Chlorhexidine
An Adjunct to Periodontal Therapy
Gary Greenstein,* Charles Bermant and
Accepted for publication 15 October 1985
Chlorhexidine is an effective antimicrobial agent. Its application can enhance peri-
odontal therapy. The pharmacology of Chlorhexidine and suggestions for its use are outlined.
In addition, its potential for inducing cancer and bacterial resistance are discussed.
Attempts to prevent gingivitis and Periodontitis by
manual plaque removal (e.g., brushing, flossing, etc.)
have only been partially successful. Currently, millions
of children and adults in the United States manifest
signs of gingival inflammation,1'2 and consequences of
periodontal diseases are considered to be the main cause
of tooth loss after the age of 35.3 Therefore, application
of antimicrobial agents as adjuncts to oral hygiene
might be beneficial. This paper reviews the pharmacol-
ogy of Chlorhexidine (CH), an effective antiplaque agent
and provides a perspective on how, when, where and
why it should be used, in a selective manner, with
periodontal patients. Additional issues, namely the le-
gality of using this drug in the United States, its alleged
carcinogenicity and the potential for developing resist-
ant bacteria will be addressed.
LEGALITY OF PRESCRIBING CH IN THE UNITED STATES
At present, no oral preparation containing CH has
been approved by the Food and Drug Administration
(FDA). This has been misinterpreted to indicate that
prescribing CH for intraoral use is illegal. A recent
paper by Berman et al.4 clarified how and why it may
be employed. They suggested oral application of diluted
Hibiclens®, an approved antiseptic skin and wound
cleanser, which contains 4% CH, alcohol, water and a
sudsing agent.5 The authors cited FDA bulletins which
indicate a practitioner may prescribe an approved drug
(e.g., Hibiclens) for an unlabeled (unapproved) indica-
tion.67 This is a common occurrence, especially if the
medical literature supports a drug's efficacy.6 At pres-
ent, over 600 articles have addressed the safety and
effectiveness of CH as an antiplaque agent.
There are complex reasons why oral formulations
containing CH have not been approved in the United
*
Private practice, Freehold, NJ 07728.
t Private practice, Hackensack, NJ 07601.
370
Robert Jaffinf
States, despite its safe use in Europe for over 20 years.
The FDA has explained that if pharmaceutical com-
panies do not initiate testing to obtain permission for a
drug's specific application, the agency will not label a
medicament approved for that particular use.6 7 Fur-
thermore, side effects associated with CH employment,
specifically staining, have discouraged manufacturers
from pursuing oral preparations.
Until oral products containing CH are marketed, and
this is likely to occur within the next year or two,
diluted Hibiclens can be used. However, prior to using
Hibiclens for an unlabeled indication in the mouth,
Berman et al.4 suggested clinicians contact their liability
carrier. It was their understanding that as long as one
is involved in lawful practice, professional liability cov-
erage applies.
PHARMACOLOGY
Structure. In the late 1940s, scientists seeking to
develop antimalarial agents formulated a group of com-
pounds called polybiguanides which demonstrated a
broad antimicrobial spectrum. Chlorhexidine, one of
the drugs created, is commonly used as an antiplaque
agent outside the United States. Its structural formula
consists of two symmetric 4-chlorophenyl rings and two
biguanide groups connected by a central hexamethylene
chain (Fig. 1).
Mechanism of Action. Chlorhexidine is a base and is
stable as a salt. The most common oral preparation,
CH digluconate, is water soluble and at physiologic pH
readily dissociates releasing the positively charged CH
component. The bactericidal effect of the drug is due
to the cationic molecule binding to extra microbial
complexes and negatively charged microbial cell walls,
thereby altering the cells' osmotic equilibrium.8"10 At
low concentrations, low molecular weight substances
will leak out, specifically potassium and phosphorous.
Volume 57
Number 6
NH NH
CI-<T^-NH-C-NH-C-NH-(CH2)6-NH-C-NH-C-HN-<rj)-CI
Figure 1. Structural formula
At higher concentrations, precipitation of cytoplasmic
contents occurs resulting in cell death. Rolla and
Meisen" suggested that CH also functions to inhibit
plaque formation by the following mechanisms: (1) by
binding to anionic acid groups on salivary glycopro-
teins, thus reducing pellicle formation and plaque col-
onization and (2) by binding to salivary bacteria and
interfering with their adsorption to teeth.
Spectrum of Activity. Chlorhexidine is bactericidal
and effective against Gram-positive, Gram-negative
and yeast organisms. Rinsing with 10 ml of 0.2% CH
(20 mg) solution has resulted in suppression of new
plaque deposits.12 Salivary bacterial counts taken im-
mediately after rinsing with a 0.2% CH solution dem-
onstrated an 80% to 90% reduction of organisms.13
Subsequent to cessation of drug application, plaque
reappears and salivary counts of organisms return to
baseline values within 48 hours.13
Hennessey14 reported that Gram-positive organisms
are more sensitive than Gram-negative microbes and
streptococci were more affected than staphylococci.
Chlorhexidine is also effective against Candida albicans
in vitro; in vivo studies in man have confirmed its
efficacy against fungal infections.15
Adsorption. CH derives its unusual antiplaque effi-
cacy from its ability to adsorb (adhere) to anionic
substrates (hydroxylapatite, pellicle, salivary glycopro-
teins and mucous membranes). Bonesvoll et al.,16 using
radioactively labeled CH, determined that approxi-
mately 30% of the drug was retained after a patient
rinsed with 10 ml of 0.2% CH solution for 1 minute.
The bound CH was subsequently released over an 8- to
12-hour period and weak concentrations could be
found in saliva for 24 hours.17 The slow release of the
drug from retention sites provides a prolonged bacteri-
cidal effect.
Metabolism and Toxicology. Poor absorption of CH
is a factor in its low toxicity. Experiments conducted
with radiolabeled CH rinses indicated that mucosal and
gingival penetration was minimal,1819 and that it was
poorly absorbed from the gastrointestinal tract.20
Bonesvoll21 reported that when oral CH rinses were
used, 4% of the solution and all of the adsorbed drug
was eventually swallowed. Ninety per cent of the re-
tained drug was excreted in the feces and the remainder
was eliminated via the urinary tract.22 Studies monitor-
ing CH also determined that none accumulated in the
body or was metabolically altered into potentially
harmful by-products.22 In particular, parachloroaniline
was not detected in the urine of animals or man.
In mice the LD50 of CH given orally was found to be
Chlorhexidine 371
NH NH
of Chlorhexidine.
1800 mg/kg.23 A LD50 has never been determined in
humans, but extrapolation of these data for the average
adult (70 kg) suggests that it could be around (70 X
1800) 126,000 mg.
SIDE EFFECTS
Staining. The most common side effect of CH is the
formation of a yellow-brown stain that develops in the
gingival third and interproximal of affected teeth. This
occurs on approximately 50% of the patients within
several days. Staining of the tongue has also been re-
ported.24 The precise staining mechanism has not been
determined, but it has been postulated that there is a
dietary etiology.25,26 Rolla et al.25 suggested stain was
formed by precipitation of iron sulfide. They speculated
sulfur was provided by exposed thiol groups from de-
natured proteins and iron originated from the diet. This
would also help explain why smoking, consumption of
tannic acid (tea, coffee and wine) and antibacterial
therapeutics which contain denaturing agents could
result in dark colorations. Similarly, Ellingsen et al.26
reported that stain caused by a combination of CH and
ferric ions was related to the concentration of the
antibacterial agent. Experimentation to reduce discol-
oration has included application of solutions (e.g., stan-
nous fluoride) and oxidizing agents to dissolve iron
sulfide.26 Additionally, Addy et al.27 tested the hypoth-
esis that rinsing only in the evening would reduce the
time food has to interact with CH, thereby decreasing
the amount of pigmentation. They found that rinsing
in the PM did cause less discoloration, although it was
not eliminated. Plaque scores were similar with single
evening or morning rinses, but were higher than those
noted after twice daily rinsing with CH. Currently, no
technique has been devised which completely prevents
stain development.
It should be noted that staining is a cosmetic nuisance
that requires professional removal. Discoloration of pits
and fissures, cementoenamel junctions, proximal sur-
faces and composite restorations are commonly ob-
served and objectionable to some patients.
Miscellaneous Effects Seen in Humans. There have
been reports of occasional dulling of taste sensation20,29
for several hours and desquamative lesions associated
with CH application.28 However, these are uncommon
sequelae and cessation of drug therapy results in a
return to normal.
CH is bitter tasting and attempts to flavor rinses have
only been partially successful.29 Similarly, Hibiclens has
a bitter and soapy taste.

372 Greenstein, Berman, Jaffin
Carcinogenicity of CH. Parachloroaniline (PCA), an
industrial chemical, is found in CH products as a trace
contaminant. It forms as a breakdown product subse-
quent to prolonged shelf life or exposure to high tem-
peratures. This process can be retarded by keeping CH
solutions in a dark, refrigerated bottle.30 Investigators
reported that Hibiclens, which contains 4% CH, gen-
erates between 19 and 51 mg of PCA per liter.31 This
quantity is one-half the amount which the FDA has
established as permissible. Both the FDA and the
United Kingdom, where Chlorhexidine products have
been used for years, have set the acceptable level of
PCA at 100 mg/liter.32
Investigators have addressed the carcinogenic poten-
tial of Chlorhexidine and PCA. Experiments conducted
with Chlorhexidine in man and animals have provided
no evidence that oral application of Chlorhexidine gave
rise to any tumorigenic effect.20 The findings with PCA
using the National Cancer Institute Bioassay were
judged to be equivocal.33"35 One study found it to be
carcinogenic in male rats, but not female rats.33 How-
ever, these results must be assessed in light of the fact
these animals were dosed with high levels of PCA during
feeding for 78 continous weeks. Williams et al.34 re-
ported PCA to be weakly genotoxic, whereas Thompson
et al.,35 using the same test, reported it to be negative.
After 20 years of oral CH use in Europe, there have
been no reports of increased cancer incidence.
Risk assessment associated with CH application must
be based upon actual applied dosages. For example, if
1 ml of Hibiclens is used for 30 days, a patient may be
exposed to ((IM liters 19-51
mg
^JCA) or 0.57
to 1.53 mg of PCA. This is a small amount considering
that in chemical plants where PCA is manufactured,
levels of PCA must exceed 20 mg/liter of urine before
workers are referred for medical treatment.
Long-Term Effects of CH Application. In 1976, in-
vestigators reported the effects of 2 years of daily CH
application.24,36-40 A test group applied 10 ml of 0.2%
CH digluconate daily in conjunction with brushing,
while a control group only brushed. Plaque, gingivitis,
changes in microbiota, systemic and local side effects
were monitored. A review of results reported in a series
of six papers follows:
Löe et al.24 indicated CH application resulted in a
decreased amount of plaque and gingivitis, but it tended
to stain the teeth. It is interesting to note that after 24
months the gingival index was not statistically different
between test and control groups, despite the decreased
plaque index in the test groups. This may be attributed
to the inability of the drug to penetrate subgingivally
and emphasizes that subgingival debridement is a
needed adjunct.
Schiott et al.36 found long-term therapy resulted in a
30% to 50% reduction of salivary bacteria without any
J. Periodontol.
June, 1986
detectable shifts in ratios of bacteria. Upon cessation of
CH use, the microbial population returned to pretreat-
ment levels. Inspection for changes of salivary flora
sensitivity revealed there was a slight shift toward or-
ganisms that were less affected by CH, which returned
to normal after completion of therapy.37
After 2 years' use, various medical parameters to
include determinations of hemoglobin, numbers of
erythrocytes, leukocytes, urine analysis, kidney and
liver function tests and assessment of general health
indicated there were no systemic side effects attributed
to CH application.38
Previously, authors28 noted white patches or desqua-
mative areas after CH rinses. To assess histological
changes associated with its use, MacKenzie et al.39
obtained gingival and palatal biopsies from nonusers
and individuals who used the drug for longer than 1
year. They reported no differences between groups with
respect to the degree of keratinization, layers of cells or
thickness of the stratum corneum. Nuki et al.40 evalu-
ated how treatment affected various oxidative enzymes
in the oral epithelium. They assayed lactic dehydrogen-
ase, malic dehydrogenase and glucose-6-phosphate de-
hydrogenase in palatal biopsy specimens from individ-
uals who applied CH for 18 months. It was concluded
there were no differences in enzyme activity in speci-
mens obtained from users and nonusers.
In conclusion, the six studies found no detrimental
effects caused by CH application in man over a 2-year
period.
Possible Development of Bacterial Resistance to CH
Application. Bacterial resistance to certain drugs ap-
pears as the result of selection of mutants that develop
due to chromosomal alterations or through transfer of
genetic information by conjugation. Antimicrobials
usually do not cause mutations, but instead participate
in the selection by providing an environment conducive
to growth of the less susceptible microbes. Chlorhexi-
dine has been reported to cause mutations41'42; however,
this does not occur often.14 Sussmuth et al.42 reported
a mutation frequency of 0.014% when Salmonella ty-
phimurium was exposed to low concentrations of CH.
Several papers addressed the possibility that CH ap-
plication resulted in the development of resistant bac-
terial strains. Hamp et al.43 applied 0.2% CH solution
twice daily to 10 beagles on a soft diet and monitored
them for 12 months. A control group received no
antimicrobial therapy and animals were monitored for
plaque, calculus, gingivitis and gingival exúdate. During
the first 6 months, the treated groups displayed no
plaque deposits and no periodontal disease, whereas
the control group manifested signs of chronic gingivitis.
After 6 months the treated group displayed plaque, and
increasing levels of gingivitis and exúdate were noted.
Plaque samples were tested in vitro and microorganisms
from the treated dogs were found to be less sensitive to
CH. A possible explanation was that microorganisms
Volume 57
Number 6
were developing resistance to CH application. Other
investigators who monitored CH application for 2 years
in humans reported no reduction of plaque inhibition
and only a minor reduction of salivary bacterial sensi-
tivity.2437 Researchers also indicated that after cessation
of CH therapy bacteria returned to pretherapy sensitiv-
ity.14'37 However, removal of selection pressure exerted
by antimicrobials may notpredictably result in rever-
sion of the bacterialpopulation to a sensitive state.44'45
The development of resistant strains is a frequently
encountered phenomenon associated with antibiotic
therapy. Korman and Karl46 and others47 monitored
patients who received long-term systemic tetracycline
and reported that subgingival plaque developed resist-
ance to drug therapy. This has not been clearly dem-
onstrated with CH, and Gjermo29 postulated that hu-
man bacteria recovered by investigators after CH ther-
apy did not develop resistance, but rather represented
strains which were less sensitive to the drug.
CLINICAL APPLICATION
Periodontal diseases are plaque-induced infections
and our therapeutic strategy should be directed at elim-
inating periodontopathic organisms. However, it is still
unclear which microbes cause gingivitis or Periodonti-
tis. Without knowing which bacteria are overt patho-
gens, clinicians have resorted to the nonspecific removal
of all microorganisms. That may be counterproductive,
because certain organisms are inhibitory for other spe-
cies. For example, in the presence of S. sanguis, Acti-
nobacillus actinomycetemcomitans, an overt pathogen
associated with juvenile Periodontitis, does not colo-
nize.48
Application of CH is a nonspecific attempt to control
microorganisms and judicious timing of therapeutic
interventions can aid in obtaining a healthy periodon-
tium. Various modes of drug delivery have been sug-
gested and each technique provides different advan-
tages. Three common methods of CH application,
namely rinsing, using oral irrigators and subgingival
irrigation with a syringe are discussed separately. The
use of CH in toothpastes and gels will not be reviewed,
since this mode of delivery is not available in the United
States.
Rinsing. In 1970 Löe and Schiott12 demonstrated
that twice daily rinsing with 10 ml of 0.2% CH solution
(20 mg CH) for 1 minute resulted in complete plaque
elimination. This reduction of plaque persisted during
the 22 days that were monitored. A later paper by Löe
et al.24 reported that reduced plaque levels were main-
tained for 2 years using daily 0.2% CH mouth rinses.
Using a similar oral rinse, Flotra et al.49 monitored
50 soldiers for 4 months. They reported a 66% reduc-
tion in plaque and 24% decrease in gingivitis. The
authors noted that the test group which had subgingival
scaling demonstrated an 88% reduction of plaque and
Chlorhexidine 373
43% decrease of gingivitis. These findings, once again
suggest the need for subgingival plaque removal to
reduce gingivitis.
Investigators have assessed the efficacy of various
concentrations. Lang and Räber50 reported a daily rinse
with 30 ml of 0.1 % CH failed to eliminate plaque and
gingivitis, whereas others claimed a 0.1 % solution was
effective in many cases.49 51 Cumming and Löe52 sug-
gested a daily rinse should employ 50 ml of 0.1 % CH
to provide a larger dose of the drug. Ten milliliters of a
2% solution applied once daily also was reported to
prevent plaque formation.12
In summary, it appears that patients respond differ-
ently to a range of concentrations. Therefore, dosages
need to be individually determined and low concentra-
tions can be compensated by increasing the volume
applied.
Oral Irrigators. Oral irrigators fail to achieve optimal
plaque removal and gingivitis can result if they are
substituted for manual hygiene procedures.50'53 54 How-
ever, they can provide a satisfactory vehicle to apply
antimicrobial agents interproximally and subgingi-
vally.50
Lang and Räber50 compared the inhibitory effect of
CH when applied as a mouth rinse and in oral irrigators.
They concluded antimicrobial agents would be more
effectively distributed with irrigating devices resulting
in a reduced plaque index. The difference was most
pronounced interproximally, an area often missed dur-
ing toothbrushing. However, their oral rinse consisted
of 30 ml of 0.1% solution (30 mg of CH) whereas 600
ml of 0.05% solution was used for irrigation (300 mg
CH). Thus, while the concentration during irrigation
was decreased, the dosage of CH was increased tenfold.
This accented the need to determine precise concentra-
tions, because suboptimal doses may not provide sat-
isfactory plaque control. Thereafter, Lang and
Grossman55 assessed several different dosages by vary-
ing the concentrations and volumes of applied solu-
tions. They found that either 400 ml or 600 ml of
0.02% CH solution (80 or 120 mg), 600 ml of 0.05%
CH solution (300 mg) or 600 ml of 0.1% CH solution
(600 mg) via an irrigating device were equally effective
in reducing plaque levels. It was concluded that 400 ml
of0.029c CH solution, applied once daily, was the lowest
concentration and best dosage (80 mg) that could
achieve optimal plaque control.55 The authors reported
it took about 1 minute to apply 400 ml of solution via
an irrigator.
Subgingival Irrigation with CH. Chlorhexidine ap-
plication resulted in a decreased plaque index, but not
a reduced gingival index after 2 years.24 It was hypoth-
esized this was due to failure of the rinsing solution to
penetrate subgingivally. Flotra et al.49 noted that lack
of reduction of inflammation was particularly apparent
at sites where pockets were greater than 3 mm. Possibly,
the inflammatory crevicular fluid released in pockets

374 Greenstein, Berman, Jaffin
created an osmotic gradient which prevented solutions
from penetrating. Subsequently, Pitcher et al.56 dem-
onstrated solutions applied as rinses or with direct
irrigation at the gingival margin failed to reach the base
of deep pockets. To determine if this problem could be
overcome, Hardy et al.57 inserted a needle 3 mm subgin-
givally and irrigated with disclosing solutions. Biopsy
specimens indicated the dyes penetrated the apical bor-
der of the plaque, regardless of pocket depths.
Subgingival CH application using a syringe was as-
sessed by Soh et al.58 who instructed individuals to
irrigate with 0.2% solution for 28 days. They found that
it was necessary to perform irrigation a minimum of 2
and a maximum of 4 weeks to obtain a reduction of
sulcular bleeding, pocket depth and subgingival plaque.
However, it was reported that clinical signs returned to
baseline values within 8 weeks after stopping therapy.
Another study which evaluated daily irrigation for 1
month reported that improved periodontal status was
maintained for longer than 2 months.59 Investigators
concluded that CH irrigation may be a useful adjunct
to scaling and root planing.58-59
Two recent studies addressed the efficacy of irrigating
deep pockets with 2% CH as a supplement to oral
hygiene and root debridement.60-61 Both papers re-
ported that bleeding scores, pocket depths and spiro-
chetal counts were reduced after nonsurgical periodon-
tal therapy with or without antimicrobial irrigation.60'61
Investigators concluded that biweekly60 or daily61 irri-
gation with 2% CH for 24 weeks did not enhance
treatment of patients with effective oral hygiene who
underwent supra- and subgingival root planing.
CONCLUDING REMARKS
Investigators who compared the antiplaque efficacy
of CH rinses to various fluoride preparations,62 quater-
nary ammonium compound D-301,63 and CuSo464 all
concluded that CH digluconate was superior and re-
mains the chemotherapeutic agent of choice. Other
methods of drug delivery are also under investigation.
Chlorhexidine has been administered subgingivally us-
ing acrylic strips65 and slow releasing dialysis tubing.66
Both techniques have resulted in significant reduction
of disease activity; however, additional studies are
needed with respect to the dose and duration of local
drug delivery systems.
Relative to local application techniques, Addy and
Moran67 reported topically applied CH was as effective
as CH mouthrinses. This reinforced the importance of
locally adsorbed CH and questioned the relevance of
the oral reservoir effect which refers to the ability of
mucous membranes, etc. to retain and provide the drug
for an extended period of time.
With respect to maintaining periodontal status, su-
pragingival CH application has not been reported to be
superior to effective manual oral hygiene.24-68"70 Simi-
larly, intracrevicular irrigation with CH has not
J. Periodontol.
June, 1986
achieved better results than subgingival scaling.60-61
However, among the handicapped,71-72 or when inade-
quate plaque control is performed, chemotherapeutic
agents have reduced the amount of plaque and gingival
inflammation.73"77
It should be noted, researchers have cautioned that
CH in low concentrations resulted in death of human
epithelial cells,78 human fibroblasts79 and rat macro-
phages in culture.80 Other side effects seen in animals
have included temporary lingual dyskeratosis in rats81
and hyperkeratinization of cheek mucosa in hamsters,
if concentrations exceeded 2% solutions.82 Accordingly,
some investigators have suggested that CH should be
applied for limited periods of time and reserved for
specific circumstances.68'81 ·83"85
Chlorhexidine can be used as an adjunct to therapy
to control gingival inflammation, especially in acute
situations (e.g., acute necrotizing gingivitis), and during
periods of interrupted hygiene. After periodontal sur-
gery, the patient's ability to perform hygiene is reduced
and therapeutic agents are worthwhile aids. Studies
addressing the value of CH after surgery in a rinse,73-74
periodontal pack75 or topically applied67-76 indicated
that the drug facilitated an improved periodontal status.
A paper which assessed its use postsurgically deter-
mined it was as effective as professional cleaning every
2 weeks at reducing plaque and gingival inflam-
mation.77 The drug also reduced pain after surgery, but
the precise neuropharmacologic alteration induced has
not been elucidated.74-76
Since pure CH is not commercially available, rec-
ommended solutions can be obtained by diluting Hib-
iclens. To deliver 20 mg of CH as an oral rinse or 80
mg via an irrigator, dilute 18 drops of Hibiclens in a
tablespoon or more of water for the rinse and 72 drops
in 400 ml of water as an irrigating solution. Computa-
tions of mg dosages are shown in Table 1. The rinse is
usually performed for 1 minute in the morning and
evening (before retiring), whereas the irrigating solu-
tion is used once daily. Drug concentrations can be
varied depending on patient response and the taste can
be improved by adding some additional water to the
dilutions. Staining can be reduced by decreasing con-
centrations and dosages.
The oral cavity is unique in that plaque formation is
a continous process, thereby providing a persistent po-
tential for gingival inflammation. Once CH application
is withdrawn, plaque levels return to preexisting
amounts. Therefore, it is the authors' feelings that
prophylactic utilization seems inappropriate, since
there is no logical end point for drug therapy. Duration
of CH application should be dictated by the clinician's
objectives and the dose determined by balancing drug
efficacy against undesirable side effects. At present, the
greatest limitation imposed on its use is due to staining
and its bitter taste. Both short- and long-term human
studies have demonstrated CH to be safe and eflica-
Volume 57
Number 6 Chlorhexidine 375
Table 1
Calculation of Concentrations for Oral Rinse and Irrigating Solution
4 gm 4000 mg° =--§
40 mg
—f—
. » ,
4% CH in
rr-,
Hibiclens = =
· -

100 ml 100 ml ml
36 drops of Hibiclens 1 ml* ~

Therefore 1 drop contains 1.11 mg CH

Oral Rinse
To rinse with an equivalent amount of CH found in 10 ml of 0.2% CH solution (2 mg/ml), add
18 drops Hibiclens (0.5 ml contains 20 mg CH) to a tablespoon of water. If the taste is not
tolerable, have the patient place 18 drops in 'h glass of water. This decreases the concentration,
but it's more palatable.
Irrigating Solution
To irrigate with an equivalent amount of CH found in 400 ml of 0.02% CH solution (0.2 mg/
ml), add 72 drops of Hibiclens (2 ml contains 80 mg of CH) to 400 ml of water in an irrigator
tank.
* ~
approximately (it could be several drops more or less depending on the size of the eye dropper
used).

cious. However, clinicians need to be aware that the
longest studies monitoring its continuous use have not
exceeded 2 years.24'36"40
ACKNOWLEDGMENTS
The authors would like to thank Barbara Fitzmartin for typing the
manuscript and Dr. Michael Rethman for reviewing the paper.
REFERENCES
1. Douglass, C. W., Gillings, D., Sollecito W., and Gammon, M.:
National trends in the prevalence and severity of the periodontal
diseases. J Am Dent Assoc 107: 403, 1983.
2. Dummett, C. O.: Epidemiology of periodontal disease. Milit
Med 148: 606, 1983.
3. Andrews, G., and Krogh, H. W.: Permanent tooth mortality.
Dent Prog I: 130, 1961.
4. Berman, C, Jaffin, R„ and Greenstein, G: The Chlorhexidine
question. J Periodontal 55: 668, 1984.
5. Hibiclens antimicrobial skin cleanser. Physicians' Desk Refer-
ence, ed 37, 1977. Oradell, NJ, Medical Economics Company,
1983.
6. Use of approved drugs for unlabeled indications. FDA Drug
Bull 12(1): 4, 1982.
7. Development of orphan products, unlabeled indications. FDA
Drug Bulll3(l): 3, 1983.
8. Hugo, W. B., and Longworth, A. R.: Some aspects of the mode
of action of Chlorhexidine. J Pharm Pharmacol 16: 655, 1964.
9. Hugo, W. B., and Longworth, A. R.: Cytological aspects of the
mode of action of Chlorhexidine diacetate. J Pharm Pharmacol 17:
28, 1968.
10. Brecx, M., and Theilade, J.: Effect of Chlorhexidine rinses on
the morphology of early dental plaque formed on plastic film. J Clin
Periodontol 11: 553, 1984.
11. Rolla, G., and Meisen, .: On the mechanism of plaque
inhibition by Chlorhexidine. J Dent Res 54: 1357, 1975.
12. Löe, ., and Schiott, C. R.: The effect of mouth rinses and
topical application of Chlorhexidine on the development of dental
plaque and gingivitis in man. J Periodont Res 5: 79, 1970.
13. Schiott, C. R., Löe, H., Jensen, S., et al.: The effect of Chlor-
hexidine mouth rinses on the human oral flora. J Periodont Res 5:
84, 1970.
14. Hennessey, T. D.: Some antibacterial properties of Chlorhexi-
dine. J Periodont Res 8: 61, 1973.
15. Budtz-Jorgensen, E., and Löe .: Chlorhexidine as a denture
disinfectant in the treatment of denture stomatitis. Scand Dent J Dent
Res 80: 457, 1972.
16. Bonesvoll, P., Lokken, P., and Rolla, G: Influence of concen-
tration, time, temperature and pH on the retention of Chlorhexidine
in the human oral cavity after mouth rinses. Arch Oral Biol 19: 1025,
1974.
17. Bonesvoll, P., Lokken, P., Rolla, G. and Paus, P. . Retention
of Chlorhexidine in the human oral cavity after mouth rinses. Arch
Oral Biol 19: 209, 1974.
18. Magnusson B., and Heyden, G: Autoradiographic studies of
14C Chlorhexidine given orally in mice. J Periodont Res 8: 49, 1973.
19. Haugen, E., and Johansen, J. R.: Penetration of the oral
mucosa of the guinea pig by radiolabelled Chlorhexidine. Acta Ódontól
Scandii: 365, 1975.
20. Case, D. E.: Safety of Hibitane. I. Laboratory experiments. J
Clin Periodontol 4: 66, 1977.
21. Bonesvoll, P.: Oral pharmacology of Chlorhexidine. J Clin
Periodontol 4: 49, 1977.
22. Winrow, M. J.: Metabolic studies with radiolabelled Chlorhex-
idine in animals and man. J Periodont Res 8: 45, 1973.
23. Foulkes, D. M.: Some toxicological observations on Chlorhex-
idine. J Periodont Res 8: 55, 1973.
24. Löe, H., Schiott, C. R., Glavind, L., and Karring, T.: Two
years' oral use of Chlorhexidine in man. I. General design and clinical
effects. J Periodont Res 11: 135, 1976.
25. Rolla, G., Ellingsen, J. E., Eriksen, H. M., and Nordbo, H.:
Dental stain by Chlorhexidine, a possible mechanism (lADR-Abstra.)
/ Dent Res 60: 528, 1981.
26. Ellingsen, J. E., Rolla, G., and Ericksen, H. M.: Extrinsic
dental stain caused by Chlorhexidine and other denaturing agents. J
Clin Periodontol 9: 317, 1982.
27. Addy, M., Moran, J., Davies, R., et al.: The effect of single
morning and evening rinses of Chlorhexidine on the development of
tooth staining and plaque accumulation. A blind cross-over trial. /
Clin Periodontol 9: 134, 1982.
28. Flotra, L., Gjermo, P., Rolla, G., and Waerhaug, J.: Side
effects of Chlorhexidine mouth washes. Scand J Dent Res 19: 119,
1971.
29. Gjermo, P.: Chlorhexidine in dental practice. J Clin Periodon-
tol 1: 143, 1974.
30. Ciarlone, A. E., Gangarosa, L., and Fong, B. C: Detection of
p-chloroaniline in Chlorhexidine solutions using thin layer chroma-
tography. J Dent Res 55: 918, 1976.
31. Vratsanos, S. M., and Kesner, L.: Nontechnical summary
paper: rapid liquid Chromatographie assay of chloroaniline isomers.
Presented at the 174th National Meeting of the American Chemical
Society, Chicago, 111., Aug 28-Sept 2, 1977.
32. British Pharmacopoea 1: 100, 1980.
33. Bioassay of p-chloroaniline for possible carcinogenicity. U. S.
Department of Health, Education and Welfare. Public Health Service,
National Institutes of Health. DHEW publication No. (NIH) 79-
1745, 1979.
34. Williams, G, Laspia, M. F., and Dunkel, V. C: Reliability of

376 Greenstein, Berman, Jaffin
the hepatocyte primary culture/DNA repair test in testing coded
carcinogens and noncarcinogens. Mutat Res 97: 359, 1982.
35. Thompson, C. Z., Hill, L., Epps, J., and Probst, G. The
induction of bacterial mutation and hepatocyte unscheduled DNA
synthesis by monosubstituted anilines. Environ Mutagen 5:803, 1983.
36. Schiott, C. R., Briner, W. W., and Löe, H.: Two-year oral use
of Chlorhexidine in man. II. The effect on the salivary bacterial flora.
J Periodont Res 11: 145, 1976.
37. Schiott, C. R., Briner, W. VV., Kirkland, J. J., and Löe, H.:
Two-year oral use of Chlorhexidine in man. III. Changes in sensitivity
of the salivary flora. J Periodont Res 11: 153, 1976.
38. Schiott, C. R., Löe, H., and Briner, W. W.: Two-year oral use
of Chlorhexidine in man. IV. Effect on various medical parameters. /
Periodont Res 11: 158, 1976.
39. MacKenzie, I. C, Nuki, K., Löe, H„ and Schiott, C. R.: Two-
year oral use of Chlorhexidine in man. V. Effects on stratum corneum
or oral mucosa. J Periodont Res 11: 165, 1976.
40. Nuki, ., Schlenker, R., Löe, H., and Schiott, C. R.: Two-
year oral use of Chlorhexidine in man. VI. Effect on oxidative enzymes
in oral epithelia. J Periodont Res 11: 172, 1976.
41. Schmidt, A. B., Sussmuth, R., and Lingens, F.: The reaction
of the mutagen , '-hexamethylene-bis [(5-/?-chlorophenyl)-biguan-
ide] with guanosine and cysteine. Biochim Biophys Acta 699: 149,
1982.
42. Sussmuth, R., Ackermann, ., and Lingens, F.: Mutagenic
effect of 1,1 hexamethylene-bis [(5-p-chlorophenyl)-biguanide], Chem
Biol Interact 28: 249, 1979.
'
43. Hamp, S. E., Lindhe, J., and Löe, .: Long-term effect of
Chlorhexidine on developing gingivitis in the beagle dog. / Periodont
Res S: 63, 1973.
44. Smith, H. W.: Antibiotic resistant E. coli in market pigs in
1956-1979. The emergence of organisms with plasmid-borne tri-
methoprim resistance. J Hyg (Cam) 84: 467, 1980.
45. Linton, A. H., Handley, B„ and Osborne, A. D.: Fluctuations
in E. coli o-serotypes in pigs throughout life in the presence of
antibiotic treatment. J Appi Bacteriol 38: 255, 1978.
46. Kormán, . S., and Karl, E. H.: The effect of long-term low
dose tetracycline therapy on the subgingival microflora in refractory
adult Periodontitis. J Periodontol 53: 604, 1982.
47. Osterberg, S. K., Williams, B., and Jorgensen, J.: Long-term
effects of tetracycline on the subgingival microflora. J Clin Periodon-
tol6: 133, 1979.
48. Socransky, S. S., Tanner, A. C, Haffajee, A.D.: Present status
of studies on the microbial etiology of periodontal disease. Host-
Parasite Interaction in Periodontal Disease, 1. Washington, DC,
American Society of Microbiology, 1982.
49. Flotra, L., Gjermo, P., Rolla, G., and Waerhaug, J.: A 4-
month study on the effect of Chlorhexidine mouth washes on 50
soldiers. Scand J Dent Res 80: 10, 1972.
50. Lang, N. P., and Räber, .: Use of oral irrigators as vehicles
for the application of antimicrobial agents in chemical plaque control.
J Clin Periodontol 8: 177, 1981.
51. Gjermo, P., Baastad, K. L., and Rolla, G.: The plaque inhib-
iting capacity of 11 antibacterial compounds. J Periodont Res 5: 102,
1970.
52. Cumming, B. R., and Löe, H.: Optimal dosage and method
of delivering Chlorhexidine solutions for the inhibition of dental
plaque. J Periodont Res 8: 57, 1973.
53. Hugoson, .: Effect of the Water Pik device on plaque accu-
mulation and development of gingivitis. / Clin Periodontol 5: 95,
1978.
54. Lobene, R. R., Soparkar, P. M., Hein, J. W., and Quigley, G.
.: A study of the effect of antiseptic agents and a pulsating irrigating
device on plaque and gingivitis. J Periodontol 43: 564, 1972.
55. Lang, N. P., and Grossman, K. R.: Optimal dosage of Chlor-
hexidine digluconate in chemical plaque control when applied by the
oral irrigator. J Clin Periodontol 8: 189, 1981.
56. Pitcher, G. R., Newman, . N., and Straham, J. D.: Access
J. Periodontol.
June, 1986
to subgingival plaque by disclosing agents using mouthrinsing and
direct irrigation. J Clin Periodontol 7: 300, 1980.
57. Hardy, J. H., Newman, H. N., and Strahan, J. D.: Direct
irrigation and subgingival plaque. J Clin Periodontol 9: 57, 1982.
58. Soh, L. L., Newman, H. N., and Strahan, J. D.: Effects of
subgingival Chlorhexidine irrigation on periodontal inflammation. J
Clin Periodontol 9: 66, 1982.
59. Wieder, S. G, Newman, . ., and Strahan, J. D.: Stannous
fluoride and subgingival Chlorhexidine irrigation in the control of
plaque and chronic Periodontitis. J Clin Periodontol 10: 172, 1983.
60. MacAlpine, R., Magnusson, I., Kiger, R. et al: Antimicrobial
irrigation of deep pockets to supplement oral hygiene instruction and
root debridement. I. Bi-weekly irrigation. J Clin Periodontol 12: 568,
1985.
61. Braatz, L., Garrett, S., Claffey, N., and Egelberg, J.: Antimi-
crobial irrigation of deep pockets to supplement nonsurgical peri-
odontal therapy. II. Daily irrigation. J Clin Periodontol 12:630, 1985.
62. Addy, M., Willis, L., and Moran, J.: Effect of toothpaste rinses
compared with Chlorhexidine on plaque formation during a 4-day
period. J Clin Periodontol 10: 89, 1983.
63. Saxer, U. P., Mormann, W., Firestone, A. R., and Eltink, B.:
Plaque control with Chlorhexidine and D-301 a quaternary ammo-
nium compound. J Clin Periodontol 9: 162, 1982.
64. Waerhaug, M., Gjermo, P., Rolla, G., and Johansen, J. R.:
Comparison of the effect of Chlorhexidine and CuS04 on plaque
formation and development of gingivitis. J Clin Periodontol 11: 176,
1984.
65. Addy, M., and Langeroudi, M.: Comparison of the immediate
effects on the subgingival microflora of acrylic strips containing 40%
Chlorhexidine, metronidazole or tetracycline. J Clin Periodontol 11:
379, 1984.
66. Coventry, J., and Newman, H. N.: Experimental use of a slow
release device employing Chlorhexidine digluconate in areas of acute
periodontal inflammation. / Clin Periodontol 9: 129, 1982.
67. Addy, M., and Moran, J.: Comparison of plaque accumulation
after topical application and mouth rinsing with Chlorhexidine glu-
conate. J Clin Periodontol 10: 69, 1983.
68. Bain, M. J., and Strahan, J. D.: The effect of a 1 % Chlorhexi-
dine gel in the initial therapy of chronic periodontal disease. J
Periodontol 49: 469, 1978.
69. Hansen, F., Gjermo, P., and Eriksen, H. M.: The effect of
chlorhexidine-containing gel on oral cleanliness and gingival health
in young adults. J Clin Periodontol 2: 153, 1975.
70. Lennon, . ., and Davies, R. M.: A short-term evaluation
of a Chlorhexidine gel on plaque deposits and gingival status. Phar-
macol Ther Dent 2: 13, 1975.
71. Flotra, L.: Different modes of Chlorhexidine application and
related side effects. J Periodont Res 8: 41, 1973.
72. Usher, P. J., Oral hygiene in mentally handicapped children.
BrDentJnS: 217, 1975.
73. Davies, R. M.: Use of hibitane following periodontal surgery.
J Clin Periodontol 4: 129, 1977.
74. Newman, P., and Addy, M.: Comparison of hypertonic saline
and Chlorhexidine mouthrinses after inverse bevel procedure. / Per-
iodontol 53: 315, 1982.
75. Pluss, E. M., Engelberger, P. R., and Rateitschak, . H.: Effect
of Chlorhexidine on dental plaque formation under periodontal pack.
J Clin Periodontol 2: 136, 1975.
76. Bakaeen, G. S., and Strahan, J. D.: Effects of a 1% Chlorhex-
idine gel during the healing phase after inverse bevel mucogingival
flap surgery. J Clin Periodontol 7: 20, 1980.
77. Westfeit, E., Nyman, S., Lindhe, J., and Socransky, S.: Use of
Chlorhexidine as a plaque control measure following surgical treat-
ment of periodontal disease. J Clin Periodontol 10: 22, 1983.
78. Helgeland, ., Heyden, G, and Rolla, G.: Effect of Chlorhex-
idine on animal cells in vitro. Scand J Dent Res 79: 209, 1971.
79. Goldschmidt, P., Cogen, R., and Taubman, S.: Cytopathologic
effects of Chlorhexidine on human cells. J Periodontol 48: 212, 1977.
Volume 57
Number 6
80. Knuuttila, M., and Soderling, E.: Effect of Chlorhexidine on
the release of lysosomal enzymes from cultured macrophages. Acta
Odontol Scand 39: 285, 1981.
81. Harvey, . V., Squier, C. ., and Hall, . K.: Effects of
Chlorhexidine on the structure and permeability of hamster cheek
pouch mucosa. J Periodontol 55: 608, 1984.
82. Sonis, S., Clark, W. B., and Shklar, G.: Chlorhexidine-induced
lingual keratosis and dysplasia in rats. J Periodontol 49: 585, 1978.
83. Hutchens, L. H.: An overview of a conference on "implica-
Abstracts
Occlusal Wear: A Follow-Up Study of 18 Subjects with
Extensively Worn Dentitions
Carlsson, G. E., Johansson, ., and Lundquist, S.
Acta Odontol Scand 43: 83, Number 2, 1985.
A group of 18 patients with wear extending into dentin were
provided with occlusal splints that were worn with various intensities
for more than one third of the follow-up period of 6 to 10 years.
When patients were re-examined there was a nonsignificant correla-
tion between original degree of wear and continued wear as measured
by assessment of casts, intraoral photographs, clinical examinations,
salivary analysis (calcium content), bite force measurements, and a
questionnaire. The questionnaire brought out other factors which
contributed to wear; for example, bruxism, acid régurgitation, intake
of citrus fruits, and dryness of the mouth. The results revealed that
high bite forces were used by those with extensive wear. A correlation
was seen between increased wear and a lower calcium content of
saliva. Continued dentinal wear was seen to be a slow process in
patients who had received an occlusal splint and therefore due time
should be allowed to examine the etiology and plan therapy. Depart-
ment of Stomatognathic Physiology, Faculty of Odontology, Univer-
sity ofGothenburg, Box 33070, S-400 33 Gothenburg, Sweden.
Dr. Laura Reidy
Pancreatic Carcinoma Metastatic to the Mandibular
Gingiva
Stecher, J. ., Mostofi, R., True, L. D., and Indresano, A. T.
J Oral Maxillofac Surg 43: 385, May, 1985.
A 46-year-old black male, previously in good health, was hospital-
ized with complaints of anorexia, weight loss, and upper abdominal
pain diagnosed as pancreatic carcinoma. When bronchoscopy was
performed. Teeth 21 to 27 were traumatized and extremely mobile,
and clinical and radiographie examination showed signs consistent
with advanced Periodontitis. Due to a hopeless prognosis, the teeth
were extracted and the excess gingiva was excised and submitted for
histologie study. Examination revealed normal epithelium covering
a submucosal connective tissue densely infiltrated with large malig-
nant cells identical with those of other sites of metastasis. Metastasis
to oral soft tissue is extremely rare and has a very poor prognosis.
Such tumors can be mistaken for other, more common conditions,
so it is advisable to analyze all oral tissue of abnormal appearance so
that appropriate treatment may be commenced if necessary. Reprint
from Dr. Indresano, Cleveland Metropolitan General Hospital, 3395
Scranton Road, Oral Surgery Department, Cleveland, OH 44109.
Dr. Michael Stressberg
Chlorhexidine 377
tions of periodontal research on predoctoral education." J Periodontol
56: 562, 1985.
84. Gjermo, P.: Hibitane in periodontal disease. J Clin Periodontol
4:94, 1977.
85. Bain, M. J.: Chlorhexidine in dentistry—a review. Dent
/76:49, 1980.
Send reprint requests to: Gary Greenstein, DDS, MS, 900 West
Main St, Freehold, NJ 07728.
Effects of Smokeless Tobacco and Snuff on Oral
Mucosa of Experimental Animals
Shklar, G, Niukian, K., Hassan, M., and Herbosa, . G.
J Oral Maxillofac Surg 43:80, February, 1985.
Snuff and chewing tobacco have both been implicated in increased
incidence of oral cancer. Three separate populations of Syrian ham-
sters were used; one to study gross and microscopic changes in the
buccal pouch, the second to study Langerhans' cell morphology and
density, and the third to study mitotic activity. Each population was
divided into three groups: Group 1 was the control, Group 2 was
exposed to chewing tobacco, and Group 3 was exposed to snuff. In
the two experimental groups, the substances were placed in the right
buccal pouches daily, the left being the untreated control. Half of the
Group I animals were manipulated with a plastic instrument to
simulate placing of the tobacco and snuff, while the other half was
untreated. To study gross and microscopic changes, half the hamsters
were sacrificed at 10 weeks and half at 20 weeks. In the other two
populations all animals were killed at 20 weeks. Grossly, at 10 and
20 weeks the buccal pouches of the exposed animals appeared normal
and autopsies were negative. The treated pouches of Group 2 and
Group 3 hamsters demonstrated some areas of light to moderate
epithelial hyperkeratosis but no dysplastic or neoplastic changes. All
major organs appeared normal. Examination of Langerhans' cell
morphology and density showed a significant increase in numbers in
the tobacco group as compared to the control. There was a small but
statistically significant difference between the tobacco and snuff
groups, and only a marginally significant difference between the
control and snuff groups. Mitotic activity in the basal epithelial layer
was significantly decreased in comparison to the controls, and al-
though there was significantly more mitotic depression in those
exposed to tobacco than in those exposed to snuff, the difference
between the control and snuff animals was less than that between the
control and tobacco hamsters. The depressed mitotic activity implies
some toxicity in the snuff and tobacco. A local immune response in
the tobacco group was suggested by the elevated Langerhans' cell
count. It is possible that chewing tobacco causes a sufficient change
in some cells to provoke an immune response while not being great
enough to induce histologically visible cellular changes. Although no
cancerous or precancerous degeneration was observed, chewing to-
bacco and snuff held in opposition to the oral mucosa could begin a
process requiring another carcinogenic agent to complete the process
leading to malignancy. Further study along these lines is indicated.
Department of Oral Medicine and Oral Biology, Harvard School of
Dental Medicine, 188 Longwood Ave, Boston, MA 02215.
Dr. Michael Strassberg