I have to admit that over the years I have had a love hate relationship with Chlorhexidine. I love it because of the positive impact I have seen it have on gingival health in my patients. I hate it because along with all of the positives come a host of negative sequela, all of which add up to patients not being able to benefit from its’ effects long term. Chlorhexidine has been around since 1954, and was introduced into dentistry in the 1970’s when it was observed to inhibit the formation of plaque. The research clearly shows that when used as an adjunct to periodontal therapy it significantly improves therapeutic outcomes. There are multiple modes of action that make Chlorhexidine effective. Most importantly Chlorhexidine is antimicrobial, effective against gram positive and gram negative bacteria, fungi and yeasts. At lower concentrations it acts as a bacteriostatic agent, preventing the bacteria from reproducing. In higher concentrations, it is actually bacteriocidal and effectively kills the bacteria present in the oral environment. This ability to vary the clinical impact allows us to use it in higher concentrations during active periodontal treatment and then once the signs of active infection and inflammation have subsided lower the concentration for maintenance. Another factor that contributes to Chlorhexidine’s effectiveness is what scientists call “substantivity”. This is the ability to remain in the oral environment for a period of time. It actually binds to the Mucin that covers the oral mucosa and then is slowly released over time.
The other side of this story with Chlorhexidine is the patient interaction and impact compliance has on therapy. Chlorhexidine is most commonly prescribed as a mouth rinse. The first barrier that I run into is having patients clearly understand the value of using it and going to the drugstore and filling the prescription. Once they do fill the prescription and begin to use it, many patients will complain about the aftertaste of the rinse, as well as the fact that it alters their taste perception, so when they eat and drink food tastes differently, often in an unpleasant way. As they use the mouth rinse the classic staining of their tongue and teeth occurs, and is unsightly as well as making their hygiene appointments more rigorous. The effectiveness is dependent on rinsing and using the product, and decreases if the patient skips rinsing. My experience is that between the taste alterations and the tooth staining, both the patient, my hygienist and I are reluctant to use Chlorhexidine as a mouth rinse over an extended time period.
Chlorhexidine is also available in a varnish delivery mode. Applied in a similar fashion to fluoride varnish at the end of a hygiene appointment it presents an improvement over many of these barriers. The issue of patient compliance in filling prescriptions and actually using the product disappears. The studies show that the Chlorhexidine is time released over a period of ninety days after application, carrying our perio maintenance patients between recalls. The varnish has been shown not to cause the traditional staining we are accustomed to from the rinse on either the teeth or the patient’s tongue. Some patients do still report mild alterations in taste perception with the varnish. A review of the literature on Chlorhexidine varnish shows its therapeutic effects against gingivitis and gingival inflammation. There are not enough studies at the moment looking at the varnish as an adjunct to scaling and root planing. There are also other delivery modalities, like PerioChip, where the Chlorhexidine is embedded in a gelatinous material and formed into a small rectangular chip designed to be placed into the sulcus in areas where the depth is 5mm or greater. This design is intended for use during scaling and root planing, and can be placed in up to eight locations at a single appointment. This delivery method also eliminates the staining and compliance components with utilizing Chlorhexidine.
The bottom line is that Chlorhexidine works, is a very valuable adjunct to periodontal therapy and we need to utilize the different formulations in order to minimize the side effects and maximize the effectiveness. One of the pieces of a soft tissue management program is to define how you will utilize adjunctive therapies to support active treatment. In our office we have created a protocol for our periodontal patients. We utilize one prescription of the mouth rinse during active scaling and root planing. At the last appointment of the active therapy we apply Cervitec Plus by Ivoclar (Chlorhexidine Varnish) and then reapply at each periodontal maintenance appointment.