See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/6866180 Rinsing with chlorhexidine gluconate solution after brushing and flossing teeth: A systematic review of effectiveness Article in Quintessence international · October 2006 Source: PubMed CITATIONS READS 43 1,264 2 authors, including: Jafar Kolahi Dental Hypotheses Journal (ISSN: 2155-82… 40 PUBLICATIONS 177 CITATIONS SEE PROFILE All in-text references underlined in blue are linked to publications on ResearchGate, Available from: Jafar Kolahi letting you access and read them immediately. Retrieved on: 19 October 2016 Kolahi.qxd 7/31/06 9:38 AM Page 605 QUINTESSENCE INTERNATIONAL Rinsing with chlorhexidine gluconate solution after brushing and flossing teeth: A systematic review of effectiveness Jafar Kolahi, DDS1/Ahmad Soolari, DMD, MS2 Objective: The purpose of this study was to discuss the concept of delaying the use of chlorhexidine mouthrinse (CHX) until some time after the use of dentifrice. Method and Materials: Sources included 13 electronic databases, 7 international drug reference books, and the World Wide Web; references of all relevant papers; and further information requested from authors and organizations. Inclusion criteria were a predefined hierarchy of evidence. Study validity was assessed with checklists. Two reviewers independently screened sources, extracted data, and assessed validity. Results: CHX, a cation, interacts and forms salts of low solubility and antibacterial activity with anions, such as sodium lau- ryl sulfate (SLS) and sodium monofluorophosphate (MFP). CHX and MFP are not compati- ble in clinically relevant concentrations in vitro. A 30-minute interval between SLS and CHX rinsing gave a significantly reduced antiplaque effect of CHX, whereas after 2 hours the neutralizing effect of SLS disappeared. Rinsing with dentifrice slurry and CHX pro- duced a significantly increased plaque score compared to CHX and water. In regard to tooth staining by CHX mouthrinses, use of dentifrice before CHX showed a reduction in staining of 18%, whereas CHX followed by dentifrice showed a reduction in staining of about 79%. Literature relating to this interaction is limited; more controlled microbiologic and clinical studies are needed to certify the inaccuracy of this modality of administration. Conclusion: To optimize the antiplaque effect of CHX, it seems best that the interval between toothbrushing and rinsing with CHX be more than 30 minutes, cautiously close to 2 hours after brushing. (Quintessence Int 2006;37:605–612) Key words: chlorhexidine administration, dentifrice, sodium lauryl sulfate, sodium monofluorophosphate Mouthrinses have been used for thousands and gram-negative cocci resembling of years and have various origins, such as Veillonella exhibit low susceptibility to CHX.4 urine of a newborn child, vinegar, and, more The agent does not cause any bacterial recently, Coca-Cola.1 Chlorhexidine glu- resistance and suprainfection following long- conate mouthrinse (CHX) is considered the term oral usage. In 1 study, long-term oral gold standard and primary agent for chemi- usage resulted in a small shift in the flora cal plaque control.2 It is a bisbiguanide anti- toward the less sensitive organisms, yet this septic that has a wide spectrum of activity was rapidly reversible at the end of 2 years.3 encompassing gram-positive and gram-neg- Following the initial demonstration of plaque ative bacteria. It is also effective against some inhibition by CHX,5 a large number of varied fungi and yeast, including Candida, and oral usages of this compound were investigat- some lipophilic viruses, including human ed6: (1) secondary prevention following oral immunodeficiency virus (HIV) and hepatitis B surgical procedures including periodontal ther- virus (HBV).3 Yet Porphyromonas gingivalis1 apy (it is recommended for use instead of brushing after surgical procedures, but within the limits of 40 hours after surgery and not 1Research Scientist, Torabinejad Research Center, Isfahan University of Medical Sciences, Isfahan, Iran. more than 10 days for each course), (2) implant 2Private Practice in Silver Spring and Potomac, Maryland. dentistry, (3) management of dental caries, (4) Reprint requests: Dr Ahmad Soolari, 8834 Tuckerman Lane, patients with maxillomandibular fixation, (5) Potomac, MD 20854. E-mail: [email protected] medically compromised patients, (6) minor VOLUME 37 • NUMBER 8 • SEPTEMBER 2006 605 Kolahi.qxd 7/31/06 9:38 AM Page 606 QUINTESSENCE INTERNATIONAL Kolahi/Soolari Table 1 Recommendations for using chlorhexidine gluconate (CHX) mouthrinse as found in international drug reference books Drug reference book Recommendation Martindale: The Complete At least 30 min should be allowed to elapse between the use of Drug Reference15 dentifrice and oral CHX preparations. British National Formulary16 10 mL for about 1 min* twice daily (nonproprietary). 15 mL for about 30 s twice daily with Chlorohex (Colgate-Palmolive). 10 mL for about 1 min* twice daily with Corsodyl (GlaxoSmithKine). Drug Facts and Comparisons17 Twice daily for 30 s, morning and evening, after brushing teeth. Usual dosage is 15 mL† (marked in cap) of undiluted drug. Mosby’s Dental Drug Reference18 Rinse with 15 mL† for 30 s twice a day after brushing and flossing teeth. Drug Dictionary for Dentistry19 10 mL† of solution twice daily. Dentifrice will reduce the substantiveness of CHX, thus these products should not be used together. 20 Mosby’s GenRx Twice-daily oral rinsing for 30 s, morning and evening after toothbrushing. Usual dosage is 1/2 fl oz† (15 mL) of undiluted CHX. Mosby’s Drug Consult21 Twice-daily oral rinsing for 30 s, morning and evening after toothbrushing. Usual dosage is 1/2 fl oz† (15 mL) of undiluted CHX. *Only in this reference book is a 60-second rinsing, instead of a 30-second rinsing, recommended. †Unfortunately this international drug reference book does not consider the difference in CHX mouthrinse concentrations between the United States and Europe. recurrent aphthous ulceration, (7) orthodontic plaque and suspended mechanical clean- patients, and (8) contol of bacteremia and ing.12 When used as an adjunct to normal operatory contamination by oral bacteria. oral hygiene, variable results were found for CHX is of major importance in the healing plaque and gingivitis reduction.12 Unfortu- process,7–10 through controlling secondary nately, study designs testing the longer-term infection and forming a white coating layer. A adjunctive benefits of CHX to mechanical white coating is formed over the damaged cleansing have yielded disappointing results. area within 24 hours following initiation of Thus, such long-term home use studies have CHX use. This coating may be due to the shown relatively small benefits for the adjunc- substantiveness of the agent, which binds to tive use of CHX.13,14 many reception sites in the oral cavity and However, in the United States Pharmaco- subsequently coagulates salivary and serum peia: Drug Information for the Health Care protein, forming a protective barrier.11 Professional (USP DI), the following modali- Despite the excellent plaque inhibitory ty of administration for CHX is recommend- property of CHX, clinical usage of the agent ed4: “15 mL of a 0.12% oral rinse for 30 is limited by the possible local adverse seconds 2 times a day after brushing and effects, including3: (1) reversible staining of flossing teeth.” USP DI monographs are the teeth and tongue, (2) transient taste per- according to strict US Food and Drug turbation, (3) oral mucosal erosion, (4) occa- Administration–approved product labeling. sional parotid gland swelling, and (5) Recommendations for use of CHX in some enhanced supragingival calculus formation. other international drug reference books are The most common and problematic adverse shown in Table 1. effect is staining.4 It may be visible as early as CHX, a cation, is chemically incompatible 1 week after therapy; after 6 months of use with soaps and other anionic materials.15 approximately 50% of patients may have a Therefore, there are some questions about measurable increase in tooth stain and rinsing with CHX solution after brushing and approximately 10% may have heavy staining. flossing teeth. Interaction between CHX and It is more pronounced in patients who have anionic materials causes inactivation or heavier accumulations of plaque.4 reduction of the antiplaque effect of CHX. The most dramatic antiplaque activity of The aim of this systematic review is to dis- CHX can be seen from those studies com- cuss the concept of delaying the use of CHX mencing rinsing from a baseline of no until some time after the use of dentifrices. 606 VOLUME 37 • NUMBER 8 • SEPTEMBER 2006 Kolahi.qxd 7/31/06 9:38 AM Page 607 QUINTESSENCE INTERNATIONAL Kolahi/Soolari METHOD AND MATERIALS viously published methodological issues.24 Evidence with high risk of bias was not con- Search strategy sidered. All evidence from international drug The search process included review of: reference books was considered. 1. Thirteen specialist databases, including Data extraction and assessment of Medline, Embase, Biosis, Current study quality Contents Search (Science Citation Index Extraction of data from studies and assess- and Social Science Citation Index), ment of validity was independently per- Healthstar (Health Service Technology, formed by 2 reviewers and checked by a Administration, and Research), Chemical third reviewer. The information regarding Abstracts, CAB Health,