Introduction

Chlorhexidine is one of the most widely and commonly used antiplaque and antigingivitis agent. Chlorhexidine is a potent antibacterial substance but this alone does not explain its antiplaque action. The antiseptic binds strongly to bacterial cell membranes. At low concentration this results in increased permeability with leakage of intracellular components including potassium. At high concentration, chlorhexidine causes precipitation of bacterial cytoplasm and cell death. In the mouth, chlorhexidine readily adsorbs to surfaces including pellicle-coated teeth. Once adsorbed, and unlike some other antiseptics, chlorhexidine shows a persistent Pain, burning sensation, taste disturbance were evaluated at first, third and seventh day.

No statistical significant difference was observed in two groups with respect to these side effects. However, the taste of 0.12% was better accepted as compared to 0.2% chlorhexidine mouthwash.

Dental plaque is the main etiological factor that causes caries, gingivitis and periodontal disease.^[1] Plaque is known to be initiating factor in the development of gingivitis when in contact with the gingival tissues. Hence, plaque control represents the cornerstone of good oral hygiene practice.^[2] The most commonly used tools in control of supragingival plaque are toothbrushes (manual or electric), floss, woodsticks and interdental brushes. Despite the availability of these oral hygiene devices, even the most meticulous patient will not be able to completely remove the plaque.^[3] To overcome these, one of the effective chemical agent known to control the plaque development is chlorhexidine.

Chlorhexidine gluconate mouthwash can provide an important adjunct to the prevention and control of gingivitis when used with the regular personnel oral hygiene procedures. Although chlorhexidine has a relatively low toxic effects following oral use.^[4] Adverse dose dependent effects include brown staining, increased calculus formation and rarely sensitization and oral mucosal desquamation. An additional side effect of regular use of chlorhexidine is an impairment of taste perturbation.^[5] Unilateral or bilateral parotid swelling, Allergic reaction, less commonly, it causes mucosal erosion which appears to be idiosyncratic. Commercially available concentrations for plaque control are 0.2% used with 10 ml volume and 0.12% used with 15 ml volume. The rationale for lowering the concentration of chlorhexidine is to reduce side effects while maintaining comparable efficacy.^[6] The purpose of this present study was to compare the short term (7 days of rinsing) subjective side effects of 0.2% and 0.12% chlorhexidine mouthwash used as an adjunct to nonsurgical periodontal treatment.

Materials and Methods

The study was carried out in 40 BDS students of Institute of dental sciences Sehora, Jammu. Patients were informed about the study and written consent was obtained.

Results

During the evaluation period of seven days, the subjects were recalled for assessing the side effects on first, third and seventh day after the commencement of rinsing. Pain: No patient in group I and group II experienced pain till the seventh day after the commencement of rinsing with chlorhexidine mouthwash Burning sensation: In both group I and group II, no patient experienced any burning sensation at the first and third day. At the seventh day, 3 patients in group I and 5 patients in group II experienced the mild burning sensation. Taste disturbance: In group I, 4 patients reported with mild and 3 patients reported with severe taste disturbance at the first day. At third day, 8 patients reported with the mild and 3 patients reported with the severe taste disturbance. There was the mild taste disturbance in 6 patients and moderate taste disturbance in 5 patients, seventh day after commencement of rinsing with chlorhexidine mouthwash. In group II, mild taste disturbance was reported in 5,8 6 patients at the first, third and seventh day respectively, after rinsing with chlorhexidine mouthwash.

Discussion

Chlorhexidine was developed in 1940's and marketed in 1954 as an antiseptic for skin wounds. Initially it was used for presurgical disinfection of mouth. The use of Chlorhexidine for plaque inhibition was first investigated in 1962 by Loe and Schiott.

They showed that rinsing for 60 seconds twice per day with 10ml of 0.2% CHX (20mg dose) inhibited plaque regrowth and the development of gingivitis.^[7] Later, a 0.12% CHX mouthwash was manufactured using a 15ml rinse volume (18mg dose) in order to maintain the 20 mg dose present in the 10ml of 0.2% rinse. Concentrations of 0.12% appear as effective as 0.2%, if the volume of the rinse was increased to 15ml. The optimum dose of CHX delivered by mouthwash, which balances efficacy against local side effects, is generally in about 20 mg twice daily. The present study has shown that there was no statistically significant difference in the frequency of reported side effects between Chlorhexidine 0.2% and 0.12% mouthwash. McCoy LC et al in 2008 reported adverse effects related to the use of 0.12% Chlorhexidine gluconate mouthwash in patients with uncontrolled diabetes. 31% cases reported taste changes, tooth staining, sore mouth and/or throat and tongue irritation.^[8]

Most of the adverse effects resolved easily by discontinuing the use of mouthwash and receiving dental prophylaxis.^[8] One patient of group I and two patients of group II reported mild burning sensation which is in accordance with study by Flotra L et al.^[6] They evaluated the side effects of chlorhexidine mouthwash (0.2% and 0.1%) in a group of 50 soldiers during a period of 4 months. Some desquamations and soreness in the oral mucosa were observed. 12% of the tooth surfaces and 62% of the silicate fillings were discoloured, while 36% of the test persons developed discoloured tongues. In the present study, only two patients reported with the tooth discoloration. Mild taste disturbance was reported with 0.12% chlorhexidine which is in accordance with the study by Hepso et al in 1988, which studied the side effects and patient acceptance of 0.2% and 0.1% chlorhexidine when used as a postoperative prophylactic mouthwash.

There was no statistical significant difference in the reported side effects of the two groups. However, taste of chlorhexidine 0.1% was better accepted.^[9] Gurgan CA et al^[4] in a double-blind clinical study evaluated the short-term side effects of 0.2% alcohol-free chlorhexidine mouthwash when used as an adjunct to non-surgical periodontal treatment. They found that rinsing with 0.2% alcohol-free CHX for 1 week caused more irritation to oral mucosa, greater burning sensation, and increased altered taste perception compared to the placebo rinse.^[10] Further a study by Ernst CP et al, compared the effects of two commercial chlorhexidine mouthwashes (0.1% and 0.2%) on dental plaque and gingival inflammation, their side effects and patient acceptance. The increase in concentration of chlorhexidine provided no clinical advantages or disadvantages.^[11] When comparing 0.2% versus 0.12% chlorhexidine (15ml for 30 sec), better compliance was reported with mouthwashes containing less than 0.2% chlorhexidine.^[6] Keijser et al in a single blind randomized study of 80 volunteers evaluated the inhibition of plaque growth using 0.12 & 0.2% chlorhexidine.^[12] No statistically significant difference was found with respect to plaque inhibition.

However, subjects favoured the shorter rinsing time of 30 seconds.^[13] Further, Smith et al evaluated the efficacy of 0.12% and 0.2% chlorhexidine on plaque accumulation for using 4 days (60 seconds rinsing time). Both concentrations of CHX resulted in considerably less plaque accumulation compared to the control, but both were similar in their effects.^[14]

Conclusion

Although CHX is considered the Gold standard because of its superior antiplaque effects, which is a result of its superior degree of persistence on the tooth surface its use in daily practice is still limited due to its several side effects. The present study evaluated the subject's attitude towards the local side effects, such as extrinsic tooth and tongue brown staining, taste disturbance, and enhanced supragingival calculus formation. CHX rinsing can also cause desquamation of the oral mucosa, but this is less common. No significant difference was found with regard to attitude of patients towards the two products. The present study recommends 0.12% Chlorhexidine mouthwash as compared to 0.2% Chlorhexidine mouthwash as an adjunct to non-surgical periodontal therapy.

Source of funding

None

Conflict of interest

None