The Influence of Chlorhexidine Mouthwash Use on Post-Operative Infection Rate of Dental Implants- A Systematic Review

Since its first introduction, the usage of chlorhexidine has increased. The same holds for dental implants. Implant failures can happen, even with the stated high survival rates of implants. This systematic review's objective. This systematic study aims to assess how often post-operative infections and early implant failures may be prevented by using a chlorhexidine peri-operative rinse. The materials and techniques included a manual search of significant journals and reference lists of relevant publications and an electronic search of the literature using predetermined search parameters at specific databases (CENTRAL, Medline, Embase, Web of Science, Scopus, ScienceDirect). After duplicates were eliminated, the 251 records found during the search were reduced to 108. Eleven full-text papers were acquired after titles and abstracts were screened. For this systematic review, one article met the eligibility requirements. There were 595 individuals in the population; 325 (the Treatment group) received a mouthwash containing 0.12% chlorhexidine prior to implant insertion surgery, whereas the Control group (325) received no peri-operative rinse. 5.8% of the treatment group and 9.3% of the control group had infectious problems. When chlorhexidine was utilized as a peri-operative rinse, the chance of infection problems after implant insertion was shown to be 36% lower, with a calculated relative risk of 0.63. In summary, very little evidence suggests that using a mouthwash containing chlorhexidine before surgery would lower the chance of infection after surgery. To enable the development of compelling recommendations based on evidence, further study in this area is required.

1.        Payer M, Tan WC, Han J, Ivanovski S, Mattheos N, Pjetursson BE, et al. The effect of systemic antibiotics on clinical and patient‐reported outcome measures of oral implant therapy with simultaneous guided bone regeneration. Clin Oral Implants Res. 2020;31(5):442-51.

2.        Davies G, Francis J, Martin A, Rose F, Swain G. 1: 6‐DI‐4′‐CHLOROPHENYLDIGUANIDOHEXANE ("HIBITANE"*). LABORATORY INVESTIGATION OF A NEW ANTIBACTERIAL AGENT OF HIGH POTENCY. Br J Pharmacol Chemother. 1954;9(2):192-6.

3.        Puig-Silla M, Montiel-Company J, Almerich-Silla J. Use of chlorhexidine varnishes in preventing and treating periodontal disease. A review of the literature. Med Oral Patol Oral Cir Bucal. 2008;13(4):E257-60.

4.        Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol. 2002;23(S12):S3-40. Available from: https://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf2002

5.        Löe H, Schiött CR, Karring G, Karring T. Two years oral use of chlorhexidine in man. I. General design and clinical effects. J Periodontal Res. 1976;11(3):135-44.

6.        Jones CG. Chlorhexidine: is it still the gold standard? Periodontology 2000. 1997;15(1):55-62.

7.        Denton GW. Chlorhexidine. In: Block, S.S., Ed., Disinfection, Sterilization, Preservations. 4 ed. Philadelphia: Lea & Fegiber; 1991.

8.        Addy M. Chlorhexidine compared with other locally delivered antimicrobials: a short review. J Clin Periodontol. 1986;13(10):957-64.

9.        Kornman KS. The role of supragingival plaque in the prevention and treatment of periodontal diseases: A review of current concepts. J Periodontal Res. 1986;21:5-22.

10.      Rölla G, Löe H, Schiøtt CR. Retention of chlorhexidine in the human oral cavity. Arch Oral Biol. 1971;16(9):1109-16.

11.      Rindom Schiøstt C. Effect of chlorhexidine on the microflora of the oral cavity. Journal of Periodontal Research. 1973;8:7-10.

12.      Tanner J, Dumville JC, Norman G, Fortnam M. Surgical hand antisepsis to reduce surgical site infection. Cochrane Database Syst Rev. 2016;2016(1):CD004288.

13.      James P, Parnell C, Harding M, Whelton H, Worthington HV, Beirne PV. Chlorhexidine mouth rinse as an adjunctive treatment for gingival health. Cochrane Library. 2010.

14.      Tjernberg A. Influence of oral hygiene measures on the development of alveolitis sicca dolorosa after surgical removal of mandibular third molars. Int J Oral Surg. 1979;8(6):430-4.

15.      Berwick MJE, Lessin CME. Effects of a chlorhexidine gluconate oral rinse on the incidence of alveolar osteitis in mandibular third molar surgery. J Oral Maxillofac Surg. 1990;48(5):444-8.

16.      Larsen PE. The effect of chlorhexidine rinses on the incidence of alveolar osteitis following the surgical removal of impacted mandibular third molars. J Oral Maxillofac Surg. 1991;49(9):932-7.

17.      Hermesch C, Hilton T, Baker R, Biesbrock A, Hamlin J, McClanahan S, et al. Prophylactic use of Peridex (R) reduces the incidence of alveolar osteitis following third molar extraction. InJournal of Dental Research 1997 Jan 1 (Vol. 76, pp. 1835-1835). 1619 DUKE ST, ALEXANDRIA, VA 22314: AMER ASSOC DENTAL RESEARCH.

18.      Hermesch CB, Hilton TJ, Biesbrock AR, Baker RA, Cain-Hamlin J, McClanahan SF, et al. Peri-operative use of 0.12% chlorhexidine gluconate for the prevention of alveolar osteitis: efficacy and risk factor analysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endodontol. 1998;85(4):381-7.

19.      Corbet E, Tam J, Zee K, Wong M, Lo E, Mombelli A, et al. Therapeutic effects of supervised chlorhexidine mouthrinses on untreated gingivitis. Oral Dis. 1997;3(1):9-18.

20.      Nyman S, Rosling B, Lindhe J. Effect of professional tooth cleaning on healing after periodontal surgery. J Clin Periodontol. 1975;2(2):80-6.

21.      Lindhe J, Nyman S. The effect of plaque control and surgical pocket elimination on the establishment and maintenance of periodontal health. A longitudinal study of periodontal therapy in cases of advanced disease. J Clin Periodontol. 1975;2(2):67-79.

22.      Rosling B, Nyman S, Lindhe J. The effect of systematic plaque control on bone regeneration in infrabony pockets. J Clin Periodontol. 1976;3(1):38-53.

23.      Rosling B, Nyman S, Lindhe J, Jern B. The healing potential of the periodontal tissues following different techniques of periodontal surgery in plaque‐free dentitions: A 2‐year clinical study. J Clin Periodontol. 1976;3(4):233-50.

24.      Nyman S, Lindhe J, Rosling B. Periodontal surgery in plaque‐infected dentitions. J Clin Periodontol. 1977;4(4):240-9.

25.      Westeelt E, Nyman S, Socransky S, Lindhe J. Significance of frequency of professional tooth cleaning for healing following periodontal surgery. J Clin Periodontol. 1983;10(2):148-56.

26.      Wallkamm B, Ciocco M, Ettlin D, Syfrig B, Abbott W, Listrom R, et al. Three-year outcomes of Straumann Bone Level SLActive dental implants in daily dental practice: a prospective non-interventional study. Quintessence Int. 2015;46(7):591-602.

27.      American Academy of Implant Dentistry. Dental Implants Facts and Figures. Available from: https://www.aaid.com/about/press_room/dental_implants_faq.html2017

28.      Needleman I, Almond N, Leow N, Phillips J. Outcomes of periodontal therapy: Strengthening the relevance of research to patients. A co‐created review. Periodontology 2000. 2023.

29.      Esposito M, Hirsch JM, Lekholm U, Thomsen P. Biological factors contributing to failures of osseointegrated oral implants, (I). Success criteria and epidemiology. Copenhagen, DK; 1998. p. 527-51.

30.      Rodríguez Sánchez F, Rodríguez Andrés C, Arteagoitia I. Which antibiotic regimen prevents implant failure or infection after dental implant surgery? A systematic review and meta-analysis. J Cranio-Maxillofac Surg. 2018;46(4):722-36.

31.      Esposito M, Hirsch JM, Lekholm U, Thomsen P. Biological factors contributing to failures of osseointegrated oral implants, (II). Etiopathogenesis. Copenhagen, DK; 1998. p. 721-64.

32.      Pye A, Lockhart D, Dawson M, Murray C, Smith A. A review of dental implants and infection. J Hosp Infect. 2009;72(2):104-10.

33.      Esposito M, Grusovin MG, Worthington HV. Interventions for replacing missing teeth: antibiotics at dental implant placement to prevent complications. Cochrane Library. 2013.

34.      Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151(4):264-9.

35.      Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med. 2009;6(7):e1000100.

36.      Schardt C, Adams MB, Owens T, Keitz S, Fontelo P. Utilization of the PICO framework to improve searching PubMed for clinical questions. BMC Med Inform Decis Mak. 2007;7(1):16.

37.      Robinson KA, Dickersin K. Development of a highly sensitive search strategy for the retrieval of reports of controlled trials using PubMed. Int J Epidemiol. 2002;31(1):150-3.

38.      Higgins JP, Green S. Cochrane handbook for systematic reviews of interventions 5.1. 0. The Cochrane Collaboration. 2011:33-49.

39.      Cabras M, Gambino A, Broccoletti R, Sciascia S, Arduino PG. Lack of evidence in reducing the risk of MRONJ after teeth extractions with systemic antibiotics. J Oral Sci. 2021;63(3):217-26.

40.      Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating the quality of evidence and strength of recommendations. (Grading of Recommendations Assessment, Development and Evaluation). Br Med J. 2008;336(7650):924.

41.      Tan LW, Ng YE, Giok KC, Veettil SK, Menon RK. Comparative Efficacy of Different Amoxicillin Dosing Regimens in Preventing Early Implant Failure—A Systematic Review with Network Meta-Analysis. Antibiotics. 2023;12(3):512.

42.      Genovesi A, Barone A, Toti P, Covani U. The efficacy of 0.12% chlorhexidine versus 0.12% chlorhexidine plus hyaluronic acid mouthwash on healing of submerged single implant insertion areas: a short‐term randomized controlled clinical trial. Int J Dent Hyg. 2017;15(1):65-72.

43.      Horwitz J, Machtei EE, Zuabi O, Peled M. Amine fluoride/stannous fluoride and chlorhexidine mouthwashes as adjuncts to single-stage dental implants: a comparative study. J Periodontol. 2005;76(3):334-40.

44.      Francetti L, Fabbro MD, Basso M, Testori T, Taschieri S, Weinstein R. Chlorhexidine spray versus mouthwash in the control of dental plaque after implant surgery. J Clin Periodontol. 2004;31(10):857-62.

45.      Young MP, Carter DH, Worthington HV, McCord JF, Korachi M, Drucker DB. The effects of an immediately pre‐surgical chlorhexidine oral rinse on the bacterial contaminants of bone debris collected during dental implant surgery. Clin Oral Implants Res. 2002;13(1):20-9.

46.      Laugisch O, Ramseier CA, Salvi GE, Hägi TT, Bürgin W, Eick S, et al. Effects of two different post-surgical protocols, including either 0.05% chlorhexidine herbal extract or 0.1% chlorhexidine, on post-surgical plaque control, early wound healing, and patient acceptance following standard periodontal surgery and implant placement. Clin Oral Investig. 2016;20(8):2175-83.

47.      Kotha VS, Kanuri A, Mandelbaum M, Lakhiani C, Hung RW, Wang J, et al. Simultaneous Zygomatic Osteotomies With Reduction Mandibuloplasty–An Approach to Mid-and Lower-Facial Feminization in the Transfeminine Patient. J Craniofac Surg. 2022;33(5):1569-73.

48.      Felo A, Shibly O, Ciancio S, Lauciello F, Ho A. Effects of subgingival chlorhexidine irrigation on peri-implant maintenance. Am J Dent. 1997;10(2):107-10.

49.      Wortmann DE, Boven CG, Schortinghuis J, Vissink A, Raghoebar GM. Patients' appreciation of pre-implant augmentation of the severely resorbed maxilla with calvarial or anterior iliac crest bone: a randomized controlled trial. Int J Implant Dent. 2019;5(1):1-9.

50.      Yohannan LM. Incidence and Outcome of Pulmonary Complications after Cardiac Surgery. Lietuvos sveikatos mokslų universiteto Leidybos namai; 2019. pp.91-3.

51.      Cheung J. On the Role of Sub-Anesthetic Ketamine For Post-Operative Analgesia Following Third Molar Surgery (Doctoral dissertation). 2019.

52.      Livie V, Livie J, Hilton-Christie S. Improving the use of the 'COUGH ' bundle in surgical high dependency unit, Ninewells Hospital, Dundee. BMJ Open Qual. 2020;9(2):e000851.

53.      Gillam DG, Chatzopoulu D. Post-operative pain following non-surgical and surgical periodontal procedures. Periodontolology and Dental Implantology. IntechOpen. 2019:163-78.

54.      Hsieh TY, Funamura JL, Dedhia R, Durbin-Johnson B, Dunbar C, Tollefson TT. Risk factors associated with complications after treatment of mandible fractures. JAMA Facial Plast Surg. 2019;21(3):213-20.

55.      El Azrak M, Polyzois I. Prescription of antibiotics for the prevention of failures and post-operative infections in oral implantology: a literature review. J Ir Dent Assoc. 2021;67(4, August/September).

56.      Khouly I, Braun RS, Chambrone L. Antibiotic prophylaxis may not be indicated for the prevention of dental implant infections in healthy patients. A systematic review and meta-analysis. Clin Oral Investig. 2019;23:1525-53.

57.      Zhao AH, Kwok CH, Jansen SJ. How to Prevent Surgical Site Infection in Vascular Surgery: A Review of the Evidence. Ann Vasc Sur. 2022;78:336-61.

58.      Chaudhari S, Jangale AG, Dhande S, Jangale SA. Breakthrough in Surgeries during Covid-19 Pandemic Era: An Orthopedic Perspective. J Rhem Ortho Sports Sci. 2022;2(1):1-7.

59.      Goswami A, Ghorui T, Bandyopadhyay R, Sarkar A, Ray A. A general overview of post-extraction complications-prevention, management, and importance of post-extraction advices. Fortune J Health Sci. 2020;3(3):135-47.

60.      Fee L. BA BDS MJDF (Word count: 2,999).

61.      Sartelli M. Healthcare-associated infections in the surgical setting: How to prevent and treat them. Adv Human Biol. 2022;12(2):127-37.

62.      Berton F, Costantinides F, Rizzo R, Franco A, Contarin J, Stacchi C, et al. Should we fear direct oral anticoagulants more than vitamin K antagonists in a simple single-tooth extraction? A prospective comparative study. Clin Oral Investig. 2019;23(8):3183-92.

63.      Nathwani S. Management of patients on oral anticoagulants in dental practice. Dent Update. 2020;47(11):912-22.

64.      Ishaq M, Noor B, Ahad A, Muhammad N, Bibi R. Chlorhexidine for the Prevention of Omphalitis in neonates with a single dose. Pak J Med Health Sci. 2023;17(04):141.

65.      Mauceri R, Panzarella V, Pizzo G, Oteri G, Cervino G, Mazzola G, et al. Platelet-Rich Plasma (PRP) in dental extraction of patients at risk of bisphosphonate-related osteonecrosis of the jaws: A two-year longitudinal study. Appl Sci. 2020;10(13):4487.

66.      Manz MC. Radiographic assessment of peri-implant vertical bone loss: DICRG Interim Report No. 9. J Oral Maxillofac Surg. 1997;55(12):62-71.

67.      Bedeloğlu E, Yalçın M, Koyuncuoğlu CZ. Is Peri-operative Antibiotic Necessary in Straightforward Implant Placement Procedures? J Oral Implantol. 2021;47(2):135-9.

68.      Grisar K, Smeets M, Ezeldeen M, Shaheen E, De Kock L, Politis C, et al. Survival and success of autotransplanted impacted maxillary canines during short‐term follow‐up: A prospective case‐control study. Orthod Craniofac Res. 2021;24(2):222-32.

69.      Cheung J, Alashi A, Koto P, Brady J, Davis B. Does Sub-Anesthetic Ketamine Provide Post-operative Analgesia for Third Molar Surgery?. J Oral Maxillofac Surg. 2019;77(12):2452-64.

70.      Shriki M, Almouslli A, Abdul Z, Hausien O, Al-Ghazal SK. Management of Muslim Patients Undergoing Local Anaesthetic Procedures During Ramadan. J Br Islam Med Assoc. 2021;7(3):1-11.

71.      Sykara M, Maniatakos P, Tentolouris A, Karoussis IK, Tentolouris N. The necessity of administrating antibiotic prophylaxis to patients with diabetes mellitus prior to oral surgical procedures systematic review. Diabetes Metab Syndr Clin Res Rev. 2022;16(10):102621.

72.      Darnell LH. The Effect of a Chitosan-based Mouthwash on Oral Pathogens During Initial Wound Healing—An In-Vitro Study. Part I: Antimicrobial Properties (Doctoral dissertation, Saint Louis University). 2020.

73.      Schwarz F, Obreja K, Mayer S, Ramanauskaite A, Sader R, Parvini P. Efficacy of autogenous tooth roots for a combined vertical and horizontal alveolar ridge augmentation and staged implant placement. A prospective controlled clinical study. J Clin Periodontol. 2022;49(5):496-505.

74.      White A, van de Lande LS, O'Hara J, Hartley J, Hayward R, James G, et al. Fronto-facial surgery: reducing infection with the development and 6-year outcome of a fronto-facial protocol. Plast Reconst Surg. 2023;152(4):833-40.

75.      Castagna V, Pardo A, Lanaro L, Signoriello A, Albanese M. Periodontal healing after lower third molars extraction: a clinical evaluation of different flap designs. InHealthcare 2022 Aug 21 (Vol. 10, No. 8, p. 1587). MDPI.

76.      Caggiano M, D’Ambrosio F, Giordano F, Acerra A, Sammartino P, Iandolo A. The “Sling” Technique for Horizontal Guided Bone Regeneration: A Retrospective Case Series. Appl Sci. 2022;12(12):5889.

77.      Jordan K, Carter E, Devine CP, Tsichlaki A, Jones J. Osteogenesis imperfecta: minimizing complications in oral surgery/orthodontic treatment. Dent Update. 2021;48(9):726-30.

78.      Stiesch M, Grischke J, Schaefer P, Heitz‐Mayfield LJ. Supportive care for the prevention of disease recurrence/progression following peri‐implantitis treatment: A systematic review. J Clin Periodontol. 2023;50(s26):113-34.

79.      Roca-Millan E, Estrugo-Devesa A, Merlos A, Jané-Salas E, Vinuesa T, López-López J. Systemic antibiotic prophylaxis to reduce early implant failure: a systematic review and meta-analysis. Antibiotics. 2021;10(6):698.

80.      Herrera D, Berglundh T, Schwarz F, Chapple I, Jepsen S, Sculean A, et al. Prevention and treatment of peri‐implant diseases—The EFP S3 level clinical practice guideline. J Clin Periodontol. 2023;50(s26):4-76.

81.      Sargent RE, Jacobsen J, Cole K, Olson R, Gibbs DM, Amaya R, et al. Association of Pre-Operative Full-Body Surgical Preparation with Reduced Incidence of Surgical Site Infection at a Large, Urban Safety-Net Medical Center. Surg Infect. 2022;23(1):1-4.

82.      Radhika B. To Evaluate the Role of Antibiotics in Periodontal Flap Surgery-A Comparative Clinical Study (Doctoral dissertation, Rajiv Gandhi University of Health Sciences (India)).

83.      Praveen AA, Venkadassalapathy S, Victor DJ, Prakash PS, Umesh SG, Ali Baeshen H, et al. Efficacy of Two Different Hydrodynamic Sinus Lift Systems for Atraumatic Elevation in Immediate Implant Placement. Patient Prefer Adher. 2023;17:1197-207.

84.      Alassy H, Pizarek JA, Kormas I, Pedercini A, Wolff LF. Antimicrobial adjuncts in the management of periodontal and peri-implant diseases and conditions: a narrative review. Front Oral Maxillofac Med. 2021;3:16.

85.      Quinton K, Guy-Frank CJ, Syed S, Klugh JM, Dhanani NH, Adibi SS, et al. Poor Oral Health in Trauma Intensive Care Unit Patients: Application of a Novel Oral Health Score. Surg Infect. 2023;24(7):657-62.

86.      Brookes ZL, Bescos R, Belfield LA, Ali K, Roberts A. Current uses of chlorhexidine for management of oral disease: a narrative review. J Dent. 2020;103:103497.

87.      Duyan HA, Evlice BU. Evaluation of Mandibular Condyle of Patients with Cleft Lip/Palate. 2021.

88.      Kij-artorn MP, Buranawat B, Suwanprateeb J. Clinical evaluation of 3D printed nano-bioengineered bone graft for alveolar ridge preservation: a randomized controlled trial (Doctoral dissertation, Thammasat University). 2019.

89.      Mekcha MP. Custom 3d printed hydroxyapatite bone block graft for alveolar ridge reconstruction: a pilot clinical study (Doctoral dissertation, thammasat university). 2021.

90.      Wongpairojpanich J, Buranawat B, Suwanprateeb J. Clinical efficacy of porous polyethylene membrane for alveolar ridge preservation: a pilot study (Doctoral dissertation, Thammasat University). 2020.

91.      Bhargava V, Renton T. Routine exodontia: preventing failed extractions. Dent Update. 2019;46(9):866-79.

92.      Solderer A, Schmidlin PR. Regenerative surgical therapy of peri-implantitis: an umbrella review of answered/unanswered questions and future perspectives. Front Dent Med. 2020;1:614240.

93.      Ockerman A. The influence of anticoagulants on bleeding and healing after dental extraction (PhD thesis). 2021.

94.      Garner SJ. Development of a Chlorhexidine-Hexametaphosphate Coating for Titanium to Combat Early Implant Failure (Doctoral dissertation, University of Bristol). 2020.

95.      Payer M, Tan WC, Han J, Ivanovski S, Mattheos N, Pjetursson BE, et al. The effect of systemic antibiotics on clinical and patient‐reported outcome measures of oral implant therapy with simultaneous guided bone regeneration. Clin Oral Implants Res. 2020;31(5):442-51.

96.      Khan AM, Gangoo IK, Ali NA, Khan M, Javed MQ, AlAttas MH, et al. The effect of calcium hydroxide, triple antibiotic paste and chlorhexidine on pain in teeth with symptomatic apical periodontitis: a randomised controlled trial. Int J Environ Res Public Health. 2023;20(4):3091.

97.      Camenzuli C. Development of a scarless and gasless trans-oral video-assisted thyroidectomy (Doctoral dissertation). 2021.