Chlorhexidine

&
Its Uses
CONTENTS
1. INTRODUCTION
2. HISTORY
3. CHEMICAL STRUCTURE
4. PROPERTIES
5. MECHANISM OF ACTION
6. GENERAL USES
7. AVAILABLE FORMS
8. STORAGE
9. USES IN CONS & ENDO
CHLORHEXIDINE
Digluconat
e

CH
X

Acetate Hydrochloride
HISTORY
 Ophthalmology,
Urology, Gynecology Use widespread
1ST Developed & in dentistry
Otorhinolaryngology

1947 1954 1957 1959 1970s

Antiseptic

Cleaning skin,
wounds & mucous Plaque Inhibition
membranes

Hibitane
Chemical Structure
 4-chlorophenyl ring
Biguanide groups
Hexamethylene chain
PROPERTIES
• Antimicrobial activity
• Substantivity
• Surface tension
• Dissolution of organic tissues, biofilm and
smear layer
• Cytotoxic effect
• Genotoxicity
• Lubricating properties
• Rheological action (present in the gel
presentation, keeping the debris in suspension)
• Inhibits metalloproteinase
• Chemically stable
• Water soluble
• Colorless - pale straw-colored / slightly
opalescent
• Odorless / almost odorless substance.
• Extremely bitter taste that must be masked in
formulations intended for oral use
 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 also retains its activity in the presence of blood and organic matters
Liquid form CHX kills microorganisms in 30 s or less, while in the gel
formulation it takes from 22 s (2% CHX gel) to 2 h (0.2% CHX gel)

Gomes BP, Vianna ME, Zaia AA, Almeida JF, Souza-Filho FJ, Ferraz CC. Chlorhexidine in
endodontics. Brazilian dental journal. 2013 Mar;24:89-102.
SUBSTANTIVITY (Long term
continued effect)
Absorption to dental hard tissues with gradual and prolonged
release at therapeutic levels
It is concentration and time dependent

CHX – highest substantivity (12hrs plaque inhibition)

As Root canal irrigating substance prevented microbial activity
from 48 h, 7 days (in the liquid and gel formulation), 21 days, 4
weeks, up to 12 weeks
 SUBSTANTIVITY (Long term continued
effect)
Absorption to dental hard tissues with gradual and prolonged
release at therapeutic levels

It is concentration and time dependent

Ruksakiet K, Hanák L, Farkas N, Hegyi P, Sadaeng W, Czumbel LM, Sang-Ngoen T, Garami A, Mikó A, Varga G, Lohinai Z.
Antimicrobial efficacy of chlorhexidine and sodium hypochlorite in root canal disinfection: a systematic review and meta-analysis
of randomized controlled trials. Journal of endodontics. 2020 Aug 1;46(8):1032-41.
Lowconcentratio
n (0.005% to
0.01%)
High concentrations

Constant
monolayer of
CHX
Efficacy : NaOCl VS CHX
MECHANISM OF
ACTION
 At high doses (2%)

Electrostatic binding between cationic molecules and

negatively charged bacterial cell wall

Bactericidal action

Precipitation & coagulation of cytoplasmic proteins

Cell death
 At low doses(0.2%)

Cell membrane integrity

altered

Bacteriostatic effect

Leakage of low molecular weight bacterial

components
Available Forms
Gel base
0.1%, 0.2%, 0.12%
pH 6-9
Toothbrush or trays

Mouth rinse
Aqueous or alcohol – 0.2% / 0.12%
optimal pH range of 5.5 to 7.0

Sprays
0.1%, 0.2%
1-2mg – delivered to all tooth surfaces
 2% CHX > 2% CHX solution

Lubricates the root canal walls

Decreasing the risks of instrument breakage
Elimination of organic tissues
Reduction of smear layer formation
Maintains almost all the dentinal tubules open because its viscosity
keeps the debris in suspension (rheological action)
keep the “active principle” of CHX in contact with the microorganisms for
a longer time, inhibiting their growth
 STORAGE
Shelf life - 1 year
Gel formulation - 10 months
CONSERVATIVE
MMP inhibition (etch and rinse)
1. Use of chlorhexidine following the etching procedure with 37% phosphoric acid and prior to the application of the bonding
agent
2. CHX acts as unspecific inhibitor of MMPs by altering their three-dimensional structure and depleting metal ions (Ca2+,
Zn2+), which are necessary for their function
3. CHX is able to inactivate all MMPs existing in dentin at a concentration of only 0.02%
4. 2% CHX for 60 s to 0.002% CHX for 15 s

5. Using chlorhexidine (CHX) as therapeutic primer in etch-and rinse systems, these enzymes are inhibited and the adhesive
bond to dentin is maintained for a longer time period.
6. MMP inactivation by CHX, it remains stable for longer periods
Dentine bonding
1. CHX application prior to acid etching has no adverse effects
on immediate composite adhesive bonds in coronal dentin,
pulp chamber dentin, enamel, or with resin-reinforced glass-
ionomer cements.
2. Endodontic irrigation with CHX solution significantly
increased bond strength to root dentin
foam pellet after the etching procedure
thorough removal of the phosphoric acid
appropriate exposure time
cavity is air-dried
re-moistened with the selected adhesive system

The utilization of CHX is not able to completely prevent nanoleakage and subsequent gradual loss of the adhesive bond, but it is
certainly an important step towards a durable and stable adhesion between dentin and composite resin. In summary, when using
etch-and-rinse systems, applying a pure aqueous solution of CHX (0.2%; 30 s) as therapeutic primer after etching and before
administration of the bonding agent can contribute to a delay of degradation processes and hence improves the long-term stability
of the adhesive bond to dentin.

Rinsing with water after CHX application should be avoided (water can remove CHX from dentin)
immediate strength of the adhesive bond is not altered by CHX application, however, after longer periods of time, the stability of
adhesive bonds created using CHX is even considerably improve
Self conditioning systems
1. CHX integration in self-conditioning systems can impair the mechanical properties of the bonding agents and the adhesive
bond to dentin
AIM:-POTENTIALLY USED IN ADHESIVE AND RESTORATIVE
DENTISTRY.
A pH-sensitive CHX release response was noted when loaded in MSN
grafted PGA nanoparticles.
The formulated drug-loaded nanocarrier demonstrated excellent
physicochemical, spectral, and biological characteristics SUCH AS
considerable
• capacity to penetrate effectively inside dentinal tubules
• high antibacterial efficacy
ENDODONTICS
 Root Canal Irrigants
1. Broad spectrum antimicrobial action, substantivity and low
toxicity
2. Incapacity of tissue dissolution and does not promote a superficial
necrosis

3. 2% CHX gel produced the cleanest dentin wall surfaces when

compared with other irrigants, including NaOCl
(Viscosity, rheological action, better mechanical cleansing)
Interaction with Endodontic Irrigants
NaOCl + CHX
Orange-brown precipitate
Chemical smear layer
Covers dentinal tubules
Interfere with the seal of the root filling

Precipitate changes the color of the tooth and is cytotoxic

Irrigation regimen : NaOCl would be used throughout
instrumentation, followed by EDTA, and CHX would be
used as a final irrigant
Intracanal medicament
1. Bactericidal and neutralizes the remaining tissue debris
2. CHX is more effective than CH against E. faecalis
infection in dentinal tubules
3. Antimicrobial activity of CHX is reduced when
combined
4. CHX alone does not act as a physical barrier and does not
present radiopacity
5. Recommended for a short period of time (3-5 days)
6. Delivered with a syringe
 CH + CHX
1. Antimicrobial activity of CH increases with the
combination with CHX (pH =13)
2. 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
3. Inflammatory internal and external root resorption
4. Best antimicrobial activity = 15-30days
DIFFUSION INTO THE DENTINAL TUBULES

Anti microbial effect

2% CHX
CH + 2%CHX
CH + 2%CHX +ZnO
CH + sterile saline
Disinfection of Obturation Cones
1. Kill vegetative forms within short periods of time
2. 2% CHX did not change gutta-percha cone properties
after exposure for up to 30 min (less harmful)
3. Some residual antibacterial action.
4. CHX was a better disinfectant compared with NaOCl,
High values of surface free energy.
CHX smaller contact angles than NaOCl
CORONAL
MICROLEAKAGE
Coronal microleakage during the intracoronal bleaching

CHX used as a vehicle for sodium perborate

Enhanced antimicrobial activity & did not affect adversely

dentin microhardness
CHX has been recommended as an alternative to NaOCl,
especially in cases of
Open apex
Root resorption
Foramen enlargement
Root perforation
 RECENT ADVANCES
Qmix (17% EDTA 2% CHX)
Mixture of a bisbiguanide antimicrobial agent (2% CHX), a
polyaminocarboxylic acid calcium-chelating agent (17% EDTA), saline, and
a surfactant [16].
QMix has shown to have superior antimicrobial property compared to CHX
in reducing E. faecalis and the ability to remove the smear layer that is
similar to EDTA

Lim BS, Parolia A, Chia MS, Jayaraman J, Nagendrababu V. Antimicrobial efficacy of QMix on
Enterococcus faecalis infected root canals: a systematic review of in vitro studies. Restorative dentistry &
endodontics. 2020 Mar 4;45(2).