Using pre-procedural rinses can be advantageous in two ways. When using handpieces or ultrasonic scalers a rinse can help decrease the bacteria in the aerosolized saliva that is released into the air potentially spreading infection to dental personal and patients in the dental office.  Another benefit is to reduce the possibility of contamination of a surgical site.  The aim would be to reduce the bacteria both anerobic and aerobic prior to and during a surgery whether that be implants or tooth removal.

Chlorhexidine (CHX)  has been commonly used as an antiplaque and anti-gingivitis agent and as an antiseptic since the 1950’s. Is disrupts the bacterial cell membrane by the chlorhexidine molecules, increasing the permeability and resulting in cell lysis. It can be either bacteriostatic or bactericidal depending on the dose and acts against gram positive and negative bacteria, yeasts and viruses including Hepatitis B and Human Immunodeficiency. CHX has a high substantivity in the mouth lasting 8-12 hours. CHX is however poorly effective in killing viruses. CHX is also often augmented with 70% isopropyl alcohol to enhance bacterial efficacy. There are a variety of strengths between 0.2% and 0.12% and is commonly used prior to, following and during dental implant surgeries.

• Presurgical oral rinse - for reduction of bacterial load
• Intra / extraoral scrub prior to implant surgery- as surface antiseptic
• Hand scrub before gowns and gloves are worn prior to implant surgery- as surface antiseptic
• Post-surgical rinse- twice a day until closure of incision line
• Peri-implant tissue maintenance
• Treatment of post-operative infections

Even though CHX has been considered the gold standard in the profession and has been used off label by irrigating into periodontal pockets, science is showing a little bit of a different story. In 2016 a study found that 0.002% of chlorhexidine has effective antibacterial effects with minimal cytotoxicity compared to the stronger dilutions used clinically.⁴  That is a lot of overdosing clinicians may have been doing. There was a time we sent patients home with a prescription to use twice daily that they often complained of the taste and for the dry mouth patients the alcohol content was difficult. (There is one FDA approved alcohol-free rinse-Paroex)

In recent years studies have shown that CHX wields cytotoxic effects on human periodontal tissues, such as gingival fibroblasts and other cells including cultured alveolar bone cells and osteoblastic cells. It also reduces gingival fibroblast adhesion to fibronectin and prevents fibroblast attachment to root surfaces, thus interfering with periodontal regeneration. Chlorhexidine has not been proven to remove viruses, fungi, volatile sulfur compounds, or break up biofilm; all of which can play a role in implant failure.  Products containing chlorhexidine have been contraindicated during implant placement. Chlorhexidine has it place primarily for 2 weeks for patients with gingivitis.  Currently we are seeing many more options using chlorine dioxide and xylitol that yield much better results. 

Contamination of the implant surface is considered the precursor for peri-implant inflammation and the removal of bacterial biofilms is an important step in therapy for peri-implantitis. Dentistry has used a host of chemotherapeutic agents (ChAs) to achieve a decontamination goal. Studies challenge the actual efficacy of such treatment and have looked closely at the alteration of the implant surfaces using such agents. Studies assessing the effect of citric acid, hydrogen peroxide and other ChAs during burnishing of titanium surfaces, found that they led to signs of oxide layer damage in a pH-related manner.⁵ In the same study it also found traces of titanium on the cotton swabs that were used after decontamination. It has been found that ChA residue left on a titanium surface alters titanium’s physical properties. “Chlorhexidine may compromise biocompatibility of titanium surfaces, and its use is not recommended to detoxify implants.”⁶  Because it produces cytotoxic effects on the decontaminated surfaces.

Maintaining the surgical field as disinfected as possible is one of the key surgical principles that can be done by using antiseptic mouthwashes such as CHX either by irrigating the wound, or a presurgical rinse. In one study when dentists used chlorhexidine of 0.12% during the immediate preoperative moment reduced the percentage of implant loss from 13.5% to 4.4% in type-2 diabetes.⁷ Questions arise as to the best treatment protocols for the patients’ health and success of their treatment. Should the application of CHX in the pre and post-surgical antiseptic treatment of the oral cavity be limited? Are there other options that would be more beneficial? Perhaps, but what if the implant procedure was less invasive reducing the number of bacteria not only entering the treatment site but ultimately the blood stream. Minimally invasive implant surgery does exactly that.

Make no mistake pre-procedural rinses are necessary prior to dental treatment. They are effective, the standard of care, and during our current times gives a bit of peace of mind. But exploring other rinses, their application, how much and when is something dentistry should take a pause and look into. 

¹ Litsky BY, Mascis JD, Litshy W. Use of an antimicrobial mouthwash to minimize the bacterial aerosol contamination generated by the high speed hand drill. Oral Surg Oral Med Oral Pathol 1970;29;25-30.

² Muir KF, Ross PW, MacPhee IT, Holbrook WP, Kowolik MJ. Reduction of microbial contamination from ultrasonic scalers. DR Dent J 1978;145:76-8.

³ Fine DH, Furgang D, Furgang D, et al. Reduction of viable bacteremia in dental aerosols by preprocedural rinsing with an antiseptic mouthrinse. AM J Dent. 1993;p219-221

⁴ Wyganowska-Swiatkowska, Marzena & Kotwicka, Malgrzata & Urbaniak, Paulina & Nowak, Agnieszka & Skrzypczak-Jankun, Ewa & Jankun, Jerzy. (2016). Clinical implications of the growth-suppressive effects of chlorhexidine at low and high concentrations on human gingival fibroblasts and changes in morphology. International Journal of Molecular Medicine. 37. 10.3892/ijmm.2016.2550.

⁵ Wheelis SE, Gindri IM, Valderrama P, Wilson TG Jr., Huang J, Rodrigues DC. Effects of decontamination solutions on the surface of titanium: Investigation of surface morphology, composition, and roughness. Clin Oral Implants Res 2016;27:329-340.

⁶ Kotsakis GA, Lan C, Barbosa J, Lill K, Chen R, Rudney J, Aparicio C. Antimicrobial Agents Used in the Treatment of Peri-Implantitis Alter the Physicochemistry and Cytocompatibility of Titanium Surfaces. J Periodontol. 2016 Jul;87(7):809-19. doi: 10.1902/jop.2016.150684. Epub 2016 Feb 28. PMID: 26923474.

⁷ Hwang D, Wang HL. Medical contraindications to implant therapy: Part II: Relative contraindications. Implant Dent. 2007;16:13–23

Please see our other related blogs Antibiotics in Implant Placement and Options in Pre-Procedural rinses