on the current applications of various chlorhexidine formulations in TJA. As the treatment of PJI is challenging and expensive, effective preparations of chlorhexidine could help in the prevention and control of PJI.