Robert Martino, DDS

Do you get a thrill from flashing lights, packed tables, and big bets? If so, Las Vegas may be for you. But dentistry is not as easy as choosing red or black on the roulette wheel. There are many high-stake risks that you may not be aware of, including the dangers of using chlorhexidine. For decades chlorhexidine was seen as the gold standard, but because of its ability to kill bacteria, we often overlooked its downsides, such as staining, calculus buildup, and loss of taste. But there are even more negatives, and the odds are not in your favor.

Unlike the Las Vegas desert, the mouth is not a traditionally dry place. Liquids such as blood, saliva, and even toothpaste are shown to greatly disrupt the antiseptic property of chlorhexidine.

 Studies suggest patients should wait 30 minutes after rinsing with chlorhexidine before introducing other dental products and wait up to 1 hour before eating or drinking to avoid inactivation.

When using chlorhexidine, it is important to recognize the impact it has on the fibroblast’s formation on the periodontal ligament. Studies show that chlorhexidine damages fibroblasts as well as other collagen-generating cells.3 The formation of these cells is an essential part of the healing process associated with periodontal therapy. If not formed properly they can cause reattachment issues and delayed healing, leaving your patient with a less-than-desirable outcome.

Between 1969 and 2015, more than 52 cases of anaphylaxis from chlorhexidine use were reported in the US. Of these cases, 2 resulted in death post-dental extractions.

 It takes 1200 ppm of chlorhexidine to achieve results, so it should not be used post-surgery or on any open wound.

Chlorhexidine was not designed to be used as a rinse for periodontal therapy, implants, or extractions. It was designed solely for use in managing inflammation, swelling, and bleeding of gingivitis, and it should be discontinued after 2 weeks.

 Off-label use of chlorhexidine can cause severe damage.

Rinses with activated chlorine dioxide do not come with the same risks as chlorhexidine. Professional rinses are not found over the counter and must be distributed by a licensed professional. Not only is activated chlorine dioxide able to kill the same bacteria that chlorhexidine can, but it is able to do it faster and with fewer parts per million. Because chlorine dioxide is a gas it is able to dissipate from the tissues quickly, leaving no long-term effects. Not only is it great at removing bacteria but it is also proven to remove viruses and fungi and neutralize volatile sulfur compounds more effectively than other products.

Sheen S, Owens J, Addy M. The effect of toothpaste on the propensity of chlorhexidine and cetyl pyridinium chloride to produce staining in vitro: A possible predictor of inactivation. 

Tsourounakis I, Palaiologou-Gallis AA, Stoute D, Maney P, Lallier TE. Effect of essential oil and chlorhexidine mouthwashes on gingival fibroblast survival and migration [published correction appears in J Periodontol. 2014 Jun;85(6):876]. 

Wyganowska-Swiatkowska M, Urbaniak P, Szkaradkiewicz A, Jankun J, Kotwicka, M. Effects of chlorhexidine, essential oils and herbal medicines (salvia, chamomile, calendula) on human fibroblast in vitro. 

FDA warns about rare but serious reactions with the skin antiseptic chlorhexidine gluconate. FDA. Updated February 9, 2017. Accessed May 17, 2022. 

https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-warns-about-rare-serious-allergic-reactions-skin-antiseptic

Articles

Chlorhexidine's risks make it too much of a gamble to use.

Chlorhexidine: High Risk, Low Reward

	Earlier this summer, researchers at the University of the Basque Country published a study that concluded that the use of chlorhexidine, a chemical widely used to combat bacteria in tooth extractions and implant placements, has a limited effect.

	While chlorhexidine only prevented bacteremia in 12 percent of cases, the researchers still recommended using chlorhexidine because the positive (but minimal) effects outweighed the risks. 

	I recently spoke to a dentist who begs to disagree. 

 is part of a team of oral health professionals who have identified a use in dentistry for a technology that is frequently used elsewhere (such as in water treatment). They believe this technology is a much more effective alternative to chlorhexidine, and I wanted to find out why.

Trending article: What you need to know about oral rinses

	Studies show that as many as 47 percent of all dental implants have peri-implantitis, and more than 10 percent of all dental implants fail with that as the major cause. Many of these implants can become unstable or at least cause gingival shrinkage, which can cause a poor cosmetic outcome. 

 was designed specifically to fight and prevent 

Check out this video to learn more about OraCare.

	How are dentists protecting their implants now?

	I think there are two options right now: either they put the implant in and just hope and pray that everything is going to go well and that the patient’s going to keep their mouth clean, or they’ll use something like chlorhexidine, which, in my opinion, is contraindicated for implants because of all the side effects. 

 was designed to treat gingivitis, not heal the gums after an implant. One of the keys for preventing peri-implantitis is prevention of plaque and calculus buildup. One of the major challenges of chlorhexidine is that it causes staining and calculus buildup and does nothing to neutralize volatile sulfur compounds or break up biofilm (dental plaque). More serious side effects include inhibiting fibroblasts, which we need for tissue repair. It can also only be used for two weeks, but it takes at least 30 to 34 days for the gingiva to heal. Although chlorhexidine does a good job of killing bacteria, we’re worried that it does more harm than good.

	How do you get the dental team excited about this product? 

	Implants are such an investment for the patient and the doctor. If you haven’t had an implant fail, you probably haven’t done enough of them. Failure can mean that the implant becomes unstable and needs to be removed. You can also have a cosmetic failure, where the gingiva around the implant shrinks because of an infection. What’s exciting is that we now have a system to help prevent failure.

	Tell me about the technology behind OraCare

	We use activated chlorine dioxide, an ingredient that has been used for over 200 years to sterilize instruments, remove odors, fumigate infected buildings and purify water. By incorporating activated chlorine dioxide into a mouthwash and gel, we can kill bacteria, viruses and fungi, break up biofilm and eliminate volatile sulfur compounds, which bacteria excrete after they die. OraCare doesn’t cause staining or calculus buildup and can be used long term. It also has a pleasant taste, resulting in high patient compliance. 

Trending article: Is professional subgingival oral irrigation necessary? 

	Where did you get the idea to use activated chlorine dioxide in a rinse?

, had been trying to find something that would replace chlorhexidine without the staining. It also needed to have high patient compliance and be safe for indefinite use to kill all of the factors that cause periodontal disease. Killing bacteria isn’t the only concern when dealing with gum disease or peri-implantitis, because other factors like volatile sulfur compounds, viruses and fungi all play a role. 

	Gum disease, whether it’s around a natural tooth or an implant, doesn’t just happen once. It’s a never-ending battle. We don’t think the mechanical removal of plaque and bacteria by just brushing and flossing is enough, so that’s why we came up with OraCare. 

	The gel, similar to the rinse, is made with two separate ingredients that, when combined, form a gas. The gel offers a slower release and is three times as strong as the rinse. So we’re really making an impact right after surgery to make sure everything is eliminated as soon as possible, then the patients go home and use the rinse for the next month at least.

	Can OraCare be used for both prevention and rehabilitation of an implant that has peri-implantitis?

	Yes. The sooner you can eliminate the pathogens, the healthier your tissue and bone will be. Once an implant has been compromised by peri-implantitis, the activated chlorine dioxide rinse and gel can also be used to help eliminate the infection and rehabilitate a healthy periodontium.

Why one dentist believes the status quo isn’t good enough, and why OraCare is a better way forward.