58776917-Chlorhexidine

7/24/2019 58776917-Chlorhexidine

1/21

Earn

4 CE creditsThis course was written for dentists, dental hygienists, and assistants.

Chlorhexidine:

A Multi-Functional Antimicrobial DrugA Peer-Reviewed Publication Written by Gary J. Kaplowitz, D.D.S., M.A., M.Ed andMarilyn Cortell, RDH, MS

PennWell is an ADA CERP recognized provider ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. PennWell is an ADA CERP Recognized Provider Concerns of complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/goto/cerp.

Go Green, Go Online to take your courseThis 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.


2/21

Educational ObjectivesUpon completion of this course, the clinician will be able to do the following:1. Explain the mechanism of action of chlorhexidine gluconate. 2. Identify the unique property that allows for a prolonged effect. 3. Describe the clinical indications for use. 4. Understand the mechanism by which chlorhexidine may cause extrinsic stain and the recommended home care strategies to reduce its occurrence.5. Apply the dosage and guidelines for the clinical use of chlorhexidine gluconate.

AbstractChlorhexidine gluconate is an effective bactericidal agent and broad-spectrum antimicrobial drug. It has been extensively researched and is the gold standard antimicrobial in oral hygiene. Chlorhexidine is useful in many clinical disciplinesincluding periodontics, endodontics, oral surgery and operative dentistry.

IntroductionChlorhexidine gluconate (chlorhexidine) is a broad-spectrum antimicrobial drug.Acting as an antiseptic, it is an effective bactericidal agent against all categories of microbes, including bacteria, yeast, and viruses. Chlorhexidine molecules are positively charged (cations) and most bacteria and surface structures inthe 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 chlorhexidine enhances this bactericidal effect, which allows for the retention of chlorhexidine in the oral cavity and a prolonged residual antimicrobial effect for up to 12 hours or longer depending on the dosage and form. Chlorhexidine is safe and has an inherent advantage over antibiotics by not producing resistant microorganisms. As a result chlorhexidine can be used repeatedly and over long periods of time. Furthermore, itdestroys all categories of microbes, not just bacteria, and there is little riskfor the development of opportunistic infections. As with many FDA approved drugs, the use of chlorhexidine does have known disadvantages; however, these disadvantages are a small trade off compared to the many advantages and are reversibleonce the use of chlorhexidine is discontinued. Chlorhexidine was first used asa mouthrinse as an adjunct to conventional non-surgical periodontal therapy

2

in Europe in the early 1970s. It received FDA approval in 1986 under the brand name PERIDEX (Zila Pharmaceuticals) based on studies showing that it reduced gingivitis by up to 41%. Soon after,1 PERIDEX was the first mouthrinse to receive the ADA Seal of Acceptance. Generic rinses have been available since 1994 and are available from many different companies. In order to qualify as a generic, the medication must prove to have 80120% of the bioavailability of the name brand to be considered bioequivalent. To date, there have been no published equivalency studies between the brand PERIDEX and any generic rinses. Chlorhexidine has proven efficacy as a broad-spectrum antimicrobial for reducing supragingival plaque. In 1997, chlorhexidine was introduced in a locally applied, controlled-release gelatin chip (PerioChip, OMNII Oral Pharmaceuticals) as a treatment to reduce pocket de

pths in patients with adult periodontitis. Since then there have been many off-label uses arising from the desire to effectively reduce microbial pathogens to enhance treatment results. Some of the uses will be reviewed so that clinicians can make an informed decision about incorporating chlorhexidine into their treatment protocols.

Figure 1. When the chlorhexidine molecules adhere to and damage the surface of bacteria, osmotic imbalance and the precipitation of cytoplasm ensue and result in cell death.


3/21

PeriodonticsGingivitis

Chlorhexidine is recognized as the gold standard antimicrobial in oral hygiene.When chlorhexidine gluconate 0.12% rinse is used in between professional dentalvisits gingival healing is significantly improved. Rinses containing chlorhexidine are intended for any patient presenting with redness and swelling of the gingivae, including gingival bleeding upon probing. However, many practitioners reserve chlorhexidine for their mostwww.ineedce.com


4/21

severe cases of gingivitis due to the potential for extrinsic staining of the teeth. The extrinsic staining, which will be discussed further, is easily remediedso the advantages to the patient far outweigh any adverse event. The recommended protocol for rinsing with chlorhexidine 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 supra- and subgingival, has been used as both a professionally delivered treatment and an adjunct tohomecare. 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 reduce bacteria within periodontal pockets by delivering the solution directly into the pocket eitherby use of a 1) syringe; 2) jet irrigator with a cannula; and/or 3) an ultrasonic unit. The goal is to treat periodontitis or prevent it from occurring. Chlorhexidine, although not alone, is the most studied drug. As a medicament, the substantive property makes it an ideal choice for irrigation. However, studies are inconclusive. Some suggest that subgingival irrigation is better for improved periodontal results. Others say patients that did not receive subgingival irrigationreceived similar results. This might be due to the fact that, although chlorhexidine is retained in the pocket it might not be retained long enough. Nevertheless, there is data to suggest that irrigation with a high level of chlorhexidinemay enhance scaling and root planing; but it seems continual therapy is more appropriate than the administration of one in-office irrigation treatment. Recommendations would be to either have patients follow-up with a regular at-home irriga

tion regimen, or to use a professionally administered locally applied alternative where the bactericidal level of chlorhexidine in the pocket is more predictable. For an at-home protocol it would be advisable for patients to continue with subgingival irrigation for at least 28 days to be followed by a 23 month reevaluation appointment after the initial scaling and root planing.3Periodontitis

Figure 2. Chlorhexidine chip being inserted into a periodontal pocket on the mesial surface of a mandibular canine. Porphyromonas gingivalis (Pg) is often difficult to eliminate especially when implicated in periodontal disease. Like many other pathogenic bacteria associated with periodontal disease, Pg becomes embedded in biofilm making it resistant to higher concentrations of antimicrobial drugs. Chlorhexidine has demonstrated an increased efficacy in eliminating Pg embedde

d in biofilm than comparable antimicrobial agents.4 By incorporating chlorhexidine into treatment protocols, this important periodontal pathogen can be significantly reduced thus promoting resolution and healing. The simplicity of the chlorhexidine chip has increased in recent years with the introduction of a non-refrigerated chip that can be placed using a standard cotton plier. Research has found that when the chlorhexidine chip was used as an adjunct to scaling and root planing, patients were 23 times more likely to have pocket depth reductions of 2 mmor more when compared to those treated with a placebo chip.5 Patients can alsobe treated, as needed, as a part of a long-term periodontal maintenance program.In one study, patients had the chlorhexidine chip inserted into periodontal pockets when they measured 5 mm deep or more. Results revealed that 91.8% of siteseither improved (73%) or stabilized (18.8%) over a two-year period.6 The advantages of incorporating chlorhexidine into non-surgical periodontal therapy should

not be underestimated. It is a simple and inexpensive addition to the traditional protocols and has yielded significant benefits for patients by enhancing resolution and recovery. Clinical research also supports the use of chlorhexidine prior to surgical procedures as part of initial therapy. In this case, the goal isless a measure of pocket depth and3

Chlorhexidine has also been used with great success in periodontal therapy in the form of a subgingival, time released, local delivery system. The chlorhexidinechip (2.5 mg) is a small gelatin chip inserted into periodontal pockets >5 mm d


5/21

eep. The chip will dissolve and release chlorhexidine over 710 days and eradicatepathogens (e.g. Porphyromonas gingivalis) commonly identified in the subgingival biofilm of patients with periodontal disease and deep subgingival pockets.www.ineedce.com


6/21

more a way to reduce the bacterial challenge within the surgical area.Regenerative periodontal surgery

One of the most significant threats to success in bone regenerative procedures is local infection and inflammation. Disinfecting the surgical site with chlorhexidine chips has been shown to increase the chance of success in regenerative periodontal procedures involving bone grafts by resulting in significant gains in bone height and bone mass over time.7 They should be used during initial therapy,one week prior to regenerative surgery, and as a part of the maintenance program, in pockets 5 mm deep. Incorporating the use of chlorhexidine chips into regenerative procedures is relatively simple, inexpensive and expected to yield significant improvements in healing.

Preprocedural RinsingThe oral cavity is largely contaminated with viruses and bacteria. Sources of these microorganisms are: dental plaque, saliva, the nose, throat, and respiratorytract. Dental procedures that utilize ultrasonic scalers, dental handpieces, air polishers and air abrasion units have the potential to create aerosolized material that could include: supra- and subgingival plaque organisms, blood, and viruses including the influenza virus and the common cold virus.8 There is no scientific evidence that supports preprocedural rinsing as a defensive measure to reduce infections of the dental office staff by patients. However, studies have shown that using an antimicrobial rinse, such as chlorhexidine, can reduce the number of organisms in aerosols created during routine dental treatment.9 This may a

lso be beneficial for patients who are at higher risk for developing bacterial endocarditis. Preprocedural rinsing has, however, been proven beneficial if doneprior to oral surgery procedures.Oral Surgery

One common complication of third molar extractions is alveolar osteitis (i.e., `dry socket') which may present with a necrotic, lysed or disintegrating blood clot accompanied by a fetid odor, unpleasant taste and severe or even incapacitating pain. Pain may radiate to the ear or the entire side of the face with the onset usually 24 days post-operative. The incidence varies but may be as high as 30%, especially for impacted third molars.. The etiology of alveolar osteitis is largely unknown. One theory is that the blood clot fails to form after the extraction.A second theory is that the blood clot forms but disintegrates or undergoes fib

rinolysis shortly after it forms. A bacterial source of fibrinolytic agents hasbeen theorized.104

Rinsing preoperatively with a 0.12% chlorhexidine gluconate solution resulted ina 97% decrease in the intraoral aerobic bacterial load that persisted for at least 1 hour.11 Rinsing with chlorhexidine for one week prior to surgical third molar extractions and for one week post-operatively resulted in a significant reduction in alveolar osteitis.12 One of the most effective protocols proposed to decrease the incidence of alveolar osteitis involves the use of a pre-operative and/or post-operative rinse with chlorhexidine.13 The most frequent protocol is for the patient to rinse with 15 mL of chlorhexidine for 30 seconds twice daily. Adecrease in bacterial load can also benefit surgical cases where implants are b

eing placed. Infection can lead to implant failure. Meticulous attention to infection control protocol and eliminating potential sources of infection are critical to enhance the successful osseointegration of implants. In addition to implementing stringent infection control measures throughout implant procedures, rinsing with chlorhexidine will significantly reduce the opportunity for microbial infections and increase the potential for successful osseointegration.14 In caseswhere the area around an implant becomes infected and results in periimplantitis, the use of chlorhexidine irrigants in conjunction with mechanical debridementmay produce significant improvements in resolution and healing.15 When implantsare placed, bone may be harvested for use in simultaneous bone augmentation proc


7/21

edures to insert around implants with gaps in the bone-implant interface. Rinsing preoperatively with chlorhexidine results in significantly fewer bacteria in harvested bone, consequently yielding a decreased chance of post-operative infections.16 When used in a regular program of routine implant maintenance with routinely scheduled recalls, rinsing with chlorhexidine can be expected to produce significant improvements in periodontal health over time. Improvements can be expected in Gingival Index, Plaque Index, Bleeding Index and Calculus Index. 17 Theimprovement in the above indices may also have a beneficial effect on caries control as well as on the control of oral malodor.

Preventive DentistryCaries

There are a number of theories concerning the development and progression of dental caries. According to the Specific Plaque Hypothesis, only a limited number of bacteria found in dental plaque can produce dental caries.18 The most prominent among these odontowww.ineedce.com


8/21

pathogenic bacteria are the Lactobacilli and the mutans streptococci.19,20 Mutans streptococci represent a group of closely related bacterial species that are the primary species that initiate enamel caries. Therefore, patients with low mutans streptococci population levels in their oral cavity generally have low caries activity and patients with high mutans streptococci population levels generally have high caries activity.21 Lactobacilli are the primary causative species ofdentinal caries and generally colonize after mutans streptococci have exposed the dentinoenamel interface. Caries is a communicable disease and is a bacterialinfection of the enamel, dentin and cementum. Infants are not born with mutans streptococci in their oral cavity.22 Mutans streptococci are transmitted from themother, father or care giver to infants and toddlers, generally between 19 to 28 months of age, with 83% of children infected by the age of four.23,24 Childrenwith demonstrable levels of mutans streptococci develop carious lesions. Children without demonstrable levels of mutans streptococci do not. Prevention of transmission of mutans streptococci from caregiver to child for the reduction of dental caries is the subject of many current caries trials and public health dentalprograms. Chlorhexidine is a very potent bactericidal agent for mutans streptococci, the most significant group of bacterium associated with caries.25 Chlorhexidine molecules adhere to the surfaces of mutans streptococci and produce cell death. Under some circumstances with professional intervention and intensive homecare, mutans streptococci can be eradicated from the oral cavity. In one protocol, patients had their teeth professionally cleaned every day for ten days. Following the dental prophylaxis, patients had 1.0% chlorhexidine applied twice in custom trays. Patients brushed three times a day and applied chlorhexidine 0.2% t

wice a day in the morning and before bed. Patients rinsed with 0.2% chlorhexidine after lunch. At four months, three out of seven subjects in the study demonstrated no detectable level of mutans streptococci.26 However three of the subjectsstill had detectable levels of mutans streptococci. These three subjects also had deep periodontal pockets and it is possible that mutans streptococci might have found refuge in them and thus eluded the bactericidal effects of chlorhexidine. The results of a three-year randomized clinical trial to provide caries management through risk assessment were presented in March 2005 by Dr. John Featherstone et al., from the University of California-San Francisco, during the International Association of Dental Research Meeting. In the study caries active subjects (N=230)www.ineedce.com

were assigned either to a conventional care group or a preventive intervention grou. Treatment in the conventional care group included restoration of any cavitatedlesions and oral health instructions. The preventive intervention group were also restored and provided oral health instructions but then also received both a0.12% chlorhexidine gluconate (CHX) rinse and a 0.05% NaF (F) daily use rinse through the study duration. The study found that combining CHX to reduce the bacterial challenge and F to enhance remineralization successfully and significantly reduced caries risk by about three times and suggested a reduced caries risk increment.27 For patients with a high risk of caries, chlorhexidine rinses can be successfully used to reduce the number of odontopathogenic bacteria. This should beintegrated into an intensive home care program to maintain the optimum level oforal hygiene. Meticulous home care can also benefit those troubled by oral malodor.

Oral Malodor

Oral malodor (i.e., breath malodor, bad breath, halitosis, etc.) afflicts a significant number of people in the United States. For many, the problem is significant and impacts daily life and social interactions. There are many, so-called, quick fixes in the form of lozenges, rinses, gum, etc, for purchase over-the-counter in pharmacies and health food stores. Awareness of this problem and the stigma associated with it has created a huge market in health care. The etiology ofbreath malodor varies, but originates about 87% of the time in the oral cavity.28,29 It is caused most frequently by bacterial products, which produce volatile


9/21

sulphur compounds with characteristic foul odor components. Many of these bacteria are embedded in periodontal pockets, plaque and calculus making them difficult to access and eradicate. Oral malodor is associated with periodontal disease,deep periodontal pockets, and an increase in the amount of calculus, a high plaque index and poor oral hygiene.30 Anaerobic bacteria residing on the dorsoposterior surface of the tongue is also an important source of volatile sulphur compounds and tongue cleaning may be required to reduce this population of bacteria inthis area.31 Many treatment protocols have been proposed for reducing or eliminating bad breath. One of the most effective treatments developed thus far is forthe patient to rinse with chlorhexidine.32 It is probable that the decrease inmalodor observed when patients rinse with chlorhexidine is due, at least in part, to the reduction in the plaque index as well as the reduction in gingival inflammation resulting in fewer bacteria capable of generating volatile sulphur compounds. Rinsing with5


10/21

chlorhexidine twice daily (i.e., once in the morning and once at night) is sufficient to produce a significant decrease in bacterium that produces volatile sulphur compounds thus decreasing oral malodor.33 Another area where chlorhexidine has found a use is in endodontics.

Table 1. Intracanal Irrigants Sodium Hypochlorite Chlorhexidine Gluconate Hydrogen Peroxide Alcohol Saline Iodine Potassium Iodide Most cases of root canal failure that have been cultured demonstrate high levels of anaerobic bacteria, notably Enterococcus faecalis and Actinomyces israelii. Actinomyces israelii is partof the normal oral flora and has been isolated from dental plaque, carious dentin and periodontal pockets; however, in certain circumstances it can cause an infection.36 These microorganisms are very susceptible to chlorhexidine. Chlorhexidine 0.12% solution is an effective antimicrobial agent when delivered to the root canal space as an intracanal irrigant. It is able to penetrate deeply into thedentinal tubules and kill the pathogenic bacteria.

EndodonticsIn endodontic therapy, chlorhexidine is now widely used as an intracanal irrigant or as an intracanal medicament. Its wide antimicrobial spectrum offers efficacy, while ease in delivery and reasonable price make it a practical choice. Unlike other intracanal irrigants and medicaments, it has no tissue toxicity. Most root canal infections involve a mixture of aerobic and anaerobic bacteria, with the anaerobic bacteria producing the dominant pathological features of infection and inflammation. The primary objective in root canal treatment is the removal of

infected pulpal tissue and infectious microbial pathogens. This is accomplishedwith mechanical debridement via instrumentation and intracanal irrigants. Mechanical instrumentation with files and reamers widens the root canal space and removes the bulk of the pulp tissue and pathogenic microbial agents. However some fragments of tissue and pathogenic microorganisms will remain even after the moststringent or aggressive mechanical instrumentation of the canal space. Two significant anaerobic pathogens isolated from root canal infections are Enterococcusfaecalis 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 tubules 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 hav

e not been eliminated by conventional mechanical instrumentation. The most widely used intracanal irrigants are sodium hypochlorite, iodine potassium iodide, hydrogen peroxide, alcohol and chlorhexidine. Each of the irrigants possesses itsown set of particular attributes. Sodium hypochlorite is commonly used because it is the most effective tissue solvent, has excellent microbicidal properties and is inexpensive. One disadvantage of sodium hypochlorite is that it can be harsh on the periapical tissues, causing destruction of the PDL at and around the apices if extruded through the apex. This can be painful to the patient, althoughthere are certain syringes and techniques that can be used to minimize this occurrence.6

Figure 3. Bacteria penetrate deeply into the dentinal tubules. There has been a

major paradigm shift in endodontic therapy protocols from the traditional multiplevisit approach to initiating and completing endodontic therapy in a single-visit whenever indicated and whenever possible. However, in certain instances a multiple-visit approach is still warranted. It is thought that, during the interimperiod between multiple visits, pathogenic microorganisms are able to repopulatein the root canal space.37 Therefore, the importance of eliminating pathogenicbacteria from infected root canals should not be underestimated. Actinomyceswww.ineedce.com


11/21

israelii can migrate into the general circulation during or after root canal treatment.38 It can also migrate out of the infected root canal into the periapicaltissue where it can produce an abscess.39 Actinomyces israelii is an opportunistic pathogen and can infect extraction sockets, periodontal surgery sites, areasof trauma and other susceptible portals of entry. A number of intracanal medicaments have been used to prevent this rebound of pathogenic microorganisms and the most frequently used are listed in Table 2. Some possess undesirable properties. Formocresol and Camphorated Monochlorophenol have exhibited some tissue toxicity. Iodine Potassium Iodide is active for only a short period of time, poisonous if ingested and provokes an allergic reaction in some patients. Calcium Hydroxide requires prolonged application in order to be maximally effective as an antimicrobial agent and is not always successful in eliminating pathogenic bacteria.40 Chlorhexidine, when introduced into the root canal space as an intracanal medicament, is the only medicament that can completely eliminate Actinomyces israelii and is far more biocompatible than the other intracanal medicaments.41 It isalso inexpensive, easy to deliver and readily removed. Table 2. Intracanal Medicaments Formocresol Camphorated Monochlorophenol (CMCP) Calcium Hydroxide CalciumHydroxide with CMCP Chlorhexidine Gluconate Iodine Potassium Iodide

all patients will experience a visually significant increase in tooth staining.In clinical testing, 56% of oral rinse users exhibited a measurable increase infacial anterior stain of the teeth, compared to 35% of control users after 6 months.44 Chlorhexidine stain, being extrinsic, is easily removed from the teeth with a variety of techniques and materials. One very effective technique is to use

an electric or battery powered toothbrush, oscillating or rotating, which can be expected to decrease stain by 75% after 4 weeks of use.45,46 Powered tooth brushing becomes more effective at reducing chlorhexidine staining over time.47 However, manual tooth brushing will also remove chlorhexidine stain, although not as rapidly or efficiently.48 Another very effective technique for chlorhexidine stain removal is to use a whitening dentifrice. These are inexpensive and can beobtained over the counter in any pharmacy.49 An advantage of using a whitening dentifrice simultaneously with the implementation of chlorhexidine rinsing is that the amount of acquired stain will be reduced and easier to remove.50 Additional studies have recommended chewing gum as a way to help reduce the potential forstaining.51 Educating patients on maintaining optimum oral hygiene will greatlyreduce the possibility of chlorhexidine stain, since stain will collect more readily in the presence of plaque biofilm.

ConclusionRecognizing the clinical application of the broadspectrum antimicrobial chlorhexidine gluconate and incorporating it into your specific clinical practice setting is an appropriate and effective mode of action. The varied and effective applications of chlorhexidine make it a viable option for use in all dental settingsand within a variety of dental procedures and pre-procedures with very few undesirable side effects.

Known Side EffectsThere are many benefits to incorporating chlorhexidine into treatment protocolsalong with some precautions. The most common side effects are altered taste perception, an increase in calculus formation, and an increase in staining of the te

eth. In addition, anyone with a known hypersensitivity to it should not be prescribed chlorhexidine.Staining

Glossary of TermsAntiseptic: A chemical that destroys or inhibits the growth of microorganisms and is sufficiently non-toxic for superficial application to the skin and mucous membranes. Can be used internally to treat infections of the intestine and bladder Osmosis: The flow of a solvent by diffusion through a semipermeable membrane from a more concentrated solution to a less concentrated one, until the concentra


12/21

tions are equalized. Substantivity: The property of an antiseptic or disinfectant that makes it effective for a prolonged period of time following its application.7

Two theories currently exist to explain the staining mechanism of chlorhexidine.One theory suggests that chlorhexidine molecules interact with chromogens present in food and beverages and the resultant precipitate produces much of the tooth staining.42 The second theory proposes that a series of chemical reactions between sugars and amino acids, called the maillard or non-enzymatic browning reaction, causes compounds to form as products of this reaction. This is also seen inthe browning of foods high in carbohydrates and sugars, such as apples and potatoes.43 Notwww.ineedce.com


13/21

ReferencesShephard S. Brushing Up on Gum Disease. FDA Consumer. Available at : www.fda.gov. 2 Beiswanger B, et al. Clinical effects of 0.12% chlorhexidine rinse as an adjunct to scaling and root planning. J Clin Dent. 1992;3:3338. 3 AAP Position Paper. The Role of Supra and subgingival irrigation in the Treatment of Periodontal Diseases. American Academy of Periodontology. Available at www.perio.org. 4 NoiriY, et al. Effects of chlorhexidine, minocycline, and metronidazole on Porphyromonas gingivalis strains 381 in biofilms. J Periodontol. 2003;74:16471651. 5 Jeffcoat M, et al. Adjunctive use of a subgingival controlledrelease chlorhexidine chip reduces probing depth and improves attachment level compared with scaling androot planing alone. J Periodontol. 1998 Sep;69(9):989997. 6 Soskolne W, et al. Probing depth changes following 2 years of periodontal maintenance therapy including adjunctive release of chlorhexidine. J Periodontol. 2003;74:420427. 7 Reddy M, et al. Efficacy of controlled-release subgingival chlorhexidine to enhance periodontal regeneration. J Periodontol. 2003;74:411419. 8 Harrel S. Aerosols and splatter in dentistry. J Am Dent Assoc. 2004;135:429437. 9 Oral Health Resources. Preprocedural mouthrinse. National Center for Chronic Disease Prevention and Health Promotion. Available at: http://www.cdc.gov/OralHealth/infectioncontrol/ faq/pre_procedural_mouthrinse/htm. 10 Nitzan D. On the genesis of dry socket. J OralMaxillofac Surg. 1983;41:706710. 11 Veksler A. Reduction of salivary bacteria bypre-procedural rinses with Chlorhexidine 0.12%. J Periodontol. 1991;62:649651. 12 Hermesch C, et al. Preoperative use of 0.12% chlorhexidine gluconate for the prevention of alveolar osteitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1998;85:381387. 13 Larsen P. The effect of chlorhexidine rinse on the incidence

of alveolar osteitis following the surgical removal of impacted mandibular third molars. J Oral Maxillofac Surg. 1991;49: 932937. 14 Lambert P et al. The influence of 0.12% chlorhexidine digluconate rinses on the incidence of infectious complications and implant success. J Oral Maxillofac Surg. 1997;55:2530. 15 MombelliA, Lang N. Antimicrobial treatment of peri-implant infections. Clin Oral Impl Res. 1992;3:162168. 16 Y oung M, et al. The effects of an immediately pre-surgicalchlorhexidine oral rinse on the bacterial contaminants of bone debris collectedduring dental implant surgery. Clin Oral Impl Res. 2002;13:2029. 17 Felo A, et al. Effects of subgingival chlorhexidine irrigation on peri-implant maintenance.Am J Dent. 1997;10:107110. 18 Loesche W. Chemotherapy of dental plaque infections. Oral Sci Rev. 1976;9:63107. 19 Enright J, et al. Studies of the cause and nature of dental caries. J Dent Res. 1932;12:759851. 20 Fitzgerald R, Keyes P. Demonstration of the etiologic role of streptococci in experimental caries in hamsters.

J Am Dent Assoc. 1960;61:919. 21 Shklar I, et al. The distribution of Streptococcus mutans on the teeth of two groups of naval recruits. Arch Oral Biol. 1974;19: 199202. 22 Carlsson J, et al. Lactobacilli and Streptococci in the mouths of children. Caries Res. 1975;9:333339. 23 Berkowitz R, et al. The early establishmentof mutans in the mouths of infants. Arch Oral Biol. 1975;20:171174. 24 CaufieldP, et al. Initial acquisition of mutans streptococci by infants: evidence for adiscrete window of infectivity. J Dent Res. 1993;72:3745. 25 Zickert L, et al. Effect of caries preventive measures in children 8 1 26 27

28

29 30 31

32 33

34 35

36

37

38 39 40


14/21

41

42 43 44 45

46

47

48

49 50 51

highly infected with the bacterium Streptococcus mutans. Arch Oral Biol. 1982;27:661668. Nomura Y, et al. Feasibility of eradication of mutans streptococci fromoral cavities. J Oral Sci. 2004;46:179183. Featherstone JDB, et al. Chlorhexidineand Fluoride Therapy Reduces Caries Risk, IADR-Baltimore Presentation 0023, Support: USDHHS NIH/NIDCR R01DE12455. Tonzetich J. Production and origin of oral malodor: a review of mechanisms and methods of analysis. J Periodontol. 1977;48: 1320. Delanghe G, et al. Multidisciplinary breath-odor clinic. Lancet 1997;350:187.Soder B, et al. The relation between foetor ex ore, oral hygiene and periodontaldisease. Swed Dent J. 2000;24:7382. de Boever E, Loesche W. Assessing the contribution of anaerobic microflora of the tongue to oral malodor. J Am Dent Assoc. 1995;126:13841393. Carvalho M, et al. Impact of mouthrinses on morning bad breathin healthy subjects. J Clin Periodontol. 2004;31:8590. Rosenberg M, et al. Daylon

g reduction or oral malodor by a twophase oil: water mouthrinse as compared to chlorhexidine and placebo rinses. J Periodontol. 1992;63:3943. Haapasalo M. In vitro infection and disinfection of dentinal tubules. J Dent Res. 1987; 66:13751379.Siqueira J, et al. A scanning electron microscope evaluation of the in vitro dental tubules penetration by selected anaerobic bacteria. J Endod. 1996;22:308310.Fukushima H, et al. Localization and identification of root canal bacteria in clinically asymptomatic periapical pathosis. J Endod. 1990;16:534538. Bystrom A, Sundqvist G. Bacteriological evaluation of the efficacy of mechanical root canalinstrumentation in endodontic therapy. Scand J Dent. 1981;89:321328. Debelian G,et al. Bacteremia in conjunction with endodontic therapy. Endod Dent Traumatol.1995;11:142149. Wesley R, et al. Periapical actinomycosis: clinical considerations. J Endod. 1977;3:352355. Bystrom A, et al. The antibacterial effect of camphorated paramonochlorophenol, camphorated phenol and calcium hydroxide in the treatm

ent of infected root canals. Endod Dent Traumatol. 1985;1:170175. Basson N, TaitC. Effectiveness of three root canal medicaments to eliminate Actinomyces Israelii from infected dentinal tubules in vitro. SA Dent J. 2000;56:499501. Jones CG.Chlorhexidine: is it still the gold standard? Periodontol. 2000;1997:5562. NathooSA. The chemistry and mechanisms in intrinsic and extrinsic discoloration. J AmDent Assoc. 1997;128: 6S10S. Peridex Package Insert Grossman E, et al. A comparative clinical study of extrinsic tooth stain removal with two electric toothbrushes (Braun D7 and D9) and a manual brush. Am J Dent. 1996;9(Spec No.):S2529. Garcia-Godoy F, Ellacuria J. Effectiveness of Sonicare power toothbrush to remove chlorhexidine stain. Am J Dent. 2002;15:290292. Moran J, et al. A clinical study toassess the ability of a powered toothbrush to remove chlorhexidine/tea dental stain. J Clin Periodontol. 2004;31:9598. McInnes C, et al. Clinical and computer-assisted evaluations of stain removal ability of the Sonicare electronic toothbru

sh. J Clin Dent. 1994;5:18. Emling R, et al. Rembrandt toothpaste: stain removalfollowing the use of Peridex. J Clin Dent. 1992:6669. Tillis T. Use of a whitening dentifrice for control of chlorhexidine stain. J Contemp Dent Pract. 1999;1:915. Yankell SL. Efficacy of chewing gum in preventing extrinsic tooth staining. Clin Dent. 1997;8(6):169167 www.ineedce.com


15/21

Author ProfileGary J. Kaplowitz, D.D.S., M.A., M.Ed

Dr. Kaplowitz retired from the military after serving as Chief Dental Officer ofThe U.S. Coast Guard. He is a graduate of the New York University College of Dentistry and is a Diplomate of the American Board of General Dentistry. He has published widely on dental materials and clinical techniques. He is editor of Osseonews.com and is in private practice in York, Pennsylvania.Marilyn Cortell, RDH, MS

emy of Dental Hygiene and The American Dental Hygienist's Association. Along withserving both on the editorial board of RDH Magazine and a consultant member to the North East Regional Board of Dental, Examiners (NERB), Marilyn has contributed to three prominent widely distributed dental hygiene textbooks and is currently serving as an appointed member of the ADHA Council on Public Relations.

DisclaimerThe authors of this course have no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.

Marilyn Cortell has extensive experience as a dental hygiene educator and national lecturer. Currently she is a full time Assistant Professor at New York City College of Technology and an Adjunct Clinical Associate Professor at New York University. She is a member of The National Speakers Association, American Acad-

Reader FeedbackWe encourage your comments on this or any PennWell course. For your convenience,an online feedback form is available at www.ineedce.com.

www.ineedce.com

9


16/21

Questions1. Chlorhexidine has a _____ charge.a. b. c. d. positive negative neutral None of the above

11. Enterococcus faecalis can penetrate dentinal tubules up to ________.a. b. c. d. 50 microns 200 microns 400 microns 1,000 microns

21. Chlorhexidine chips can be used in regenerative periodontal therapy to ________.a. facilitate graft placement b. facilitate membrane removal c. reduce the incidence of infection and inflammation d. All of the above

2. The surfaces of the teeth have a _________ charge.a. b. c. d. positive negative neutral None of the above

12. In endodontic therapy, chlorhexidine is effective against ________.a. b. c. d. enterococcus faecalis actinomyces Israelii most bacteria All of theabove

3. The cell walls of microorganisms have a ________ charge.a. b. c. d. positive negative neutral None of the above

22. Porphyromonas gingivalis is often difficult to eliminate because ________.a. b. c. d.

13. One advantage sodium hypochlorite has, as an intracanal irrigant compared tochlorhexidine is that ________.a. b. c. d. a. b. c. d. it is less expensive it has a recognizable odor it is easier to deliver it dissolves soft tissue very well hereditary disease communicable disease reactive disease immunologic disease

it is very resilient it reproduces rapidly it develops resistance to chlorhexidine it is often embedded in biofilm

4. Side effects of chlorhexidine that some patients experience are:a. b. c. d. bitter taste extrinsic staining of teeth increased rate of formationof calculus All of the above

14. Caries is a ________.

23. Preprocedural rinsing may be a good idea because aerosolized material may include: supra- and subgingival plaque organisms, blood, and viruses including influenza and the common cold.a. True b. False

5. Chlorhexidine is not an antibiotic. It is an ________.a. b. c. d. antigen antidote antiseptic anticodon

15. The most prevalent bacteria associated with caries is ________.a. b. c. d. Porphyromonas gingivalis Prevotella intermedia Mutans streptococci T

reponema denticola

24. Oral malodor is most often caused by ________.a. b. c. d. hepatic dysfunction bacteria in the oral cavity ketosis alkalosis

6. The unique property of substantivity allows for the ________.a. b. c. d. short action of chlorhexidine prolonged effect of chlorhexidine buffering effect of chlorhexidine bactericidal effect of chlorhexidine

16.The signs and symptoms of alveolar osteitis include ________.


17/21

a. b. c. d. pain radiating to the ear onset 2-4 days post-operatively oral malodor All of the above

25. Oral malodor is frequently associated with ________.a. b. c. d. periodontal disease increased amounts of calculus a high plaque index All of the above

7. In order for a generic drug to be approved by the FDA, the drug must ________.a. b. c. d. work 80% of the time be 20% as effective be no more than 80% effective be at least 80% bioequivalent

17. Rinsing with chlorhexidine before or after third molar extractions can result in an ________.a. b. c. d. increased chance of alveolar osteitis decreased chance of alveolar osteitis increased chance of salivary flow compromise decreased chance of salivary flow compromise

26. The most effective of the treatments for oral malodor is ________.a. b. c. d. lozenges fragrant mouth sprays anti-bacterial gels rinses with chlorhexidine

8. The advantages of using chlorhexidine as an intracanal irrigant in endodontictherapy include:

a. b. c. d. Broad spectrum activity Ease of delivery Low tissue toxicity All ofthe above

9. One of the objectives of using chlorhexidine as an intracanal medicament between visits is to ________.a. b. c. d.

18. Patients with an increased chance of developing bacterial endocarditis should ________.a. b. c. d.

27. Chlorhexidine staining is largely due to the reaction of chlorhexidine with________.

a. b. c. d. a. b. c. d. a. b. c. d. bisguanides dications chromogens dichromides

prevent rebound of pathogenic microorganisms fill the root canal space seal theroot canal space dissolve residual tissue

rinse once post-operatively with chlorhexidine rinse twice post-operatively withchlorhexidine rinse pre-operatively with chlorhexidine not rinse with chlorhexidine

28. Chlorhexidine stain is ________.intrinsic extrinsic internal covalently bound

10. Mechanical debridement of the root canal space does not remove all pathogeni

c microorganisms because ________.

19. Chlorhexidine rinse when used in conjunction with routine scaling and root planing can be expected to produce ________.a. b. c. d. a significant reduction in pocket depths a significant reduction inbleeding on probing None of the above All of the above

29. Chlorhexidine stain is ________.difficult to remove easy to remove rarely noticeable a myth


18/21

a. the microorganisms adhere tenaciously to the root canal walls b. the pathogenic microorganisms in the root canal space penetrate deeply into the dentinal tubules c. the pathogenic microorganisms are resistant to mechanical debridement d.mechanical debridement is ineffective at removing microorganisms

20. Chlorhexidine chips can be ________.

a. inserted into pockets 5 mm deep b. placed with a standard cotton plier c. usedrepeatedly as a part of a long-term periodontal maintenance program d. All of the above

30. To reduce the occurrence of staining, patients rinsing with chlorhexidine can ________.a. b. c. d.

brush their teeth with a powered toothbrush chew gum use a whitening toothpasteAll of the above www.ineedce.com

10


19/21

ANSWER SHEET

Chlorhexidine: A Multi-Functional Antimicrobial DrugName: Address: City: Telephone: Home ( ) Title: E-mail: State: Office ( ) ZIP: Specialty:

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 answerfor 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.

Educational Objectives1. Explain the mechanism of action of chlorhexidine gluconate. 2. Identify the unique property that allows for a prolonged effect. 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 patient home care strategies to reduce its occurrence. 5. Apply the dosage andguidelines for the clinical use of chlorhexidine gluconate in periodontics, endodontics, oral surgery, operative dentistry and preventive dentistry.

Mail completed answer sheet to

Academy of Dental Therapeutics and Stomatology,

A Division of PennWell Corp.

P.O. Box 116, Chesterland, OH 44026 or fax to: (440) 845-3447For immediate results, go to www.ineedce.com and click on the button take tests Online. answer sheets can be faxed with credit card payment to (440) 845-3447, (216) 398-7922, or (216) 255-6619. P ayment of $59.00 is enclosed. (Checks and credit cards are accepted.) If paying by credit card, please complete the following:MC Visa AmEx Discover Acct. Number: _______________________________ Exp. Date:

_____________________ Charges on your statement will show up as PennWell 4 4 4 44 4 Yes Yes 3 3 3 3 3 3 2 2 2 2 2 2 No No 1 1 1 1 1 1 0 0 0 0 0 0

Course EvaluationPlease evaluate this course by responding to the following statements, using a s

cale of Excellent = 5 to Poor = 0. 1. Were the individual course objectives met?Objective #1: Yes No Objective #2: Yes No Objective #3: Yes No 2. To what extent were the course objectives accomplished overall? 3. Please rate your personalmastery of the course objectives. 4. How would you rate the objectives and educational methods? 5. How do you rate the author's grasp of the topic? 6. Please ratethe instructor's effectiveness. 7. Was the overall administration of the course effective? 8. Do you feel that the references were adequate? 9. Would you participate in a similar program on a different topic? 5 5 5 5 5 5 Objective #4: Yes NoObjective #5: Yes No

10. If any of the continuing education questions were unclear or ambiguous, please list them. __________________________________________________________________

_ 11. Was there any subject matter you found confusing? Please describe. _______

____________________________________________________________ ___________________________________________________________________ 12. What additional continuingdental education topics would you like to see? _________________________________

__________________________________ ___________________________________________________________________ PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.AUTHOR DISCLAIMER The authors of this course have no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course. SPONSOR/PROVIDER This course was made possible through an unrestricted educational grant. No manufacturer or third party has had any input into the development o


20/21

f course content. All content has been derived from references listed, and or the opinions of clinicians. Please direct all questions pertaining to PennWell orthe administration of this course to Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or [email protected]. COURSE EVALUATION and PARTICIPANT FEEDBACK We encourage participant feedback pertaining to all courses. Please be sure tocomplete the survey included with the course. Please e-mail all questions to: [email protected]. INSTRUCTIONS All questions should have only one answer. Grading of this examination is done manually. Participants will receive confirmation of passing by receipt of a verification form. Verification forms will be mailed within two weeks after taking an examination. EDUCATIONAL DISCLAIMER The opinions of efficacy or perceived value of any products or companies mentioned in this course and expressed herein are those of the author(s) of the course and do not necessarily reflect those of PennWell. Completing a single continuing education course does not provide enough information to give the participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. COURSE CREDITS/COST All participants scoring at least 70% (answering 21 or more questions correctly) on the examinationwill receive a verification form verifying 4 CE credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. PennWell is a California Provider. The California Provider number is 3274.The cost for courses ranges from $49.00 to $110.00. Many PennWell self-study cou

rses have been approved by the Dental Assisting National Board, Inc. (DANB) andcan be used by dental assistants who are DANB Certified to meet DANB's annual continuing education requirements. To find out if this course or any other PennWellcourse has been approved by DANB, please contact DANB's Recertification Departmentat 1-800-FOR-DANB, ext. 445. RECORD KEEPING PennWell maintains records of yoursuccessful completion of any exam. Please contact our offices for a copy of yourcontinuing education credits report. This report, which will list all credits earned to date, will be generated and mailed to you within five business days ofreceipt. CANCELLATION/REFUND POLICY Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. 2008by the Academy of Dental Therapeutics and Stomatology, a division of PennWell

AGD Code 016

www.ineedce.com

11


21/21

58776917-Chlorhexidine

Documents