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Home , Antimicrobial spectrum, Phenol, Prevotella intermedia

Earn 4 CE credits This course was written for dentists, dental hygienists, and assistants.

Chlorhexidine: A Multi-Functional Antimicrobial Drug A Peer-Reviewed Publication Written by Gary J. Kaplowitz, D.D.S., M.A., M.Ed and Marilyn Cortell, RDH, MS

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This course has been made possible through an unrestricted educational grant. The cost of this CE course is $59.00 for 4 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. Educational Objectives in Europe in the early 1970s. It received FDA approval Upon completion of this course, the clinician will be able to in 1986 under the brand name PERIDEX® (Zila Phar- do the following: maceuticals) based on studies showing that it reduced 1. Explain the mechanism of action of by up to 41%. Soon after,1 PERIDEX®‚ was the gluconate. first mouthrinse to receive the ADA Seal of Acceptance. 2. Identify the unique property that allows for a Generic rinses have been available since 1994 and are prolonged effect. available from many different companies. In order to 3. Describe the clinical indications for use. qualify as a generic, the must prove to have 4. Understand the mechanism by which chlorhexidine may 80–120% of the bioavailability of the name brand to be cause extrinsic stain and the recommended home care considered bioequivalent. To date, there have been no strategies to reduce its occurrence. published equivalency studies between the brand PERI- 5. Apply the dosage and guidelines for the clinical use of DEX® and any generic rinses. chlorhexidine gluconate. Chlorhexidine has proven efficacy as a broad-spectrum antimicrobial for reducing supragingival plaque. Abstract In 1997, chlorhexidine was introduced in a locally ap- Chlorhexidine gluconate is an effective bactericidal agent plied, controlled-release gelatin chip (PerioChip®, OMNII and broad-spectrum antimicrobial drug. It has been exten- Oral Pharmaceuticals) as a treatment to reduce pocket depths sively researched and is the “gold standard” antimicrobial in in patients with adult periodontitis. . Chlorhexidine is useful in many clinical disci- Since then there have been many off-label uses arising plines including periodontics, endodontics, oral and from the desire to effectively reduce microbial pathogens to operative . enhance treatment results. Some of the uses will be reviewed so that clinicians can make an informed decision about incor- Introduction porating chlorhexidine into their treatment protocols. Chlorhexidine gluconate (chlorhexidine) is a broad-spectrum antimicrobial drug. Acting as an , it is an effective bactericidal agent against all categories of microbes, includ- ing , , and viruses. Chlorhexidine molecules are positively charged (cations) and most bacteria and surface structures in the oral cavity, including the surfaces of teeth and mucous membranes, are negatively charged (anions). In accordance with the principle that opposite charges attract, chlorhexidine binds strongly to all these surface structures. When chlorhexidine binds to microbial cell walls it induces changes, damaging the surface structure, leading to an osmotic imbalance with consequent precipitation of cytoplasm causing cell death. The substantivity of chlorhexi- dine enhances this bactericidal effect, which allows for the retention of chlorhexidine in the oral cavity and a prolonged Figure 1. When the chlorhexidine molecules adhere to and damage residual antimicrobial effect for up to 12 hours or longer the surface of bacteria, osmotic imbalance and the precipitation of depending on the dosage and form. cytoplasm ensue and result in cell death. Chlorhexidine is safe and has an inherent advantage over by not producing resistant . As a result chlorhexidine can be used repeatedly and over Periodontics long periods of time. Furthermore, it destroys all categories of microbes, not just bacteria, and there is little risk for the Gingivitis development of opportunistic infections. Chlorhexidine is recognized as the gold standard anti- As with many FDA approved drugs, the use of chlorhex- microbial in oral hygiene. When chlorhexidine gluco- idine does have known disadvantages; however, these nate 0.12% rinse is used in between professional dental disadvantages are a small trade off compared to the many visits gingival healing is significantly improved. Rinses advantages and are reversible once the use of chlorhexidine containing chlorhexidine are intended for any patient is discontinued. presenting with redness and swelling of the gingivae, Chlorhexidine was first used as a mouthrinse as an including gingival bleeding upon probing. However, adjunct to conventional non-surgical periodontal many practitioners reserve chlorhexidine for their most

2 www.ineedce.com severe cases of gingivitis due to the potential for extrinsic staining of the teeth. The extrinsic staining, which will be discussed further, is easily remedied so the advantages to the patient far outweigh any adverse event. The recommended protocol for rinsing with chlorhex- idine is 15 mL for 30 seconds twice a day. Patients will experience significant reductions in plaque, gingivitis and bleeding sites.2 Gingival irrigation to reduce oral bacteria, both su- pra- and subgingival, has been used as both a profession- ally delivered treatment and an adjunct to homecare. The goal of supragingival irrigation is to flush away bacteria to reduce the development of gingivitis, or to decrease the patient’s existing gingivitis. Supragingival irrigation is most beneficial in patients where interdental plaque control is ineffective. Subgingival irrigation aims to re- duce bacteria within periodontal pockets by delivering the solution directly into the pocket either by use of a 1) syringe; 2) jet irrigator with a cannula; and/or 3) an ultra- Figure 2. Chlorhexidine chip being inserted into a periodontal sonic unit. The goal is to treat periodontitis or prevent it pocket on the mesial surface of a mandibular canine. from occurring. Chlorhexidine, although not alone, is the most stud- (Pg) is often difficult to ied drug. As a medicament, the substantive property eliminate especially when implicated in periodontal makes it an ideal choice for irrigation. However, studies disease. Like many other associ- are inconclusive. Some suggest that subgingival irriga- ated with , Pg becomes embedded in tion is better for improved periodontal results. Others biofilm making it resistant to higher concentrations of say patients that did not receive subgingival irrigation antimicrobial drugs. Chlorhexidine has demonstrated an received similar results. This might be due to the fact increased efficacy in eliminating Pg embedded in biofilm that, although chlorhexidine is retained in the pocket it than comparable antimicrobial agents.4 By incorporating might not be retained long enough. Nevertheless, there chlorhexidine into treatment protocols, this important is data to suggest that irrigation with a high level of can be significantly reduced thus chlorhexidine may enhance ; but promoting resolution and healing. it seems continual therapy is more appropriate than the The simplicity of the chlorhexidine chip has increased administration of one in-office irrigation treatment. in recent years with the introduction of a non-refriger- Recommendations would be to either have patients ated chip that can be placed using a standard cotton plier. follow-up with a regular at-home irrigation regimen, Research has found that when the chlorhexidine chip was or to use a professionally administered locally applied used as an adjunct to scaling and root planing, patients alternative where the bactericidal level of chlorhexidine were 2–3 times more likely to have pocket depth reduc- in the pocket is more predictable. For an at-home pro- tions of 2 mm or more when compared to those treated tocol it would be advisable for patients to continue with with a placebo chip.5 Patients can also be treated, as subgingival irrigation for at least 28 days to be followed needed, as a part of a long-term periodontal maintenance by a 2–3 month reevaluation appointment after the initial program. In one study, patients had the chlorhexidine scaling and root planing.3 chip inserted into periodontal pockets when they mea- sured 5 mm deep or more. Results revealed that 91.8% Periodontitis of sites either improved (73%) or stabilized (18.8%) over Chlorhexidine has also been used with great success in a two-year period.6 periodontal therapy in the form of a subgingival, time The advantages of incorporating chlorhexidine into released, local delivery system. The chlorhexidine chip non-surgical periodontal therapy should not be under- (2.5 mg) is a small gelatin chip inserted into periodontal estimated. It is a simple and inexpensive addition to the pockets >5 mm deep. The chip will dissolve and release traditional protocols and has yielded significant ben- chlorhexidine over 7–10 days and eradicate pathogens efits for patients by enhancing resolution and recovery. (e.g. Porphyromonas gingivalis) commonly identified Clinical research also supports the use of chlorhexidine in the subgingival biofilm of patients with periodontal prior to surgical procedures as part of initial therapy. In disease and deep subgingival pockets. this case, the goal is less a measure of pocket depth and www.ineedce.com 3 more a way to reduce the bacterial challenge within the Rinsing preoperatively with a 0.12% chlorhexidine surgical area. gluconate solution resulted in a 97% decrease in the intraoral aerobic bacterial load that persisted for at least Regenerative periodontal surgery 1 hour.11 Rinsing with chlorhexidine for one week prior One of the most significant threats to success in bone to surgical third molar extractions and for one week regenerative procedures is local infection and inflamma- post-operatively resulted in a significant reduction in tion. Disinfecting the surgical site with chlorhexidine alveolar osteitis.12 chips has been shown to increase the chance of success One of the most effective protocols proposed to in regenerative periodontal procedures involving bone decrease the incidence of alveolar osteitis involves the grafts by resulting in significant gains in bone height use of a pre-operative and/or post-operative rinse with and bone mass over time.7 They should be used during chlorhexidine.13 The most frequent protocol is for the pa- initial therapy, one week prior to regenerative surgery, tient to rinse with 15 mL of chlorhexidine for 30 seconds and as a part of the maintenance program, in pockets twice daily. ≥5 mm deep. Incorporating the use of chlorhexidine A decrease in bacterial load can also benefit surgical chips into regenerative procedures is relatively simple, cases where implants are being placed. Infection can lead inexpensive and expected to yield significant improve- to implant failure. ments in healing. Meticulous attention to infection control protocol and eliminating potential sources of infection are critical Preprocedural Rinsing to enhance the successful osseointegration of implants. The oral cavity is largely contaminated with viruses and In addition to implementing stringent infection control bacteria. Sources of these microorganisms are: dental measures throughout implant procedures, rinsing with plaque, saliva, the nose, throat, and respiratory tract. chlorhexidine will significantly reduce the opportunity Dental procedures that utilize ultrasonic scalers, dental for microbial infections and increase the potential for handpieces, air polishers and air units have the successful osseointegration.14 potential to create aerosolized material that could in- In cases where the area around an implant becomes clude: supra- and subgingival plaque organisms, blood, infected and results in periimplantitis, the use of and viruses including the influenza virus and the com- chlorhexidine irrigants in conjunction with mechanical mon cold virus.8 may produce significant improvements in There is no scientific evidence that supports preproce- resolution and healing.15 dural rinsing as a defensive measure to reduce infections When implants are placed, bone may be harvested of the dental office staff by patients. However, studies for use in simultaneous bone augmentation procedures have shown that using an antimicrobial rinse, such as to insert around implants with gaps in the bone-implant chlorhexidine, can reduce the number of organisms in interface. Rinsing preoperatively with chlorhexidine aerosols created during routine dental treatment.9 This results in significantly fewer bacteria in harvested bone, may also be beneficial for patients who are at higher risk consequently yielding a decreased chance of post-opera- for developing bacterial endocarditis. tive infections.16 Preprocedural rinsing has, however, been proven When used in a regular program of routine implant beneficial if done prior to oral surgery procedures. maintenance with routinely scheduled recalls, rinsing with chlorhexidine can be expected to produce significant Oral Surgery improvements in periodontal health over time. Improve- One common complication of third molar extractions ments can be expected in Gingival Index, Plaque Index, is alveolar osteitis (i.e., ‘dry socket’) which may present Bleeding Index and Index. 17 with a necrotic, lysed or disintegrating blood clot ac- The improvement in the above indices may also have companied by a fetid odor, unpleasant taste and severe or a beneficial effect on caries control as well as on the con- even incapacitating pain. Pain may radiate to the ear or trol of oral malodor. the entire side of the face with the onset usually 2–4 days post-operative. The incidence varies but may be as high Preventive Dentistry as 30%, especially for impacted third molars.. The etiology of alveolar osteitis is largely unknown. Caries One theory is that the blood clot fails to form after the There are a number of theories concerning the devel- extraction. A second theory is that the blood clot forms opment and progression of dental caries. According to but disintegrates or undergoes fibrinolysis shortly after the Specific Plaque Hypothesis, only a limited number it forms. A bacterial source of fibrinolytic agents has of bacteria found in can produce dental been theorized.10 caries.18 The most prominent among these odonto-

4 www.ineedce.com pathogenic bacteria are the Lactobacilli and the mu- were assigned either to a “conventional care” group or tans streptococci.19,20 Mutans streptococci represent a a “preventive intervention” group. Treatment in the group of closely related bacterial species that are the conventional care group included restoration of any cavi- primary species that initiate enamel caries. Therefore, tated lesions and oral health instructions. The preventive patients with low mutans streptococci population lev- intervention group were also restored and provided oral els in their oral cavity generally have low caries activity health instructions but then also received both a 0.12% and patients with high mutans streptococci population chlorhexidine gluconate (CHX) rinse and a 0.05% NaF levels generally have high caries activity.21 Lactobacilli (F) daily use rinse through the study duration. The study are the primary causative species of dentinal caries and found that “combining CHX to reduce the bacterial generally colonize after mutans streptococci have ex- challenge and F to enhance remineralization successfully posed the dentinoenamel interface. and significantly reduced caries risk by about three times Caries is a communicable disease and is a bacterial and suggested a reduced caries risk increment.”27 infection of the enamel, dentin and . Infants For patients with a high risk of caries, chlorhexidine are not born with mutans streptococci in their oral rinses can be successfully used to reduce the number of cavity.22 Mutans streptococci are transmitted from the odontopathogenic bacteria. This should be integrated mother, father or care giver to infants and toddlers, into an intensive home care program to maintain the generally between 19 to 28 months of age, with 83% optimum level of oral hygiene. of children infected by the age of four.23,24 Children Meticulous home care can also benefit those trou- with demonstrable levels of mutans streptococci de- bled by oral malodor. velop carious lesions. Children without demonstrable levels of mutans streptococci do not. Prevention of Oral Malodor transmission of mutans streptococci from caregiver Oral malodor (i.e., breath malodor, bad breath, halito- to child for the reduction of dental caries is the sub- sis, etc.) afflicts a significant number of people in the ject of many current caries trials and United States. For many, the problem is significant dental programs. and impacts daily life and social interactions. There Chlorhexidine is a very potent bactericidal agent for are many, so-called, quick fixes in the form of lozeng- mutans streptococci, the most significant group of bac- es, rinses, gum, etc, for purchase over-the-counter in terium associated with caries.25 Chlorhexidine molecules and health food stores. Awareness of this adhere to the surfaces of mutans streptococci and produce problem and the stigma associated with it has created cell death. a huge market in health care. Under some circumstances with professional inter- The etiology of breath malodor varies, but origi- vention and intensive home care, mutans streptococci nates about 87% of the time in the oral cavity.28,29 It is can be eradicated from the oral cavity. In one protocol, caused most frequently by bacterial products, which patients had their teeth professionally cleaned every produce volatile sulphur compounds with character- day for ten days. Following the dental prophylaxis, pa- istic foul odor components. Many of these bacteria are tients had 1.0% chlorhexidine applied twice in custom embedded in periodontal pockets, plaque and calculus trays. Patients brushed three times a day and applied making them difficult to access and eradicate. chlorhexidine 0.2% twice a day — in the morning and Oral malodor is associated with periodontal dis- before bed. Patients rinsed with 0.2% chlorhexidine ease, deep periodontal pockets, and an increase in the after lunch. amount of calculus, a high plaque index and poor oral At four months, three out of seven subjects in the hygiene.30 Anaerobic bacteria residing on the dorso- study demonstrated no detectable level of mutans posterior surface of the tongue is also an important streptococci.26 However three of the subjects still had source of volatile sulphur compounds and tongue detectable levels of mutans streptococci. These three cleaning may be required to reduce this population of subjects also had deep periodontal pockets and it is bacteria in this area.31 possible that mutans streptococci might have found Many treatment protocols have been proposed for refuge in them and thus eluded the bactericidal effects reducing or eliminating bad breath. One of the most ef- of chlorhexidine. fective treatments developed thus far is for the patient The results of a three-year randomized to rinse with chlorhexidine.32 It is probable that the to provide caries management through risk assessment decrease in malodor observed when patients rinse with were presented in March 2005 by Dr. John Featherstone chlorhexidine is due, at least in part, to the reduction et al., from the University of California-San Francisco, in the plaque index as well as the reduction in gingival during the International Association of Dental Research inflammation resulting in fewer bacteria capable of Meeting. In the study caries active subjects (N=230) generating volatile sulphur compounds. Rinsing with www.ineedce.com 5 chlorhexidine twice daily (i.e., once in the morning Table 1. Intracanal Irrigants and once at night) is sufficient to produce a significant Sodium decrease in bacterium that produces volatile sulphur Chlorhexidine Gluconate compounds thus decreasing oral malodor.33 Another area where chlorhexidine has found a use is in endodontics. Saline Potassium Iodide Endodontics In endodontic therapy, chlorhexidine is now widely Most cases of root canal failure that have been used as an intracanal irrigant or as an intracanal me- cultured demonstrate high levels of anaerobic bacte- dicament. Its wide antimicrobial spectrum offers effi- ria, notably Enterococcus faecalis and Actinomyces cacy, while ease in delivery and reasonable price make israelii. Actinomyces israelii is part of the normal oral it a practical choice. Unlike other intracanal irrigants flora and has been isolated from dental plaque, carious and medicaments, it has no tissue toxicity. dentin and periodontal pockets; however, in certain Most root canal infections involve a mixture of circumstances it can cause an infection.36 These micro- aerobic and anaerobic bacteria, with the anaerobic bac- organisms are very susceptible to chlorhexidine. teria producing the dominant pathological features of Chlorhexidine 0.12% solution is an effective anti- infection and inflammation. The primary objective in microbial agent when delivered to the root canal space root canal treatment is the removal of infected pulpal as an intracanal irrigant. It is able to penetrate deeply tissue and infectious microbial pathogens. into the dentinal tubules and kill the pathogenic This is accomplished with mechanical debridement bacteria. via instrumentation and intracanal irrigants. Mechani- cal instrumentation with files and reamers widens the root canal space and removes the bulk of the pulp tis- sue and pathogenic microbial agents. However some fragments of tissue and pathogenic microorganisms will remain even after the most stringent or aggressive mechanical instrumentation of the canal space. Two significant anaerobic pathogens isolated from root canal infections are Enterococcus faecalis and Actinomyces israelii. Both can penetrate into the dentinal tubules, making them difficult to eradicate. Enterococcus faecalis can penetrate 400 microns with Actinomyces israelii penetrating deeply into dental tu- bules as well.34,35 For this reason, infectious microbial agents can be eliminated only after the introduction of appropriate intracanal irrigants. Irrigants are introduced into the root canal space to dissolve tissue and kill pathogenic bacteria that have not been eliminated by conventional mechani- cal instrumentation. The most widely used intracanal irrigants are , iodine potassium Figure 3. Bacteria penetrate deeply into the dentinal tubules. iodide, hydrogen peroxide, alcohol and chlorhexi- dine. Each of the irrigants possesses its own set of There has been a major paradigm shift in endodon- particular attributes. tic therapy protocols from the traditional multiple- Sodium hypochlorite is commonly used because visit approach to initiating and completing endodontic it is the most effective tissue solvent, has excellent therapy in a single-visit whenever indicated and when- microbicidal properties and is inexpensive. One disad- ever possible. However, in certain instances a mul- vantage of sodium hypochlorite is that it can be harsh tiple-visit approach is still warranted. It is thought on the periapical tissues, causing destruction of the that, during the interim period between multiple vis- PDL at and around the apices if extruded through the its, pathogenic microorganisms are able to repopulate apex. This can be painful to the patient, although there in the root canal space.37 Therefore, the importance are certain syringes and techniques that can be used to of eliminating pathogenic bacteria from infected root minimize this occurrence. canals should not be underestimated. Actinomyces

6 www.ineedce.com israelii can migrate into the general circulation dur- all patients will experience a visually significant in- ing or after root canal treatment.38 It can also migrate crease in tooth staining. In clinical testing, 56% of oral out of the infected root canal into the periapical tissue rinse users exhibited a measurable increase in facial where it can produce an abscess.39 Actinomyces israelii anterior stain of the teeth, compared to 35% of control is an opportunistic pathogen and can infect extraction users after 6 months.44 sockets, periodontal surgery sites, areas of trauma and Chlorhexidine stain, being extrinsic, is easily other susceptible portals of entry. removed from the teeth with a variety of techniques A number of intracanal medicaments have been used and materials. One very effective technique is to use to prevent this rebound of pathogenic microorganisms an electric or battery powered , oscillating and the most frequently used are listed in Table 2. or rotating, which can be expected to decrease stain by Some possess undesirable properties. Formocresol and 75% after 4 weeks of use.45,46 Camphorated have exhibited some Powered tooth brushing becomes more effective at tissue toxicity. Iodine Potassium Iodide is active for reducing chlorhexidine staining over time.47 However, only a short period of time, poisonous if ingested and manual tooth brushing will also remove chlorhexi- provokes an allergic reaction in some patients. Calcium dine stain, although not as rapidly or efficiently.48 requires prolonged application in order to Another very effective technique for chlorhexidine be maximally effective as an antimicrobial agent and is stain removal is to use a whitening dentifrice. These not always successful in eliminating pathogenic bac- are inexpensive and can be obtained over the counter teria.40 Chlorhexidine, when introduced into the root in any .49 An advantage of using a whitening canal space as an intracanal medicament, is the only dentifrice simultaneously with the implementation of medicament that can completely eliminate Actino- chlorhexidine rinsing is that the amount of acquired myces israelii and is far more biocompatible than the stain will be reduced and easier to remove.50 Additional other intracanal medicaments.41 It is also inexpensive, studies have recommended chewing gum as a way to easy to deliver and readily removed. help reduce the potential for staining.51 Educating patients on maintaining optimum oral Table 2. Intracanal Medicaments hygiene will greatly reduce the possibility of chlorhex- Formocresol idine stain, since stain will collect more readily in the Camphorated Monochlorophenol (CMCP) presence of plaque biofilm. Calcium Hydroxide Calcium Hydroxide with CMCP Conclusion Chlorhexidine Gluconate Recognizing the clinical application of the broad- Iodine Potassium Iodide spectrum antimicrobial chlorhexidine gluconate and incorporating it into your specific clinical practice Known Side Effects setting is an appropriate and effective mode of action. There are many benefits to incorporating chlorhexi- The varied and effective applications of chlorhexidine dine into treatment protocols along with some precau- make it a viable option for use in all dental settings and tions. The most common side effects are altered taste within a variety of dental procedures and pre-proce- perception, an increase in calculus formation, and an dures with very few undesirable side effects. increase in staining of the teeth. In addition, anyone with a known hypersensitivity to it should not be Glossary of Terms prescribed chlorhexidine. Antiseptic: A chemical that destroys or inhibits the growth of microorganisms and is sufficiently Staining non-toxic for superficial application to the skin Two theories currently exist to explain the staining and mucous membranes. Can be used internally to mechanism of chlorhexidine. One theory suggests treat infections of the intestine and bladder that chlorhexidine molecules interact with chromo- gens present in food and beverages and the resultant Osmosis: The flow of a solvent by diffusion through precipitate produces much of the tooth staining.42 a semipermeable membrane from a more concen- The second theory proposes that a series of chemical trated solution to a less concentrated one, until the reactions between sugars and amino , called the concentrations are equalized. maillard or non-enzymatic browning reaction, causes compounds to form as products of this reaction. This Substantivity: The property of an antiseptic or is also seen in the browning of foods high in carbohy- that makes it effective for a prolonged drates and sugars, such as apples and potatoes.43 Not period of time following its application. www.ineedce.com 7

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Demonstration of the etiologic role of 2002;15:290–292. streptococci in experimental caries in hamsters. J Am Dent Assoc. 47 Moran J, et al. A clinical study to assess the ability of a powered 1960;61:9–19. toothbrush to remove chlorhexidine/tea dental stain. J Clin 21 Shklar I, et al. The distribution of Streptococcus mutans on the Periodontol. 2004;31:95–98. teeth of two groups of naval recruits. Arch Oral Biol. 1974;19: 48 McInnes C, et al. Clinical and computer-assisted evaluations of 199–202. stain removal ability of the Sonicare electronic toothbrush. J Clin 22 Carlsson J, et al. Lactobacilli and Streptococci in the mouths of Dent. 1994;5:1–8. children. Caries Res. 1975;9:333–339. 49 Emling R, et al. Rembrandt toothpaste: stain removal following 23 Berkowitz R, et al. The early establishment of mutans in the the use of Peridex. J Clin Dent. 1992:66–69. mouths of infants. Arch Oral Biol. 1975;20:171–174. 50 Tillis T. 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8 www.ineedce.com Author Profile emy of Dental Hygiene and The American Dental Hygienist’s Association. Along with serving both on Gary J. Kaplowitz, D.D.S., M.A., M.Ed the editorial board of RDH Magazine and a consultant Dr. Kaplowitz retired from the military after serving as member to the North East Regional Board of Dental, Chief Dental Officer of The U.S. Coast Guard. He is a Examiners (NERB), Marilyn has contributed to three graduate of the New York University College of Dentist- prominent widely distributed dental hygiene textbooks ry and is a Diplomate of the American Board of General and is currently serving as an appointed member of the Dentistry. He has published widely on dental materials ADHA Council on Public Relations. and clinical techniques. He is editor of Osseonews.com and is in private practice in York, Pennsylvania. Disclaimer The authors of this course have no commercial ties with Marilyn Cortell, RDH, MS the sponsors or the providers of the unrestricted educa- Marilyn Cortell has extensive experience as a dental tional grant for this course. hygiene educator and national lecturer. Currently she is a full time Assistant Professor at New York City Col- Reader Feedback lege of Technology and an Adjunct Clinical Associate We encourage your comments on this or any PennWell course. Professor at New York University. She is a member of For your convenience, an online feedback form is available at The National Speakers Association, American Acad- www.ineedce.com.

www.ineedce.com 9 Questions

1. Chlorhexidine has a _____ charge. 11. Enterococcus faecalis can penetrate 21. Chlorhexidine chips can be used a. positive dentinal tubules up to ______. in regenerative periodontal therapy b. negative a. 50 microns to ______. c. neutral b. 200 microns a. facilitate graft placement d. None of the above c. 400 microns b. facilitate membrane removal 2. The surfaces of the teeth have a d. 1,000 microns c. reduce the incidence of infection ______charge. 12. In endodontic therapy, chlorhexi- and inflammation a. positive dine is effective against ______. d. All of the above b. negative a. enterococcus faecalis 22. Porphyromonas gingivalis c. neutral b. actinomyces Israelii d. None of the above is often difficult to eliminate c. most bacteria because ______. 3. The cell walls of microorganisms d. All of the above a. it is very resilient have a ______charge. b. it reproduces rapidly a. positive 13. One advantage sodium c. it develops resistance to chlorhexidine b. negative hypochlorite has, as an intracanal d. it is often embedded in biofilm c. neutral irrigant compared to chlorhexidine d. None of the above is that ______. 23. Preprocedural rinsing may be a a. it is less expensive 4. Side effects of chlorhexidine that good idea because aerosolized mate- b. it has a recognizable odor some patients experience are: rial may include: supra- and subgin- c. it is easier to deliver a. bitter taste gival plaque organisms, blood, and d. it dissolves soft tissue very well b. extrinsic staining of teeth viruses including influenza and the c. increased rate of formation of calculus 14. Caries is a ______. common cold. d. All of the above a. hereditary disease a. True 5. Chlorhexidine is not an . b. communicable disease b. False It is an ______. c. reactive disease 24. Oral malodor is most often caused a. antigen d. immunologic disease by ______. b. antidote 15. The most prevalent bacteria associ- a. hepatic dysfunction c. antiseptic ated with caries is ______. b. bacteria in the oral cavity d. anticodon a. Porphyromonas gingivalis c. ketosis 6. The unique property of substantiv- b. intermedia d. alkalosis ity allows for the ______. c. Mutans streptococci 25. Oral malodor is frequently associ- a. short action of chlorhexidine d. denticola b. prolonged effect of chlorhexidine ated with ______. 16.The signs and symptoms of alveolar a. periodontal disease c. buffering effect of chlorhexidine osteitis include ______. d. bactericidal effect of chlorhexidine b. increased amounts of calculus a. pain radiating to the ear c. a high plaque index 7. In order for a generic drug to be b. onset 2-4 days post-operatively d. All of the above approved by the FDA, the drug c. oral malodor 26. The most effective of the treat- must ______. d. All of the above a. work 80% of the time ments for oral malodor is ______. b. be 20% as effective 17. Rinsing with chlorhexidine before a. lozenges c. be no more than 80% effective or after third molar extractions can b. fragrant mouth sprays d. be at least 80% bioequivalent result in an ______. c. anti-bacterial gels 8. The advantages of using chlorhexi- a. increased chance of alveolar osteitis d. rinses with chlorhexidine b. decreased chance of alveolar osteitis dine as an intracanal irrigant in 27. Chlorhexidine staining is largely endodontic therapy include: c. increased chance of salivary flow compromise d. decreased chance of salivary flow compromise due to the reaction of chlorhexidine a. Broad spectrum activity with ______. b. Ease of delivery 18. Patients with an increased chance a. bisguanides c. Low tissue toxicity of developing bacterial endocarditis b. dications d. All of the above should ______. c. chromogens a. rinse once post-operatively with chlorhexidine 9. One of the objectives of using d. dichromides chlorhexidine as an intracanal b. rinse twice post-operatively with chlorhexidine medicament between visits is c. rinse pre-operatively with chlorhexidine 28. Chlorhexidine stain is ______. to ______. d. not rinse with chlorhexidine a. intrinsic b. extrinsic a. prevent rebound of pathogenic microorganisms 19. Chlorhexidine rinse when used in c. internal b. fill the root canal space conjunction with routine scaling c. seal the root canal space and root planing can be expected to d. covalently bound d. dissolve residual tissue produce ______. 29. Chlorhexidine stain is ______. 10. Mechanical debridement of the a. a significant reduction in pocket depths a. difficult to remove root canal space does not remove b. a significant reduction in b. easy to remove all pathogenic microorganisms c. None of the above c. rarely noticeable because ______. d. All of the above d. a myth a. the microorganisms adhere tenaciously to the root canal walls 20. Chlorhexidine chips can 30. To reduce the occurrence of b. the pathogenic microorganisms in the root canal be ______. staining, patients rinsing with space penetrate deeply into the dentinal tubules a. inserted into pockets ≥5 mm deep chlorhexidine can ______. c. the pathogenic microorganisms are resistant to b. placed with a standard cotton plier a. brush their teeth with a powered toothbrush mechanical debridement c. used repeatedly as a part of a long-term b. chew gum d. mechanical debridement is ineffective at periodontal maintenance program c. use a whitening toothpaste removing microorganisms d. All of the above d. All of the above

10 www.ineedce.com ANSWER SHEET Chlorhexidine: A Multi-Functional Antimicrobial Drug

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Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 4 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp.

Mail completed answer sheet to Educational Objectives Academy of Dental Therapeutics and Stomatology, 1. Explain the mechanism of action of chlorhexidine gluconate. A Division of PennWell Corp. 2. Identify the unique property that allows for a prolonged effect. P.O. Box 116, Chesterland, OH 44026 or fax to: (440) 845-3447 3. Describe the clinical indications for the use of chlorhexidine gluconate. 4. Understand the mechanism by which chlorhexidine may cause extrinsic stain in some patients and the recommended For immediate results, go to www.ineedce.com patient home care strategies to reduce its occurrence. and click on the button “Take Tests Online.” Answer 5. Apply the dosage and guidelines for the clinical use of chlorhexidine gluconate in periodontics, endodontics, oral sheets can be faxed with credit card payment to (440) 845-3447, (216) 398-7922, or (216) 255-6619. surgery, operative dentistry and preventive dentistry. Payment of $59.00 is enclosed. (Checks and credit cards are accepted.) Course Evaluation If paying by credit card, please complete the Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. following: MC Visa AmEx Discover

1. Were the individual course objectives met? Objective #1: Yes No Objective #4: Yes No Acct. Number: ______Objective #2: Yes No Objective #5: Yes No Exp. Date: ______Objective #3: Yes No Charges on your statement will show up as PennWell

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AUTHOR DISCLAIMER INSTRUCTIONS COURSE CREDITS/COST RECORD KEEPING The authors of this course have no commercial ties with the sponsors or the providers of All questions should have only one answer. Grading of this examination is done All participants scoring at least 70% (answering 21 or more questions correctly) on the PennWell maintains records of your successful completion of any exam. Please contact our the unrestricted educational grant for this course. manually. Participants will receive confirmation of passing by receipt of a verification examination will receive a verification form verifying 4 CE credits. The formal continuing offices for a copy of your continuing education credits report. This report, which will list form. Verification forms will be mailed within two weeks after taking an examination. education program of this sponsor is accepted by the AGD for Fellowship/Mastership all credits earned to date, will be generated and mailed to you within five business days SPONSOR/PROVIDER credit. Please contact PennWell for current term of acceptance. Participants are urged to of receipt. This course was made possible through an unrestricted educational grant. No EDUCATIONAL DISCLAIMER contact their state dental boards for continuing education requirements. PennWell is a manufacturer or third party has had any input into the development of course content. The opinions of efficacy or perceived value of any products or companies mentioned California Provider. The California Provider number is 3274. The cost for courses ranges CANCELLATION/REFUND POLICY All content has been derived from references listed, and or the opinions of clinicians. in this course and expressed herein are those of the author(s) of the course and do not from $49.00 to $110.00. Any participant who is not 100% satisfied with this course can request a full refund by Please direct all questions pertaining to PennWell or the administration of this course to necessarily reflect those of PennWell. contacting PennWell in writing. Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or [email protected]. Many PennWell self-study courses have been approved by the Dental Assisting National Completing a single continuing education course does not provide enough information Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet © 2008 by the Academy of Dental Therapeutics and Stomatology, a division COURSE EVALUATION and PARTICIPANT FEEDBACK to give the participant the feeling that s/he is an expert in the field related to the course DANB’s annual continuing education requirements. To find out if this course or any other of PennWell We encourage participant feedback pertaining to all courses. Please be sure to complete the topic. It is a combination of many educational courses and clinical experience that PennWell course has been approved by DANB, please contact DANB’s Recertification survey included with the course. Please e-mail all questions to: [email protected]. allows the participant to develop skills and expertise. Department at 1-800-FOR-DANB, ext. 445.

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