Q U I N T E S S E N C E I N T E R N AT I O N A L
ENDODONTICS
The properties of chlorhexidine and undesired effects
of its use in endodontics
Anarela Bernardi, DDS, MSc 1/Cleonice Silveira Teixeira, DDS, MSc, PhD 2
Objective: The purpose of this article was to review the litera-
ture on the properties of chlorhexidine (CHX) and the adverse
effects that may occur from its use in endodontics. In addition,
adverse effects that may result from its use, such as dark stain-
ing of teeth, chemical interaction with sodium hypochlorite and
formed flocculate, biologic hazards, and interactions with the
filling material were evaluated. Data Sources: Relevant publi-
cations on the use CHX in endodontics were thoroughly
reviewed from the literature published between the years 2007
and 2014. Method and Materials: The authors conducted an
electronic search using the English language databases Medline
and PubMed. Results: According to the reviewed studies, it
was concluded that CHX has proven antimicrobial activity,
excellent substantivity, low surface tension, and low cytotoxicity
Key words: chlorhexidine, endodontics, properties, root canal therapy
The chemomechanical preparation of root canals is a
crucial step for endodontic treatment, and it is impor-
tant to use irrigating solutions that are associated with
endodontic instruments for cleaning, disinfecting, and
shaping the root canal system, preparing them for the
root filling treatment.1
The solution used as an irrigant during endodontic
treatment should be antimicrobial, biocompatible with
1 Master, Postgraduate Program in Dentistry, Federal University of Santa Catarina,
Center for Health Sciences, Florianópolis, Santa Catarina, Brazil.
2 Professor, Department of Dentistry, Federal University of Santa Catarina, Center
for Health Sciences, Florianópolis, Santa Catarina, Brazil.
Correspondence: Dr Anarela Bernardi Vassen, Avenida Nossa Senhora
da Conceição, 1725, sl 02, Bairro: Vila Betariz, Maracajá – SC, CEP 88915-
000, Brazil. Email: anarela.bernardi@hotmail.com
VOLUME 46 • NUMBER 7 • JULY/AUGUST 2015
Anarela Bernardi Cleonice Silveira
Teixeira
and genotoxicity that depend on the dose and exposed area.
There is scientific evidence showing the possibility of tooth
staining and formation of brown precipitate when its use is
associated with sodium hypochlorite. On the other hand, it is
not well established that its use interferes with the quality of
endodontic fillings. With respect to the biologic risks, the degra-
dation of CHX may generate para-chloroaniline and free radi-
cals, which are harmful to the vital tissues. There is no
established consensus on the potential risk of CHX.
Conclusion: The final considerations of this review will encour-
age researchers to seek scientific evidence demonstrating the
safety of the use and applicability of CHX in endodontic therapy.
(Quintessence Int 2015;46:575–582; doi: 10.3290/j.qi.a33934)
pulp and periapical tissues, have the ability to dissolve
organic matter, and be able to lubricate the root
canals.2,3 Sodium hypochlorite (NaOCl) solution is most
commonly used during mechanical preparation, and its
main advantages are its antimicrobial action, whitening
effect, and power of dissolving organic tissue.4,5
However, in teeth with pulp necrosis and chronic
periapical lesions, it is difficult to eliminate microorgan-
isms that remain in the root canal system, dentinal
tubules, apical external root surface, and apical peri-
odontium, even after the biomechanical preparation,
demonstrating the need to complement endodontic
therapy with a root canal dressing.6
Calcium hydroxide has commonly been used as a
root canal dressing. Though the use of this dressing is
575
Q U I N T E S S E N C E I N T E R N AT I O N A L
Bernardi/Teixeira

widespread and accepted in endodontic practice, some CHX has interesting properties, among which the
microorganisms are resistant to its action.7,8 following can be highlighted.
Therefore, many drugs have been studied and
tested to supplement and/or potentiate its antimicro- Substantivity
bial effect. One of the various alternative irrigating solu- CHX digluconate is a broad spectrum antibacterial
tions and intracanal medications on the dental market agent with substantivity (Table 1), ie, it binds to the
is chlorhexidine (CHX). This drug is an effective antimi- hydroxyapatite of the enamel and dentin or anionic
crobial agent in the root canal that has potential for use groups of glycoproteins, is slowly released, and its con-
as an irrigant or intracanal medication. centration decreases in the middle, prolonging its anti-
Based on the above considerations, the purpose of bacterial effects for a long period of time.8,11-15 It has
this article was to review the literature on the properties been recommend that the substantivity property of
of CHX and its possible adverse effects during endodon- CHX should be harnessed in endodontics through its
tic use. In addition, some adverse effects that may result use as a final irrigant16 because its residual effect can
from its use are discussed, such as dark tooth staining, remain for up to 12 weeks.17 In another study, Souza et
chemical interaction with NaOCl and formed flocculate, al18 investigated the substantivity of CHX solution and
biologic hazards, and interaction with the filling material. gel within a system of canals for 24 hours, 30 days, and
90 days. The CHX solution showed a higher substantiv-
ity than CHX gel, except for groups incubated for 90
METHOD AND MATERIALS days. The results indicate that solution and gel chlor-
Relevant publications on the use CHX in endodontics hexidine are retained in the root dentin for 90 days.
were thoroughly reviewed from the literature pub-
lished between the years 2007 and 2014, using the
English language databases Medline and PubMed.
Table 1 Studies related to chlorhexidine regarding
substantivity and antimicrobial activity
PROPERTIES
Antimicrobial
Study Substantivity activity
CHX has been used as a therapeutic agent in several
Gomes et al8 X X
areas of dentistry, including periodontics, surgery, and
11
Rölla et al X
more recently endodontics. The mechanism of action
Komorowski et al12 X
of CHX can be explained by the chemical interaction
Basrani et al13 X
between this substance and bacterial cell membranes. 14
Soares et al X X
For a high dose (2%), the electrostatic binding between
Mohammadi and Abbott15 X X
their cationic molecules and negatively charged bac- Cook et al 16 X
terial cell wall causes CHX to exert a bactericidal action, Rosenthal et al17 X
resulting in precipitation and coagulation of cytoplas- Souza et al18 X
mic proteins, and, consequently, cell death. At lower Vaghela et al 19 X
doses (0.2%), the cell membrane integrity is altered, Mohammadi et al20 X
resulting in a bacteriostatic effect due to leakage of low Atila-Pektas et al 21 X
molecular weight bacterial components.9,10 Krithikadatta et al22 X

Because of its higher solubility, the salt of CHX diglu- Souza-Filho et al 23 X

conate is most commonly used in endodontic treatment, Delgado et al24 X

including as an irrigant during chemomechanical prepar- Lee et al25 X

30
Signoretti et al X
ation or as intracanal medication in cases of pulp necrosis.

576 VOLUME 46 • NUMBER 7 • JULY/AUGUST 2015


Antimicrobial activity
Studies have shown that CHX has efficient antimicro-
bial activity in endodontics,8,15,19 and that this effect can
be observed with both the use of CHX as irrigating
solution20 and as an intracanal medicament.21 The
action against resistant organisms, especially Enterococ-
cus faecalis and Candida albicans, has been studied in
detail.8,14,22,23 Some studies show better antimicrobial
activity of CHX alone compared to calcium hydroxide
[Ca(OH)2], especially against E faecalis.22-24 The use of a
polymeric device for the controlled release of CHX has
also been shown to be more effective against E faecalis
compared to the use of Ca(OH)2 paste.25 Other studies
report that there is no difference in the reduction of
bacterial counts using an intracanal dressing of CHX
because this reduction is already achieved in the first
session of biomechanical treatment using 2.5% NaOCl26
and 1.3% NaOCl.27 Interestingly, another study showed
that the use of CHX as an irrigant during root canal
preparation also appears to be sufficient for reducing
the bacterial count, but there is no further significant
reduction from using a dressing of Ca(OH)2 mixed with
2% CHX.28,29 Several studies claim that CHX enhances
the antibacterial activity of residual Ca(OH)2.14,15,30 Sil-
veira et al31 reported that medications consisting of
Ca(OH)2 and other drugs (camphorated paramonochlo-
rophenol [CMCP], propylene glycol) perform better
than when added to CHX, eliminating, in a short period
of time, Staphylococcus aureus and E faecalis.
Surface tension
22,32
CHX has a low surface tension, providing faster
propagation on the tooth surface, and allowing greater
flow of the drug into the root canal with a high pene-
tration coefficient. This drug is an interesting option as
a vehicle for Ca(OH)2.33
Dissolution of organic tissue, biofilm, and
smear layer
The literature has shown that the action of CHX depends
on pH (it is most stable at a pH between 5 and 8) and its
activity is greatly reduced in the presence of organic
matter.28 CHX does not dissolve organic tissues,15,34 it is
VOLUME 46 • NUMBER 7 • JULY/AUGUST 2015
Q U I N T E S S E N C E I N T E R N AT I O N A L
Bernardi/Teixeira
not as efficient in removing or dissolving the bio-
film,15,35,36 and it does not remove the smear layer.37
Permeability interference in dentinal tubules
and root canal filling
The use of CHX does not seem to hinder the sealing of
the root canal filling in the apical region,38 and it does
not affect the sealing ability in the root canal length as
a whole.39 Another study found decreased apical seal-
ing ability using AH Plus, Epiphany SE, and MM-Seal
when CHX was used as an irrigating solution.40 Homay-
ouni et al41 reported that the presence of the precipi-
tate that is formed from the interaction between NaOCl
and CHX has a negative effect on the sealing ability of
gutta-percha and AH26 sealers.
Cytotoxic effect
Several studies have shown that CHX may have cyto-
toxic effects that increase with the concentration of the
solution.42,43 Moreover, because of its low toxicity, it has
been indicated for treating teeth with incomplete root
formation or hypersensitivity to NaOCl.44 Another study
reported that CHX does not alter cell viability or immu-
nostimulatory and anti-inflammatory properties.45 Pre-
viously, Silva et al46 concluded that the addition of 0.4%
CHX to Calen paste allows for an adequate tissue
response, whereas Ca(OH)2 with 2% CHX has unsatisfac-
tory results.
Genotoxicity
Studies have shown that the genotoxicity of CHX may
be irrelevant.47,48 However, Yeung et al49 found that CHX,
when associated with NaOCl or with Ca(OH)2, exhibits
antioxidant and pro-oxidant reactions. Furthermore,
Arabaci et al50 showed the dose-dependent genotoxic
and cytotoxic effects of CHX on human lymphocytes in
vitro. In this way, when the chlorhexidine is extruded, in
high concentrations, to the periapical tissues, the poten-
tial genotoxic and tissue damage should be considered.
Based on the results of the cytotoxicity and genotoxicity
studies, it is worth noting that the use of CHX should be
restricted to the root canal space and care must be
taken with the choice of the concentrations used.
577
Q U I N T E S S E N C E I N T E R N AT I O N A L
Bernardi/Teixeira

Figs 1a to 1c Endodontic
access cavities containing: CHX
(a), CHX and EDTA (b), and CHX
and NaOCl (c). The interaction
between EDTA and CHX causes
a white precipitate (b). The
interaction between CHX and
NaOCl results in the formation
of a precipitate with a dark
a b c amber color (c).

Table 2 Studies related to chlorhexidine regarding chemical interactions, degradation, and resulting metabolites

Study Chemical interactions of EDTA Chemical interactions of NaOCl CHX: Degradation pathway (PCA)
Mohammadi and Abbott15 X
González-López et al51 X
Rasimick et al29 X
52
Prado et al X X
Basrani et al53 X X
Bui et al54 X
Vianna and Gomes55 X
56
Marchesan et al X
Akisue et al57 X
Basrani et al58 X
Krishnamurthy and Sudhakaran59 X
60
Thomas and Sem X
Cintra et al61 X
Zong and Kirsch62 X
Barbin et al65 X
66
Barbin et al X
Havlíková et al67 X
WHO68 X
EC69 X
70
Alexander and Lustigman X
Kohlbecker71 X
EDTA, ethlyenediaminetetraacetic acid; PCA, para-chloroanaline.

Chemical interactions The mixing of 1% CHX with 17% ethylenediamine-

The use of chlorhexidine with other chemicals in end-
odontics may result in the formation of precipitates (Fig 1
and Table 2). The formed precipitate is of clinical rele-
vance with respect to the impairment of dental staining,
interference with dentin permeability, effect on the diffu-
sion of intracanal dressing, and damage to the sealing of
the root canal filling. Furthermore, some of the products
formed from the interaction of chlorhexidine with other
chemical substances may be harmful to host tissues.
tetraacetic acid (EDTA) instantly generates a highly
insoluble solid precipitate, staining pink.51 However,
Rasimick et al29 reported that this interaction between
EDTA and CHX causes a white precipitate and over 90%
of the precipitate mass is either EDTA or CHX, although
para-chloroaniline (PCA) is not detected. It was sug-
gested that the precipitate is most likely a salt formed
by the neutralization of the cationic ions of CHX. In
another study, Prado et al52 observed a milky white

578 VOLUME 46 • NUMBER 7 • JULY/AUGUST 2015


precipitate that formed after the association between
EDTA and CHX, and when combined with saline solu-
tion and ethanol, it produced a precipitated salt.
The interaction between CHX and NaOCl results in
the formation of a precipitate with a dark amber color.
Some studies have reported that higher levels of
chloride in the NaOCl solution result in higher levels of
precipitate.53-61 Prado et al52 studied the byproducts
formed by the associations between the irrigators that
are most commonly used in endodontic practice. CHX
produced an orange-brown precipitate when associ-
ated with 1% to 5.25% NaOCl and an orange-white
precipitate when combined with 0.16% NaOCl. The
minimum concentration of NaOCl required for the for-
mation of the precipitate is 0.19%, and 0.023% for a
color change.54 The precipitate is flocculated and has
dimensions of approximately 250 nm, reducing the
dentin permeability in the apical third.58 This precipi-
tate generates an undesirable chromatic effect on the
dental crown.15,57 Furthermore, the precipitate forma-
tion has been related to tooth staining.55-58 Bui et al54
also observed changes in the permeability of dentinal
tubules, which become more plugged in the cervical
and middle thirds of the canal. Several authors have
also observed higher precipitation levels in these loca-
tions and suggest that this could affect the sealing of
the root canal filling.15,59 Cintra et al61 demonstrated, in
an in vivo study, that the precipitate has greater toxicity
than NaOCl or CHX alone.
In order to prevent or remove the precipitate
formed by the interaction of chlorhexidine with hypo-
chlorite, studies have been performed in the search for
a possible solvent.56,59 The use of acetic acid (vinegar)
seemed to have a proven action on the dissolution of
flocculate. However, this solvent did not remove the
brown color already established.56 Another option to
avoid or minimize the formation of the precipitate is
the use of irrigation in larger volumes of saline and
distilled water for dilution of NaOCl, and to irrigate with
absolute alcohol before using CHX as final irrigant.59
VOLUME 46 • NUMBER 7 • JULY/AUGUST 2015
Q U I N T E S S E N C E I N T E R N AT I O N A L
Bernardi/Teixeira
DEGRADATION AND RESULTING
METABOLITES
Zong and Kirsh62 studied the degradation pathway of
CHX and concluded that under acidic conditions, CHX
leads to the direct formation of PCA. Under alkaline
conditions, CHX indirectly leads to the formation of
PCA by forming p-chlorophenylurea.
For dentistry, CHX degradation can occur through
the action of NaOCl53,58,63,64 and Ca(OH)2 as well by the
temperature and storage time, which generate byprod-
ucts (Table 2).65,66 It has been observed that CHX diglu-
conate alone decomposes into different products,
including PCA.53,62,65,67 Due to their molecular structure
and the high pH level of Ca(OH)2, when CHX is associ-
ated with this drug, it can produce reactive oxygen
species and oxidative DNA. In this way, the use of CHX,
mainly at higher concentrations, could result in a
potential genotoxicity and tissue damage when it
extrudes into the periradicular tissue during endodon-
tic and periodontal procedures.49,65
Para-chloroaniline (PCA)
PCA, CAS (registry number) no. 106-47-8, is a colorless
to slightly amber-colored crystalline solid with a mild
aromatic odor. The chemical is soluble in water and
common organic solvents.68
The general public may be exposed to PCA from the
use of PCA-based dyed/printed textiles, papers, cosmet-
ics, and pharmaceutical products. Exposure can result
from residual PCA in the commercial product or from
degradation of this product to PCA during use. It can be
dermal (from wearing clothes and using soaps or
mouthwashes), oral (small children sucking on clothes
and other materials and the use of mouthwashes), or
from direct entry into the bloodstream (eg, through the
breakdown products of CHX in spray antiseptics).
From the use of CHX-containing mouthwashes, the
following oral and dermal (via mucous membrane)
exposure concentrations can be estimated. In the Euro-
pean Union (EU), the maximum permitted level of CHX
in cosmetic products is 0.3%.69 According to a German
manufacturer, CHX contains < 500 mg PCA/kg,70 result-
579
Q U I N T E S S E N C E I N T E R N AT I O N A L
Bernardi/Teixeira
ing in a maximum of approximately 1.5 mg PCA/L com-
mercial CHX solution. PCA concentrations between 0.5
and 2.4 mg/L were detected in CHX preparations (CHX
content 0.2%). Assuming two mouthwashes per day
with 10 mL of the CHX solution in each, the mucous
membrane is exposed to between 10 and 48 μg of
PCA.71 Approximately 30% of CHX is retained in the oral
cavity and approximately 4% is swallowed.72 Therefore,
uptake of PCA from mouthwash is from 50 to 255 ng/kg
body weight (average body weight 64 kg).73
According to the World Health Organization,74 there
are reports of severe methemoglobinemia in neonates
from neonatal intensive care units in two countries in
which premature babies were exposed to PCA as a
breakdown product of CHX; CHX, which had been inad-
vertently used in the humidifying fluid, broke down to
PCA upon heating in a new type of incubator. Three
neonates in one report (14.5% to 43.5% methemoglobin)
and 33 of 415 neonates in another report (6.5% to 45.5%
methemoglobin during the 8-month screening period)
were found to be methemoglobin-positive. A prospec-
tive clinical study showed that immaturity, severe illness,
time exposed to PCA, and low concentrations of NADH
reductase probably contributed to the condition.
CLINICAL RELEVANCE
Any drug may simultaneously have positive and nega-
tive effects. Medicines from small, chemically produced
molecules may generate many residues when they
degrade. In endodontics, the use of CHX has little scien-
tific evidence originated from in vivo studies, and a
variety of in vitro studies provide conflicting results.
The substantivity characteristics and residual effect
(considered virtues) may even be a cause for concern
because they could keep CHX or its degradative
byproducts in the host tissues for a long period of time.
The formation of PCA and free radicals has sparked
many discussions in the literature. Consensus on the
potential therapeutic risk has not been established. The
final considerations of this review encourage research-
ers to seek scientific evidence to prove the safety of
their use and applicability in endodontic therapy.
580
CONCLUSION
According to the studies reviewed, it can be concluded
that CHX:
• has antimicrobial activity, excellent substantivity,
and low surface tension
• has cytotoxicity and genotoxicity that are dose-
dependent and depend on the exposed contact area
• does not dissolve organic tissue, biofilm, and smear
layers
• could cause dental staining and the formation of a
brown precipitate when its use is associated with
NaOCl
• used in combination with hypochlorite, with a sol-
vent applied before or afterwards, may have
decreased formation of precipitate
• use during endodontic treatment is not well estab-
lished to interfere with the quality of the root canal
filling
• use can cause degradation into CHX byproducts,
such as PCA and free radicals, that are harmful to
host tissues
• use has unknown potential therapeutic risk in end-
odontics.
REFERENCES
1. Siqueira JF Jr, Guimarães-Pinto T, Roças IN. Effects of chemomechanical prep-
aration with 2.5% sodium hypochlorite and intracanal medication with calci-
um hydroxide on cultivable bacteria in infected root canals. J Endod
2007;33:800–805.
2. Zehnder M. Root canal irrigants. J Endod 2006;32:389–398.
3. Young GR, Parashos P, Messer HH. The principles of techniques for cleaning
root canals. Aust Dent J 2007;52:S52–S63.
4. Zehnder M, Kosicki D, Luder H, Sener B, Waltimo T. Tissue dissolving capacity
and antibacterial effect of buffered and unbuffered hypochlorite solutions.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94:756–762.
5. Mohammadi Z. Sodium hypochlorite in endodontics: an update review. Int
Dent J 2008;58:329–341.
6. Nair, PN. On the causes of persistent apical periodontitis: a review. Int Endod
J 2006;39:249–281.
7. Evans M, Davies JK, Sundqvist G, Figdor D. Mechanisms involved in the resis-
tance of Enterococcus faecalis to calcium hydroxide. Int Endod J
2002;35:221–228.
8. Gomes BP, Vianna ME, Sena NT, Zaia AA, Ferraz CC, de Souza Filho FJ. In vitro
evaluation of the antimicrobial activity of calcium hydroxide combined with
chlorhexidine gel used as intracanal medicament. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2006;102:544–550.
9. Davies A. The mode of action of chlorhexidine. J Periodontal Res 1993;12(Suppl
1):S68–S75.
VOLUME 46 • NUMBER 7 • JULY/AUGUST 2015

10. Athanassiadis B, Abbott PV, Walsh LJ. The use of calcium hydroxide, antibiot-
ics and biocides as antimicrobial medicaments in endodontics. Aust Dent J
2007;52:S64–S82.
11. Rölla G, Löe H, Schiott CR. The affinity of chlorhexidine for hydroxyapatite and
salivary mucins. J Periodontal Res 1970;5:90–95.
12. Komorowski R, Grad H, Wu XY, Friedman S. Antimicrobial substantivity of
chlorexidine treated bovine root dentin. J Endod 2000;26:315–317.
13. Basrani B, Santos JM, Tjäderhane L, et al. Substantive antimicrobial activity in
chlorhexidine-treated human root dentin. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2002;94:240–245.
14. Soares JA, Leonardo MR, Tanomaru Filho M, Silva LA, Ito IY. Residual antibac-
terial activity of chlorhexidine digluconate and camphorated p-monochloro-
phenol in calcium hydroxide-based root canal dressings. Br Dent J
2007;18:8–15.
15. Mohammadi Z, Abbott PV. The properties and applications of chlorhexidine
in endodontics. Int Endod J 2009;42:288–302.
16. Cook J, Nandakumar R, Fouad AF. Molecular- and culture-based comparison
of the effects of antimicrobial agents on bacterial survival in infected dentinal
tubules. J Endod 2007;33:690–692.
17. Rosenthal S, Spångberg L, Safavi K. Chlorhexidine substantivity in root canal
dentin. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98:488–492.
18. Souza M, Cecchin D, Farina AP, et al. Evaluation of chlorhexidine substantivity
on human dentin: a chemical analysis. J Endod 2012;38:1249–1252.
19. Vaghela DJ, Kandaswamy D, Venkateshbabu N, Jamini N, Ganesh A. Disinfec-
tion of dentinal tubules with two different formulations of calcium hydroxide
as compared to 2% chlorhexidine: as intracanal medicaments against Entero-
coccus faecalis and Candida albicans: an in vitro study. J Conserv Dent
2011;14:182–186.
20. Mohammadi Z, Giardino L, Palazzi F. Evaluation of the antifungal activity of
four solutions used as a final rinse in vitro. Aust Endod J 2013;39:31–34.
21. Atila-Pektaş B, Yurdakul P, Gülmez D, Görduysus O. Antimicrobial effects of
root canal medicaments against Enterococcus faecalis and Streptococcus
mutans. Int Endod J 2013;46:413–418.
22. Krithikadatta J, Indira R, Dorothykalyani AL. Disinfection of dentinal tubules
with 2% chlorhexidine, 2% metronidazol, bioactive glass when compared with
calcium hydroxide as intracanal medicaments. J Endod 2007;33:1473–1476.
23. Souza-Filho FJ, Soares Ade J, Vianna ME, Zaia AA, Ferraz CC, Gomes BP. Anti-
microbial effect and pH of chlorhexidine gel and calcium hydroxide alone and
associated with other materials. Br Dent J 2008;19:28–33.
24. Delgado RJ, Gasparoto TH, Sipert CR, et al. Antimicrobial effects of calcium
hydroxide and chlorhexidine on Enterococcus faecalis. J Endod
2010;36:1389–1393.
25. Lee Y, Han SH, Hong SH, Lee JK, Ji H, Kum KY. Antimicrobial efficacy of a
polymeric chlorhexidine release device using in vitro model of Enterococcus
faecalis dentinal tubule infection. J Endod 2008;34:855–858.
26. Paquette L, Legner M, Fillery ED, Friedman S. Antibacterial efficacy of chlor-
hexidine gluconate intracanal medication in vivo. J Endod 2007;33:788–795.
27. Malkhassian G, Manzur AJ, Legner M, et al. Antibacterial efficacy of MTAD final
rinse and two percent chlorhexidine gel medication in teeth with apical
periodontitis: a randomized double-blinded clinical trial. J Endod
2009;35:1483–1490.
28. Wang CS, Arnold RR, Trope M, Teixeira FB. Clinical efficiency of 2% chlorhexi-
dine gel in reducing intracanal bacteria. J Endod 2007;33:1283–1289.
29. Rasimick BJ, Nekich M, Hladek MM, Musikant BL, Deutsch AS. Interaction
between chlorhexidine digluconate and EDTA. J Endod 2008;34:1521–1523.
30. Signoretti FG, Gomes BP, Montagner F, Barrichello Tosello F, Jacinto RC. Influ-
ence of 2% chlorhexidine gel on calcium hydroxide ionic dissociation and its
ability of reducing endotoxin. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2011;111:653–658.
31. Silveira CF, Cunha RS, Fontana CE, et al. Assessment of the antibacterial activ-
ity of calcium hydroxide combined with chlorhexidine paste and other intra-
canal medications against bacterial pathogens. Eur J Dent 2011;5:1–7.
VOLUME 46 • NUMBER 7 • JULY/AUGUST 2015
Q U I N T E S S E N C E I N T E R N AT I O N A L
Bernardi/Teixeira
32. Taşman F, Cehreli ZC, Oğan C, Etikan I. Surface tension of root canal irrigants.
J Endod 2000;26:586–587.
33. Basrani B, Ghanem A, Tjäderhane L. Physical and chemical properties of chlor-
hexidine and calcium hydroxide-containing medications. J Endod
2004;30:413–417.
34. Okino LA, Siqueira EL, Santos M, Bombana AC, Figueiredo JA. Dissolution of
pulp tissue by aqueous solution of chlorhexidine digluconate and chlorhexi-
dine digluconate gel. Int Endod J 2004;37:38–41.
35. Chávez de Paz LE, Bergenholtz G, Svensäter G. The effects of antimicrobials on
endodontic biofilm bacteria. J Endod 2010;36:70–77.
36. Del Carpio-Perochena AE, Bramante CM, Duarte MA, et al. Biofilm dissolution
and cleaning ability of different irrigant solutions on intraorally infected den-
tin. J Endod 2011;37:1134–1138.
37. Menezes AC, Zanet CG, Valera MC. Smear layer removal capacity of disinfec-
tant solutions and without EDTA for the irrigation of canals: a SEM study.
Pesqui Odontol Br 2003;17:349–355.
38. Wuerch RM, Apicella MJ, Mines P, Yancich PJ, Pashley DH. Effect of 2% chlor-
hexidine gel as an intracanal medication on the apical seal of the root-canal
system. J Endod 2004;30:788–791.
39. Kontakiotis EG, Tsatsoulis IN, Papanakou SI, Tzanetakis GN. Effect of 2% chlor-
hexidine gel mixed with calcium hydroxide as an intracanal medication on
sealing ability of permanent root canal filling: a 6-month follow-up. J Endod
2008;34:866–870.
40. Bodrumlu E, Parlak E, Bodrumlu EH. The effect of irrigation solutions on the
apical sealing ability in different root canal sealers. Br Oral Res 2010;24:165–169.
41. Homayouni H, Majd NM, Zohrehei H, et al. The effect of root canal irrigation
with combination of sodium hypochlorite and chlorhexidine gluconate on
the sealing ability of obturation materials. Open Dent J 2014 8:184–187.
42. Souza LB, de Aquino SG, de Souza PP, Hebling J, Costa CA. Cytotoxic effects of
different concentrations of chlorhexidine. Am J Dent 2007;20:400–404.
43. Lessa FC, Aranha AM, Nogueira I, Giro EM, Hebling J, Costa CA. Toxicity of
chlorhexidine on odontoblast-like cells. J Appl Oral Sci 2010;18:50–58.
44. Jeansonne MJ, White RR. Comparison of 2% chlorhexidine gluconate and
5.25% sodium hypochlorite as antimicrobial endodontic irrigants. J Endod
1994;20:276–278.
45. Silva RA, Leonardo MR, da Silva LA, Faccioli LH, de Medeiros AI. Effect of a
calcium hydroxide–based paste associated to chlorhexidine on RAW 264.7
macrophage cell line culture. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2008;106:e44–e51.
46. Silva RA, Assed S, Nelson-Filho P, Silva LA, Consolaro A. Subcutaneous tissue
response of isogenic mice to calcium hydroxide-based pastes with chlorhexi-
dine. Braz Dent J 2009;20:99–106.
47. Hikiba H, Watanabe E, Barrett JC, Tsutsui T. Ability of fourteen chemical agents
used in dental practice to induce chromosome aberrations in Syrian hamster
embryo cells. J Pharmacol Sci 2005;97:146–152.
48. Ribeiro DA, Scolastici C, De Lima PL, Marques ME, Salvadori DM. Genotoxicity
of antimicrobial endodontic compounds by single cell gel (comet) assay in
Chinese hamster ovary (CHO) cells. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2005;99:637–640.
49. Yeung SY, Huang CS, Chan CP, et al. Antioxidant and pro-oxidant properties
of chlorhexidine and its interaction with calcium hydroxide solutions. Int
Endod J 2007;40:837–844.
50. Arabaci T, Türkez H, Canakçi CF, Ozgöz M. Assessment of cytogenetic and
cytotoxic effects of chlorhexidine digluconate on cultured human lympho-
cytes. Acta Odontol Scand 2013;71:1255–1260.
51. González-López S, Camejo-Aguilar D, Sanchez-Sanchez P, Bolaños-Carmona
V. Effect of CHX on the decalcifying effect of 10% citric acid, 20% citric acid, or
17% EDTA. J Endod 2006:32:781–784.
52. Prado M, Santos Júnior HM, Rezende CM, et al. Interactions between irrigants
commonly used in endodontic practice: a chemical analysis. J Endod
2013;239:505-510.
53. Basrani BR, Manek S, Sodhi RN, Fillery E, Manzur A. Interaction between sodi-
um hypochlorite and chlorhexidine gluconate. J Endod 2007;33:966–969.
581
Q U I N T E S S E N C E I N T E R N AT I O N A L
Bernardi/Teixeira
54. Bui TB, Baumgartner JC, Mitchell JC. Evaluation of the interaction between
sodium hypochlorite and chlorhexidine gluconate and its effect on root
dentin. J Endod 2008;34:181–185.
55. Vianna ME, Gomes BP. Efficacy of sodium hypochlorite combined with chlor-
hexidine against Enterococcus faecalis in vitro. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2009;10:585–589.
56. Marchesan MA, Pasternak Júnior B, Afonso MM, Sousa-Neto MD, Paschoalato
C. Chemical analysis of the flocculate formed by the association of sodium
hypochlorite and chlorhexidine. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2007;103:e103–e105.
57. Akisue E, Tomita VS, Gavini G, Poli de Figueiredo JA. Effect of the combination
of sodium hypochlorite and chlorhexidine on dentinal permeability and scan-
ning electron microscopy precipitate observation. J Endod 2010;36:847–850.
58. Basrani BR, Manek S, Mathers D, Fillery E, Sodhi RN. Determination of 4-chlo-
roaniline and its derivatives formed in the interaction of sodium hypochlorite
and chlorhexidine by using gas chromatography. J Endod 2010;36:312–314.
59. Krishnamurthy S, Sudhakaran S. Evaluation and prevention of the precipitate
formed on interaction between sodium hypochlorite and chlorhexidine. J
Endod 2010;36:1154–1157.
60. Thomas JE, Sem DS. An in vitro spectroscopic analysis to determine whether
para-chloroaniline is produced from mixing sodium hypochlorite and chlor-
hexidine. J Endod 2010;36:315–317.
61. Cintra LT, Watanabe S, Samuel RO, et al. The use of NaOCl in combination
with CHX produces cytotoxic product. Clin Oral Investig 2014;18:935–940.
62. Zong Z, Kirsch LE. Studies on the instability of chlorhexidine, part I: kinetics
and mechanisms. J Pharm Sci 2012;101:2417–2427.
63. Basrani BR, Manek S, Fillery E. Using diazotization to characterize the effect of
heat or sodium hypochlorite on 2.0% chlorhexidine. J Endod 2009;35:1296–
1299.
64. Kim HS, Zhu Q, Baek SH, et al. Chemical interaction of alexidine and sodium
hypochlorite. J Endod 2012;38:112–116.
582
65. Barbin LE, Saquy PC, Guedes DF, Sousa-Neto MD, Estrela C, Pécora JD. Determi-
nation of para-chloroaniline and reactive oxygen species in chlorhexidine and
chlorhexidine associated with calcium hydroxide. J Endod 2008;34:1508–1514.
66. Barbin LE, Estrela C, Guedes DF, Spanó JC, Sousa-Neto MD, Pécora JD. Detec-
tion of para-chloroaniline, reactive oxygen species, and 1-chloro-4-itroben-
zene in high concentrations of chlorhexidine and in a mixture of chlorhexidine
and calcium hydroxide. J Endod 2013;39:664–668.
67. Havlíková L, Matysová L, Nováková L, Hájková R, Solich P. HPLC determination
of chlorhexidine gluconate and p-chloroaniline in topical ointment .J Pharm
Biomed Anal 2007;43:1169–1173.
68. World Health Organization. International Agency for Research on Cancer:
Monographs on the Evaluation of Carcinogenic Risks to Humans—Occupa-
tional Exposures of Hairdressers and Barbers and Personal Use of Hair Colou-
rants; Some Hair Dyes, Cosmetic Colourants, Industrial Dyestuffs and
Aromatic Amines. Lyon: International Agency for Research on Cancer,
1993:1–436.
69. EC. Cosmetics legislation. Cosmetic products. Brussels: European Commis-
sion, DG III Enterprise, 2003.
70. Alexander M, Lustigman BK. Effect of chemical structure on microbial degra-
dation of substituted benzenes. J Agric Food Chem 1966;14:410–413.
71. Kohlbecker G. Toxic impurities in chlorhexidine digluconate. Deutsch Zahnar-
ztl Z 1989;44:273–276.
72. Bonesvoll P, Lökken P, Rölla G, Paus PN. Retention of chlorhexidine in the
human oral cavity after mouth rinses. Arch Oral Biol 1974;19:209–212.
73. IPCS. Assessing human health risks of chemicals. Derivation of guidance val-
ues for health-based exposure limits. Geneva: World Health Organization,
International Programme on Chemical Safety (Environmental Health Criteria
170), 1994.
74. World Health Organization. Concise international chemical assessment docu-
ment (No 48): 4-Chloroaniline (2003). Geneva: WHO, 2003:1–56.
VOLUME 46 • NUMBER 7 • JULY/AUGUST 2015
Copyright of Quintessence International is the property of Quintessence Publishing Company
Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv
without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.