Chlorhexidine – the good, the bad and the ugly

When you hear the word chlorhexidineThese things are probably coming to mind:

• “Slipped.”
• “A great bacterial killer.”
• “Has poor compliance with patients.”
• “It works well … but it causes account.”
• “Terrible flavors.”
• “Adds a lot more work.”

Given these characteristics, it is not surprising that clinicians generally fall into two camps in chlorhexidine. There are those who hate it and refuse to use it and there are those who use it and choose to overlook the side effects. For the clinics who use it, if we asked why, they would probably not say, “because I love it!” Instead, they would probably say things like “there is no alternative” or “I use it because it is what I learned at school”. However, there is an alternative to chlorhexidine and, as most of us know, doing something only because you learned it at school is not always good enough.

To understand this position of the controversial chemical in dentistry, as well as the possible alternatives, let’s take a hard look at chlorhexidine – good, evil and ugly.

Good: When used as designed

Chlorhexidine was admitted to dentistry in 1954 as a biocytic wide spectrum effective against Gram-Postal and Gram-Arnetic Bacteria.¹ It was designed to be temporarily used to help patients reverse gingivitis.

Chlorhexidine is a large bacterial killer. There is no reason to discuss this, as the study after study confirmed it. However, it requires an incredibly high concentration to achieve positive results: 1,200 parts per million.² This is one of the reasons why chlorhexidin is not intended to be used for more than two weeks.

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Although chlorhexidine has many side effects, it can be safely used to treat gingivitis. However, many dental professionals use chloroxidine beyond the label, and this is where contraindications and safety concerns come into force.

The bad: side effects

The main reason why many clinical doctors do not like chlorhexidine is due to its side effects. We all know chlorheraexidine teeth and another common side effect is the accumulation of software. No side effects are something you would like reasonable to patients after their scales, traitors or surgery.

Patients are struggling to remain adhered to chlorhexidine due to taste. They cannot rinse with water afterwards because they make chlorhexidine ineffective. In fact, water actually increases bitterness!³ After use, patients may complain about a “metal” aftertaste that sticks for several hours.⁴ Some patients even experience a change in taste.⁴ In rare cases, the permanent change of taste is observed after the treatment is performed.⁵

The ugly: things you may not know

Side effects such as staining and calculus are not ideal, but they are not dangerous. Clinicians may be willing to reconcile in an effort to get better treatment results. However, studies and cases of real world show us that we may want to re -examine.

Even with the treatment of gingivitis, there are unrealistic guidelines and expectations for patients to follow. Because chlorhexidine is easily inactivated, it should be used 30 minutes after other dental products. It is disabled by anionic compounds, including anionic surfaces used in toothpaste.⁶ Thus, patients should not rinse immediately after brushing.⁶ In addition, they must then avoid drinking, food and smoking for at least one hour after use.

There is also information stating that saliva and blood inactivate chlorhexidine.^7.8 How do we avoid saliva in the mouth? We can’t. So, does it make sense to use chlorhexidine at all?

The serious side effects of chlorhexidine also include its effect on the formation of fibroblasts in the periodontal pocket. The most alarming findings date back to 1991, when Charles D. Alleyn, DDS, studied the restoration of the attachment of the lost connective tissue to the root surface after periodontal treatment. Chlorhexidine was found to harm fibroblasts, who are key factors for reconnecting,⁹ which is the purpose of escalating and root design. Chlorhexidine has stopped the healing process, causing the treatment phase to last longer and reducing the likelihood of a favorable outcome with treatment.

Another study published in 2006 discussed the cytotoxic effect of chlorhexidine on cells and warned against its use after scaling and root processes (such as irrigation) due to catastrophic cells that help in the healing process (such as fibroblasts).¹⁰ A different study said that the higher concentration (≥ 0.04%) of chlorhexidine inhibits cell proliferation and, to some extent, affects cell morphology. The study concluded that “the application of CHX to post-surgical antiseptic treatment of the oral cavity must be limited”.¹¹ (However, it should be noted in the defense of chlorhexidine that it was never intended to be used in this way.)

Uses outside chlorhexidine are where many of the serious issues come from. It was not created to be used with implants, periodontal treatment or oral surgery. The Food and Drug Administration has reported more than 52 cases of anaphylaxis between 1998 and 2010 and this number is increasing.⁵ Serious cases involving allergic reactions reported results that required emergency visits or hospitalizations to receive drugs and other medical treatments. Two of these cases really led to death. In both scenarios, each patient had left the dental office after extraction with instructions for the use of chlorhexidine rinsing at home. As mentioned earlier, 1,200 ppm of chlorhexidine is needed to achieve results.² For this reason, it must not be used with open wounds. In cases where patients died, both had open wounds and the intake of the active ingredient was too high, causing severe allergic reactions.⁵

An alternative

Many dental professionals feel “the bad” and “ugly” of chlorhexidine compensate for “good”, letting them look for an alternative. More than 10 years ago, a group of dentists sharing this feeling decided to develop an alternative. After years of research and development, they came with Oracare.

The active ingredient in Oracare, activated chlorine dioxide, kills the same bacteria as chlorhexidin but with only 44 ppm.² Chlorine dioxide is a gas, so it is quickly dissolved through tissues and without prolonged side effects. Overall, these characteristics make it safe for everyday use. In addition, activated chlorine dioxide has been shown to effectively remove biofilm, neutralizing sulfur volatile compounds and kills fungi and viruses.²

Oracare differs in that he does not leave stains, does not cause an additional accumulation of calculus and has no negative impact on fibroblasts. The most common uses for Oracare are for bleeding, periodontitis, implant maintenance, dry mouth, poor breathing and mouth wounds.

While chlorhexidine is an effective bacterial killer, its side effects and dangerous out -of -service use Open the door to safer and equally effective alternatives. If you are ready to make the switch, an alternative to chlorhexidine can help you give you “good” and avoid “bad” and “ugly”.

Note by the author: Originally published in 2020 and informed by March 2025.

References

1. Horner C, Mawer D, Wilcox M. Reduced Sensitivity to Chlorhexidine in Staphylococcus: Increased and does it matter? J Acticrob Chemotherapy. 2012, 67 (11): 2547-2559.
2. Downs R, Banas Ja, Zhu M. An in vitro study comparing a bilateral dioxide of chlorine from oral to chlorhexidine. Counseling. Published on January 21, 2015 .https: //www.perioimplantvisory.com/clinical-tips/hygiene-techniques/article/16411500/an-in -Vitro-world-comparing-a-twopart-activated-cchlorine-diars-ral-rinse-to-chlorhexidine
3. About chlorhexidine: mechanism of action. 2019. Chlorhexidinefacts.com/mechanism-ope-action.html.
4. Wyganowska-swiatkowska M, kotwicka M, urbaniak r, et al. The clinical effects of the effects that destroy the growth of chlorhexidine at low and high concentrations on human fibroblasts of gum and changes in morphology. Int j mol med. 2016; 37 (6): 1594-1600. DOI/10.3892/IJMM.2016.2550
5. FDA for drug safety: FDA warns of rare but serious allergic reactions with skin antiseptic gluconate chlorhexidin. US Food and Drug Administration. Published on 9 February 2017. https://www.fda.gov/drugs/drug-safety-and-vailability/fda-drug-safety-communication-fda-warns-About-rare-preserious.
6. Tsourounakis I, Palaiologou -gallis Aa, Stoute D, et al. Effect of essential oil and chlorhexidine oral dissolution on survival and migration gum fibroblasts. J Peronol. 2013; 84 (8): 1211-1220.
7. Salam M, Arslan U, Bozkurt B, Hakki SS. Irrigation of boric acid as a complement to mechanical periodontal treatment in patients with chronic periodontitis: randomized clinical trial. J Peronol. 2013; 84 (9): 1297-1308.
8. Van Maanen-Schakel NWD, Slot de, Bakker Ewp, Van der Weijden Ga. The effect of an oxygenation factor on chlorhexidine exogenous tooth staining: a systematic review. Int j dend hyg. 2012; 10 (3): 198-208. DOI: 10.1111/J.1601-5037.2012.00555.x
9. Alleyn Cd, O’Neal RB, Strong, SL, et al. The effect of chlorhexidine treatment of root surfaces to attaching human fibroblasts of in vitro. J Peronol. 1991; 62 (7): 434-438. DOI/10.1902/JOP.1991.62.7.434
10. Polimeni G, Xiropaidis av, wikesjö ume. Biology and principles of periodontal healing/regeneration. 2000 magazine. 2006, 41: 30-47.
11. Wyganowska-swiatkowska M, kotwicka M, urbaniak r, et al. The clinical effects of the effects that destroy the growth of chlorhexidine at low and high concentrations on human fibroblasts of gum and changes in morphology. Int j mol med. 2016; 37 (6): 1594-1600. doi.org/10.3892/ijmm.2016.2550