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 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, 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. 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. Bagis B, Baltacioglu E, Özcan M, Ustaomer S. Evaluation of chlorhexidine gluconate mouthrinse-induced staining using a digital colorimeter: an in vivo study. Quintessence Int. 2011;42:213–223. Duss C, Lang NP, Cosyn J, Persson GR. A randomized, controlled clinical trial on the clinical, microbiological, and staining effects of a novel 0.05% chlorhexidine/herbal extract and a 0.1% chlorhexidine mouthrinse adjunct to periodontal surgery. J Clin Periodontol. 2010;37:988–997. 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. 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. BMC Oral Health. 2017;17:129. Peridex (chlorhexidine gluconate) [prescribing information]. London, Ontario: 3M Canada Dental Products; June 2017. PerioGard (chlorhexidine gluconate) [prescribing information]. New York, NY: Colgate Oral Pharmaceuticals; July 2015. 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.