Contraindications for Chlorhexidine

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 awarded 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.2,3 The FDA has determined that, based on the evidence, formulations that contain CHG are safe and effective.2,3 CHG is available in the United States 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 Serious allergic reactions have been reported, including anaphylaxis.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

However, there are numerous adverse oral events associated with using CHG mouthrinse.8,9 Most notably, CHG stains the teeth, mucosa, gingiva, and the dorsum of the tongue. Tooth staining may occur on any surface, but tends to be worse on anterior teeth and when there is a significant amount of biofilm present, as observed in patients with poor oral hygiene.10-14 Stain on tooth surfaces may be removed during a prophylaxis. However, stain may also occur on or around composite restorations, acrylic dental materials, and around restorations with an open margin.15,16 This stain may be difficult to completely remove without compromising the integrity of the material. 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 alterations in their perceptions of taste.8-10,13,14 This adverse effect is typically temporary and has only rarely been reported as permanent.

Approximately 30% of the oral rinse is retained in the oral cavity and is slowly released, which supports the substantivity of CHG, but also contributes to taste alteration.4 Patients and clinicians may notice an increase in supragingival calculus formation.8,9,13,14 It I unknown whether using CHG mouthrinse increases subgingival calculus formation.4 Patients with a history of alcohol abuse should be advised that use of an alcohol-containing mouthrinse, such as CHG, may induce relapse and that they should consult with their abuse sponsor before use.

Manufacturers of alcohol-containing mouthrinses generally state that these products are contraindicated for use in patients either with or recovering from alcoholism.9,17,18 Further, alcohol-containing mouthrinse should be used with caution in children younger than 12 without supervision, to ensure that the child can rinse and expectorate without swallowing.9 The use of alcohol-containing mouthrinse in individuals taking metronidazole (Flagyl) or disulfiram (Antabuse) is contraindicated, because, in combination, they may induce nausea, vomiting, and other unpleasant side effects.9 Clinicians may elect to prescribe an alcohol-free formula of CHG instead.   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.19 To minimize risk for this interaction, a waiting period of at least 30 minutes should elapse after dentifrice use prior to rinsing with CHG.19

Finally, research suggests that CHG may be cytotoxic to human gingival fibroblasts.20-23 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

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