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What Are the Contraindications to Chlorhexidine Use

The only absolute contraindication to CHG mouthrinse use is hypersensitivity to CHG or to any components found in the product formulation.

By Ann Eshenaur Spolarich, RDH, PhD, FSCDH On May 26, 2020 0

WHAT ARE THE CONTRAINDICATIONS TO CHLORHEXIDINE USE?

In 1987, the prescription mouthrinse 0.12% chlorhexidine gluconate (CHG) was accepted by the American Dental Association (ADA) as an effective aid for reducing supragingival plaque and gingivitis and received the ADA Seal of Acceptance by the Council on Scientific Affairs.¹ CHG was reviewed and approved by the United States Food and Drug Administration (FDA) by means of a new drug application, and classified as safe and effective.^2,3The FDA has determined that, based on the evidence, formulations that contain CHG are safe and effective.^2,3 CHG is available in the US only by prescription.

The only absolute contraindication to CHG mouthrinse use is hypersensitivity to CHG or to any components found in the product formulation.⁴ Most reported allergic reactions occurred during the perioperative period of medical surgeries in hospital settings, and were primarily attributed to exposure to chlorhexidine as a surface disinfectant.⁵ However, cases of allergic reactions and anaphylaxis have also been documented using CHG mouthrinse.^6,7

CHG mouthrinse can stain the teeth, mucosa, gingiva, and the dorsum of the tongue. Stain on tooth surfaces may be removed during a prophylaxis. However, stain may also occur on or around composite restorations, acrylic dental materials, and restorations with an open margin, which may be difficult to completely remove.^8,9 For this reason, clinicians should assess whether another antiseptic mouthrinse may be preferred for those with cosmetic dentistry. Patients who use CHG mouthrinse may also notice temporary alterations in their perceptions of taste.^10–14

Patients with a history of alcohol abuse should be advised that the use of an alcohol-containing mouthrinse may induce relapse, and they should consult with their abuse sponsor before use. Formulations of CHG mouthrinse without alcohol are available.

For gingivitis reduction, patients should be instructed to brush and floss their teeth, then rinse all toothpaste from the mouth thoroughly. CHG, a cation, negatively interacts with anions, including sodium lauryl sulfate and sodium monofluorophosphate.¹⁵ To minimize risk for this interaction, a waiting period of at least 30 minutes should elapse after dentifrice use prior to rinsing with CHG.¹⁵

Finally, research suggests that CHG may be cytotoxic to human gingival fibroblasts.^16–19 Exposure to CHG has been shown to negatively affect fibroblast viability, adhesion, and proliferation, and stimulate apoptosis in vitro, all of which may impede wound healing. It is important to note that CHG mouthrinse is approved for use supragingivally. Risk for cytotoxicity and compromised wound healing negate its use as a subgingival irrigant.

REFERENCES

American Dental Association. Council on Dental Therapeutics accepts Peridex. J Am Dent Assoc. 1988;117:516–517.
Imrey PB, Chilton NW, Philstrom BL, et al. Recommended revisions to American Dental Association guidelines for acceptance of chemotherapeutic products for gingivitis control. J Periodont Res. 1994;29:299–304.
United States Food and Drug Administration. Oral health care drug products for over-the-counter human use: antigingivitis/antiplaque drug products; establishment of a monograph: proposed rules. Fed Regist. 2003;68:3222–3287.
Lexicomp. Drug Information Handbook for Dentistry. 24th ed. Alphen aan den Rijn, The Netherlands: Wolters Kluwer; 2018.
Opstrup MS, Jemec GBE, Garvey LH. Chlorhexidine allergy: On the rise and often overlooked. Curr Allergy Asthma Rep. 2019;19:23.
Gu JQ, Liu S, Zhi YX. Provocation test-confirmed chlorhexidine-induced anaphylaxis in dental procedure. Chin Med J (Engl). 2018;131:2893–2894.
Pemberton MN. Allergy to chlorhexidine. Dent Update. 2016;43:272–274.
Cal E, Güneri P, Kose T. Digital analysis of mouthrinses’ staining characteristics on provisional acrylic resins. J Oral Rehabil. 2007;34:297–303.
Derafshi R, Khorshidi H, Kalantari M, Ghaffarlou I. Effect of mouthrinses on color stability of monolithic zirconia and feldspathic ceramic: an in vitro study. BMC Oral Health. 2017;17:129.
McCoy LC, Wehler CJ, Rich SE, Garcia RI, Miller DR, Jones JA. Adverse events associated with chlorhexidine use: results from the Department of Veterans Affairs Dental Diabetes Study. J Am Dent Assoc. 2008;139:178–183.
DePaola LG, Spolarich AE. Safety and efficacy of antimicrobial mouthrinses in clinical practice. J Dent Hyg. 2007;81(Suppl, Pt 2):13–25.
Li W, Wang RE, Finger M, Lang NP. Evaluation of the antigingivitis effect of a chlorhexidine mouthwash with or without an antidiscoloration system compared to placebo during experimental gingivitis. J Investig Clin Dent. 2014;5:15–22.
Kumar S, Patel S, Tadakamadla J, Tibdewal H, Duraiswamy P, Kulkarni S. Effectiveness of a mouthrinse containing active ingredients in addition to chlorhexidine and triclosan compared with chlorhexidine and triclosan rinses on plaque, gingivitis, supragingival calculus and extrinsic staining. Int J Dent Hyg. 2013;11:35–40.
Gürgan CA, Zaim E, Bakirsoy I, Soykan E. Short-term side effects of 0.2% alcohol-free chlorhexidine mouthrinse used as an adjunct to non-surgical periodontal treatment: a double-blind clinical study. J Periodontol. 2006;77:370–384.
Kolahi J, Soolari A. Rinsing with chlorhexidine gluconate solution after brushing and flossing teeth: a systematic review of effectiveness. Quintessence Int. 2006;37:605–612.
Balloni S, Locci P, Lumare A, Marinucci L. Cytotoxicity of three commercial mouthrinses on extracellular matrix metabolism and human gingival cell behaviour. Toxicol In Vitro. 2016;34:88–96.
John G, Becker J, Schwarz F. Effects of taurolidine and chlorhexidine on SaOS-2 cells and human gingival fibroblasts grown on implant surfaces. Int J Oral Maxillofac Implants. 2014;29:728–734.
Reti R, Kwon E, Qiu P, Wheater M, Sosne G. Thymosin beta4 is cytoprotective in human gingival fibroblasts. Eur J Oral Sci. 2008;116:424–430.
Ozan F, Sümer Z, Polat ZA, Er K, Ozan U, Deger O. Effect of mouthrinse containing propolis on oral microorganisms and human gingival fibroblasts. Eur J Dent. 2007;1:195–201.

The Ask the Expert column features answers to your most pressing clinical questions provided by Dimensions of Dental Hygiene’s online panel of key opinion leaders, including: Jacqueline J. Freudenthal, RDH, MHE, on anesthesia; Nancy K. Mann, RDH, MSEd, on cultural competency; Claudia Turcotte, CDA, RDH, MSDH, MSOSH, on ergonomics; Van B. Haywood, DMD, and Erin S. Boyleston, RDH, MS, on esthetic dentistry; Michele Carr, RDH, MA, on ethics and risk management; Erin Relich, RDH, BSDH, MSA ,on fluoride use; Kandis V. Garland, RDH, MS, on infection control; Mary Kaye Scaramucci, RDH, MS, on instrument sharpening; Kathleen O. Hodges, RDH, MS, on instrumentation; Karen Davis, RDH, BSDH, on insurance coding; Cynthia Stegeman, EdD, RDH, RD, LD, CDE, on nutrition; Olga A.C. Ibsen, RDH, MS, on oral pathology; Martha McComas, RDH, MS, patient education; Michael W. Roberts, DDS, MScD, on pediatric dentistry; Timothy J. Hempton, DDS, on periodontal therapy; Ann Eshenaur Spolarich, RDH, PhD, on pharmacology; and Caren M. Barnes, RDH, MS, on polishing. Log on to dimensionsofdentalhygiene.com/asktheexpert to submit your question.

From Dimensions of Dental Hygiene. May 2020;18(5):47.