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Evaluation of chlorhexidine gluconate te
tio
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mouthrinse–induced staining using a ss e n c e
fo r
digital colorimeter: An in vivo study
Bora Bagis, DDS, PhD1/Esra Baltacioglu, DDS2/
Mutlu Özcan, DDS, Dr Med Dent, PhD3/Seda Ustaomer, DDS2

Objective: To investigate the persistence of staining after the use of chlorhexidine gluco-
nate mouthrinse. Method and Materials: Twenty-four subjects (nine women and 15 men)
who underwent periodontal therapy and were prescribed the use of 0.2% chlorhexidine
gluconate mouthrinse participated in this study. Color values of maxillary central incisors,
canines, and first molars were recorded at baseline; 3 days; and 1, 2, and 3 weeks of
twice-daily chlorhexidine gluconate use with a digital intraoral colorimeter according to the
CIE L*a*b* coordinates. Results: While color-change (∆E) values showed significant dif-
ferences (P = .020) at different time points (10.1, 8.9, 8.9, 9.4, after 3 days and 1, 2, and
3 weeks, respectively), the duration of chlorhexidine gluconate use did not significantly
affect the results (P = .873) (two-way ANOVA, Tukey test). No significant difference was
found among ∆L* (P = .070), ∆a* (P = .169), and ∆b* (P = .691) values at any time point
(one-way ANOVA). Measurements of baseline to day 3 differences showed significantly
higher ∆E values than those at other time points (P < .05), but this change remained non-
significant after 1, 2, and 3 weeks of chlorhexidine gluconate use (P > .05) (Tukey test).
The highest visible staining occurred on the first molars at all time points (83%, 79%,
79%, and 96% after 3 days and 1, 2, and 3 weeks, respectively) compared to the other
teeth evaluated. Conclusion: The staining effect of chlorhexidine gluconate mouthrinse
on natural dentition should be expected to be the highest in the first few days of use.
(Quintessence Int 2011;42:213–223)

Key words: chlorhexidine, color, dental staining

The etiopathogenetic role of bacterial This approach may be especially helpful

plaque in periodontal diseases has long
been known.1 To prevent plaque forma-
tion and early bacterial recolonization of
the treated area during the postoperative
period, it may be necessary to integrate
or replace mechanical hygiene regimes
with the use of antimicrobial agents.2–4
1
Assistant Professor, Karadeniz Technical University, Faculty of
Dentistry, Department of Prosthodontics, Trabzon, Turkey.
2
Associate Professor, Karadeniz Technical University, Faculty of
Dentistry, Department of Prosthodontics, Trabzon, Turkey.
3
Professor, University of Zurich, Dental Materials Unit, Center
for Dental and Oral Medicine, Clinic for Fixed and Removable
Prosthodontics and Dental Materials Science, Zurich,
Switzerland.
Correspondence: Prof Dr Med Dent Mutlu Özcan, Clinic for
Fixed and Removable Prosthodontics and Dental Materials
Science, Center for Dental and Oral Medicine, University of
Zurich, Plattenstrasse 11, CH-8032, Zurich, Switzerland. Email:
mutluozcan@hotmail.com
when mechanical cleaning is impaired.
Among antimicrobials, antiseptics with vari-
ous groups of chemical substances could
establish antibacterial action that is different
from conventional therapies based on pre-
scription of antibiotics. Among a variety of
antiseptic agents, chlorhexidine gluconate
mouthrinse has been successfully used to
control or reduce plaque formation.5 Of all
the biguanides, chlorhexidine gluconate is
the most often studied substance with anti-
plaque action, and most studies show it to
be effective.6,7
Chlorhexidine gluconate mouthrinse for-
mulations do have local adverse effects that
tend to limit their long-term use as a preven-
tive or maintenance medium. One major
drawback of chlorhexidine gluconate is that
it promotes yellow-brown staining on dental

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Q U I N T E S S E N C E I N T E R N AT I O N A L
Bagis et al
hard tissue, restorative material surfaces,
and the tongue. This kind of staining is
observed when the antiseptic is employed
as a mouthrinse or gel and is specifically
cited as the reason against its long-term
use.6 Much of the information on staining
has been derived from studies that were
conducted to measure chlorhexidine glu-
conate’s mouthrinse effect on plaque and
gingivitis, where incidence of staining was
reported to be of secondary importance.8,9
Furthermore, staining on teeth and the pos-
terior of the tongue appears yellow-brown
and turns blackish in time.10
The mechanisms that determine the
dental staining caused by chlorhexidine
gluconate mouthrinse have not yet been
determined.11,12 Browning is attributed to
nonenzyme-based effects, also known as
Maillard reactions, which are processes of
condensation and polymerization of carbo-
hydrates, peptides, and proteins leading to
the formation of brown-staining substances
known as melanoidins.11,12 Among the pos-
tulated mechanisms are the deterioration
of the chlorhexidine gluconate molecule
that releases parachloranilin and the pro-
tein denaturing with the formation of metal
sulfide. It was also suggested that the
adsorbed chlorhexidine gluconate and the
chromogens present in food and bever-
ages that contain polyphenols may react
with each other, thereby leading to staining.
The potential staining effect on the sub-
stance also depends on the concentration
of chlorhexidine gluconate. The resulting
staining is reversible and can be removed
by suspending use of the mouthrinse or
employing conventional cleaning proce-
dures using bicarbonate or abrasive pro-
phylaxis pastes.13,14
Several scoring systems based on visu-
al assessment have been suggested to
measure the staining effect of chlorhexidine
gluconate or toothpastes.15–18 Methodology
for the assessment of color change could
be debated when subjective evaluation
means such as visual analog scales (VAS)
are used.19 Cultural attitudes, social factors,
the level of perception, and psychologic
variables (eg, situational and emotional
factors) can profoundly alter the degree of
opinion.19 For these reasons, to avoid the
inherent subjectivity of color evaluation,
214
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digital measurement methods are available
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to collect data for color measurements.
Digital intraoral colorimeters are being used
ss
fo r
en c e
for identifying color changes in teeth and
restorative materials that eliminate the pos-
sible subjective bias.20
Patients participating in a clinical study
actually show progressively improved
oral hygiene (Hawthorne effect).21,22 This
may have positive effects on oral hygiene
regimes, so at a later stage, staining may
not be as severe as in the beginning of
the observation period. Therefore, it was of
interest to assess staining after short- and
long-term use of chlorhexidine gluconate.
The objectives of this study were to exam-
ine the staining effect of 0.2% chlorhexi-
dine gluconate mouthrinse on the maxillary
central incisors, canines, and first molars
after 3 days, and 1, 2, and 3 weeks of
chlorhexidine gluconate use. The tested
null hypothesis was that all teeth would
exhibit increased staining with prolonged
use of chlorhexidine gluconate mouthrinse.
METHOD AND MATERIALS
Subjects who had gingivitis, underwent
periodontal therapy, and were prescribed
the use of 0.2% chlorhexidine gluconate
mouthrinse (Klorhex, Drogsan) participated
in this study. The study took place from
October to November 2008.
Subjects were informed that with the
use of chlorhexidine gluconate, they could
expect some staining of teeth and oral soft
tissues (especially the tongue) and that it
would be reversible with prophylactic clean-
ing. Patients were treated at the Department
of Periodontics and Prosthetic Dentistry,
University of Karadeniz, Trabzon, Turkey,
after signing the appropriate informed con-
sent form approved by the ethical committee
of the university’s institutional review board
(vote number of the local Ethical Committee
no: 3/583-35/2008). The subjects were not
admitted to the study if any of the following
criteria were present: (1) younger than 18
years of age; (2) not able to read or sign the
informed consent document; (3) physically
or psychologically abnormal; (4) having
general health-compromising conditions;
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Excluded due to not meeting inclusion criteria (n = 75)
ss e n c e
fo r
• General health-compromising prognosis and medication (n = 9)
• Pregnant (n = 1)
Assessed for eligibility • History of endodontic therapy (n = 7)
(n = 105) • Any restoration of the teeth (n = 26)
• Active periodontal and/or orthodontic therapy (n = 3)
• Using teeth-whitening toothpaste (n = 1)
• Smokers (n = 16)
• Missing teeth of any central, canine, or first molar (n = 11)
• Refused to participate (n = 1)

Allocated to intervention (n = 30)

Received allocated intervention (n = 28)
Allocation Did not receive allocated intervention (due to unavailability for 3
weeks) (n = 2)

Lost to follow-up
Follow-up 1st week follow-up (n = 2)
3rd week follow-up (n = 2)

Analyzed at each follow-up

Analysis (nsubjects = 24, nteeth = 72)

Fig 1 CONSORT flowchart presenting the inclusion and exclusion criteria and the final characteristics of the patients
recruited to participate in this study.

(5) medicated; (6) using any antibiotics
within the past 14 days; (7) pregnant or a
history of ectopic pregnancy; (8) history of
endodontic therapy and/or any restoration
on the teeth to be evaluated; (9) undergo-
ing active periodontal and/or orthodontic
therapy; (10) an impaired response to infec-
tion; (11) using tooth-whitening toothpaste;
(12) smokers; (13) missing teeth; and (14)
residence outside the city of Trabzon, insuf-
ficient address for follow-up, or unwilling-
ness to return for follow-up as outlined by
the investigators.
Complementary to the use of chlorhexi-
dine gluconate mouthrinse, subjects were
instructed to brush their teeth with their
assigned study supplies of fluoride-con-
taining toothpaste (Colgate, Palmolive) and
brush twice daily for 2 minutes. They were
required to maintain a diary to document
the unsupervised brushings and chlorhexi-
dine gluconate use and were instructed
to avoid all other assigned forms of oral
hygiene regimens or instruments (nonstudy
toothbrushes, toothpastes, chewing gum,
etc) for the duration of the study. Subjects
were also asked to refrain from routine den-
tal treatment during the study but should
not defer any necessary or emergency
treatment. They were required to inform
the examining dentists immediately if they
received emergency dental treatment, took
any medication (antibiotic or anti-inflam-
matory), received dental treatment that
might interfere with the study, or became
pregnant.
Finally, 24 subjects (nine women and
15 men; mean age 31 years, minimum 18
years, maximum 65 years) fulfilled the inclu-
sion/exclusion criteria and were recruited to
participate in the study (Fig 1).

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Color measurements
Prior to color measurements, the labial and
lingual surfaces of the teeth were cleaned
and polished using water and fluoride-free
pumice (Clinpro Prophy Powder, 3M ESPE)
with a prophylaxis brush under slow speed
for approximately 5 minutes, rinsed with
water, and dried using an air syringe. Color
values of maxillary central incisors, canines,
and first molars were recorded at base-
line (before chlorhexidine gluconate use);
and after 3 days and 1, 2, and 3 weeks of
chlorhexidine gluconate twice-daily use in
accordance with the manufacturer’s instruc-
tions. All measurements were performed
between 11 and 12 PM at the same dental
unit.
The color measurements were per-
formed with a digital intraoral colorime-
ter (Eye-Ex Dental Chroma Meter, Shofu)
according to the CIE L*a*b* coordinates
with a D65 standard light source. The CIE
L* parameter corresponds to the degree of
lightness and darkness, whereas the a* and
b* coordinates correspond to red or green
(+a*, red; –a*, green) and yellow or blue
(+b*, yellow; –b*, blue), respectively. The
colorimeter was fully charged and calibrat-
ed with a standard white plate according
to the manufacturer’s instruction. The color
change (∆E) for each tooth was calculated
using the following equation:
∆E = [(∆L*)² + (∆a*)² + (∆b*)²]½
where ∆L*, ∆a*, and ∆b* are the differ-
ences in the respective values at baseline
and after 3 days and 1, 2, and 3 weeks of
chlorhexidine gluconate mouthrinse use.
Measurements were made 3 to 4 mm
from the free gingival margin on the middle
of the gingival third of each tooth in ques-
tion. The mean of three measurements was
recorded for each tooth.
216
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Statistical analysis
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Statistical analysis was performed using
Statistix for Windows (Analytical Software
ss en c e
fo r
version 8.0). The results of ∆E values
were evaluated using two-way analysis
of variance (ANOVA) and Tukey multiple
comparison tests with the ∆E values as
the dependent variable and measurement
time points as the independent factors.
P values less than .05 were considered
to be statistically significant in all tests.
Since the ANOVA assumes equal vari-
ances across the samples, all data were
subjected to the Levene test of homoge-
neity of variance (α = 0.05). If the statisti-
cal significance of the test is greater than
0.05, one may assume equal variances.
When the equal variance assumption was
not accepted (P < .05), the Dunnett T3
multiple comparison test was used to
compare the groups. The mean values of
L*, a*, and b* at baseline were compared
to the respective values at 3 days and 1,
2, and 3 weeks using the t test (α = 0.05).
Furthermore, intersubject variation was
analyzed using one-way ANOVA.
RESULTS
Intersubject variation was not significant
(P = .876) (one-way ANOVA) (Table 1).
While ∆E values showed significant differ-
ences (P = .020) at different time points (10.1,
8.9, 8.9, and 9.4 after 3 days and 1, 2, and 3
weeks, respectively), the duration of chlorhex-
idine gluconate use did not significantly affect
the results (P = .873) (two-way ANOVA, Tukey
test) (Table 2). Interaction terms were signifi-
cant (P = .000). No significant difference was
found between ∆L* (P = .070), ∆a* (P = .169),
and ∆b* (P = .691) values at all time points
(one-way ANOVA) (Table 3). Measurements
of the difference from baseline to day 3
showed significantly higher ∆E values than
those at other time points (P < .05), but this
change remained nonsignificant after 1, 2,
and 3 weeks of chlorhexidine gluconate use
(P > .05) (Tukey test). Mean ∆L*, ∆a*, and
∆b* values at all time points are presented in
Table 4.
A color change is said to be clinically
visible in any site when ∆E is higher than
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Table 1 te ot n

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Results of one-way ANOVA of ∆E values for the intersubject variation
ss e n c e
fo r
Sum of squares Degrees of freedom Mean square F Significance
Between groups 56.455 3 18.818 0.229 .876
Within groups 23,358.983 284 82.250
Total 23,415.438 287

P < .05.

Table 2 Results of two-way ANOVA with ∆E as the dependent value

and measurement time points as independent factors

Type II sum
Source of squares Degrees of freedom Mean square F Significance
Corrected model 696.891* 5 139.378 1.730 .128

∆E 640.436 2 320.218 3.975 .020

Time 56.455 3 18.818 0.234 .873

Time vs ∆E 25,676.186 1 25,676.186 318.712 .000

Error 22,718.547 282 80.562

Total 49,091.624 288

Corrected total 23,415.438 287

*R2, 0.030 (adjusted R2, 0.013). P < .05.

Table 3 Results of two-way ANOVA with ∆L*, ∆a*, and ∆b* as the dependent
values and measurement time points as independent factors

Sum of squares Degrees of freedom Mean square F Significance

∆L
Between groups 812.437 3 270.812 2.383 .070
Within groups 32,268.345 284 113.621
Total 33,080.782 287

∆a
Between groups 36.904 3 12.301 1.692 .169
Within groups 2,064.714 284 7.270
Total 2,101.618 287

∆b
Between groups 64.721 3 21.574 0.487 .691
Within groups 12,569.249 284 44.258
Total 12,633.970 287

P < .05.

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Table 4 te ot n

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Mean ∆L*, ∆a*, and ∆b* values and standard deviations at
3 days and 1, 2, and 3 weeks of chlorhexidine gluconate use
ss e n c e
fo r
Time No. of Standard Standard
points measurements Mean deviation error Minimum Maximum

∆L
3d 72 –3.26 11.63 1.37 –33.5 26.4
1 wk 72 –2.84 9.56 1.13 –26.2 23.0
2 wk 72 –6.68 10.72 1.26 –35.4 13.8
3 wk 72 –6.06 10.62 1.25 –45.6 15.9
Total 288 –4.71 10.74 0.63 –45.6 26.4

∆a
3d 72 –0.83 2.61 0.31 –14.2 3.1
1 wk 72 –0.52 2.79 0.33 –13.3 6.8
2 wk 72 0.10 2.67 0.31 –12.0 9.3
3 wk 72 –0.14 2.71 0.32 –11.2 5.0
Total 288 –0.35 2.71 0.16 –14.2 9.3

∆b
3d 72 –1.92 7.43 0.88 –36.2 15.0
1 wk 72 –0.91 6.32 0.75 –23.1 13.7
2 wk 72 –2.12 6.32 0.74 –26.6 13.6
3 wk 72 –1.94 6.47 0.76 –26.0 18.6
Total 288 –1.72 6.63 0.39 –36.2 18.6

Table 5 Visible staining per tooth type after 3 days and 1, 2, and 3
weeks of chlorhexidine gluconate use

Tooth 3d 1 wk 2 wk 3 wk Total
Central incisor 13 (54%) 12 (50%) 12 (50%) 11 (46%) 48 (50%)
(n = 24)
Canine 16 (67%) 13 (54%) 16 (67%) 16 (67%) 61 (64%)
(n = 24)
First molar 20 (83%) 19 (79%) 19 (79%) 23 (96%) 81 (84%)
(n = 24)
Total (n = 72) 49 (68%) 44 (61%) 47 (65%) 50 (69%)

Visible staining is defined based on the ∆E values (> 3.7 is visible).

3.7 units.16–18 If this value is taken as a refer-
ence, the highest visible staining occurred
on the first molars at all time points (83%,
79%, 79%, and 96% after 3 days and 1, 2,
and 3 weeks, respectively) compared to the
other teeth evaluated. The least amount of
staining was observed on the central inci-
sors followed by the canines (Table 5).
Representative typical clinical situations
at baseline, after 3 days, and after 3 weeks
of chlorhexidine gluconate mouthrinse use
are presented in Figs 2a to 2c.

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Fig 2 Representative typical clinical situation (a) at baseline, (b) after 3

days, and (c) after 3 weeks of chlorhexidine gluconate mouthrinse use.

DISCUSSION whiteness, redness, and yellowness did not

The results of this study showed that the
mean ∆E values obtained from central
incisors, canines, and first molars after
chlorhexidine gluconate mouthrinse use
revealed no significant difference, leading
to rejection of the null hypothesis. Similarly,
show significant differences at 3 days or 1,
2, and 3 weeks.
The highest increase in staining was
observed already after 3 days when com-
pared to the baseline values. However, the
staining remained stable at the measure-
ment intervals of 1 and 2 weeks until the

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Bagis et al
end of 3 weeks. This information could
be helpful when giving informed consent
to patients who are prescribed to use
chlorhexidine gluconate mouthrinses. The
highest staining could therefore be expect-
ed within the first few days of chlorhexidine
gluconate use. As a therapy concept, ear-
lier professional prophylactic cleaning or
bleaching could be performed to prevent
staining, especially when teeth have exist-
ing tooth-colored restorations. As a preven-
tive measure for natural dentition, Addy et
al23 recommended the use of chlorhexidine
gluconate only at night instead of twice
daily. In the present study, the subjects used
the mouthrinse twice a day. Decreased use
of chlorhexidine gluconate may lead to less
staining, but its microbiologic effect may
also be impaired. Nevertheless, since the
maximum staining effect was observed at
the third day of measurement, meaning
only six usages, decreasing or increasing
the frequency of chlorhexidine gluconate
mouthrinse use seems not to be neces-
sary to avoid staining. In other words, the
staining effect of chlorhexidine gluconate
mouthrinse was inevitable and therefore
prescribing it for the proper duration without
sacrificing its microbiologic effect in the oral
flora should be the best practice.
Although surface texture was not con-
sidered in the exclusion criteria, during
measurements, texture variations in enamel
could be observed on the labial surfaces
of the evaluated teeth. However, the find-
ings indicated that brushing performance
seemed to function adequately even on
enamel surfaces with deeper textures, lead-
ing to similar staining level regardless of the
surface characterization.
The potential staining effect of chlorhex-
idine gluconate mouthrinse may vary
depending on its concentration, typically
ranging between 0.2% and 0.12%.24 In this
study, a 0.2% chlorhexidine gluconate was
used. The staining effect of chlorhexidine
gluconate was reported to be reversible by
both suspending use and by means of con-
ventional cleaning regimens using bicar-
bonate or abrasive paste for prophylaxis.
In the present study, patients used only the
supplied toothbrushes and fluoride-con-
taining toothpaste twice daily for 2 minutes.
Since the staining level remained stable
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between 3 days and 3 weeks of use, it can
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be stated that the practiced toothbrushing
regimen was sufficient only to keep the level
ss en c e
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of staining minimum, but it did not have an
additional stain removal effect. One limita-
tion of this study was that after termination
of chlorhexidine gluconate mouthrinse use,
no further measurements were made to
investigate the relapse in staining. This was
due to the fact that some patients had to
be assigned to different periodontal treat-
ments, depending on the individual case,
which could affect the study design.
In vivo color measurement can be
achieved utilizing intraoral digital colorim-
eters. The validity of the devices available
and reproducibility of the measurements
may vary depending on the measuring
device. In this study, a relatively new intra-
oral contact colorimeter was used that
consists of a handheld measuring unit
and a desktop printer (DPU-201GS, PM
Company) and controller. The measuring
unit is equipped with a disposable con-
tact tip that measures 2.5 mm in diameter,
with an outside diameter of 5.0 mm at the
base and 4.0 mm at the top. A holder
with a 10-mm base diameter fits over the
disposable contact tip. The unit uses a
pulsating xenon lamp and a 0-degree dif-
fuse configuration to trigger three auto-
matic measurements. This colorimeter is
designed to measure the shade of natural
teeth when set at tooth mode. Among other
colorimeters, Tung et al25 showed the high-
est reliability and repeatability with Shade
Eye-Ex Dental Chroma Meter for measuring
the color of natural teeth. Insignificant dif-
ference between the intersubject ∆E val-
ues also indicates reliability of the device
employed. Recently, in a study in which
validity and reliability of the visual assess-
ment of tooth color using a commercial
shade guide (Vitapan Classical) was com-
pared with the digital spectrophotometer
(Vita Easyshade), sensitivity and specific-
ity of both methods were found to present
good reliability, especially for differentiating
between dark and light colors.26 However, it
must be noted that in that study, the opera-
tors were calibrated for the use of a former
shade guide. In that respect, computer-aid-
ed shade determination could still eliminate
experience in color measurements. On the
VOLUME 42 • NUMBER 3 • MARCH 2011

other hand, in another study in which visual
(Chromascop Complete) and computer-aid-
ed (SpectroShade) assessment was com-
pared on bleached teeth, the measurement
methods matched only 45.8% of the time.27
That study was in vitro, and as such, a
direct comparison cannot be made with this
current study. Nonetheless, even though the
original objective of this study was not to
compare the shade guides, variations could
be expected among such devices since
color science carries many factors that can
influence results.28
Although some authors29,30 considered
∆E difference (discrepancy between two
hue values) of 3.0 units an indicator for vis-
ible mismatch in color, according to other
studies on color stability, a color change is
said to be clinically visible in any site with
∆E data being higher than 3.7 units.31,32
Based on this information, ideally, CIE
L*a*b* ∆E values should have been at least
lower than 3.7 units after chlorhexidine glu-
conate mouthrinse use so that the color dif-
ference could not be noticed by the naked
eye between the two sites. When this value
is considered as a reference unit in the
present study, 54% to 83% of the evaluated
teeth showed visible staining after 3 days of
use. After 3 weeks of use, nearly all (96%)
of the maxillary right first molars presented
visible staining. Esthetic consequences due
to staining may discourage patients and
dentists, which could lead to discontinua-
tion of long-term chlorhexidine gluconate
use, even though the staining is known to
be reversible. Therefore, by using intraoral
shade guides similar to the one used in this
study or simply visual inspections, staining
could be monitored and early prophylactic
measures could be undertaken.
The exact mechanism of stain promo-
tion by chlorhexidine gluconate is unknown.
Three possible mechanisms were reviewed
by Watts and Addy,33 namely that chlorhexi-
dine gluconate may accelerate the nonen-
zymatic browning reaction of protein and
carbohydrate in the acquired pellicle; that
chlorhexidine gluconate denature compo-
nents within the dental pellicle acceler-
ate formation of pigmented sulfides of tin
and iron; and that chlorhexidine gluconate
precipitates dietary chromagens. Dramatic
increase was observed in staining due to the
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possible binding mechanism of chlorhexi-
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dine gluconate to polyphenols found in tea t
ess c e n
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34
onto dental surfaces. No restrictions were en
made in the diet of the subjects involved in
this study. However, even such a mecha-
nism could exist due to the early staining
after 3 days of chlorhexidine gluconate use:
Consumption of tea could be considered
only as a confounding factor. The former
mechanisms could be dominating the lat-
ter. A possible treatment to avoid increased
tooth staining could be to rinse the mouth
with water shortly after chlorhexidine glu-
conate mouthrinse use and prior to eating
or drinking, thus decreasing the possibility
that the chlorhexidine gluconate would bind
polyphenols to hydroxyapatite. One other
study on the mechanism of the plaque-con-
trolling action of chlorhexidine gluconate
suggested that the effect of chlorhexidine
gluconate was most acute initially and not
as a result of a slowly released reservoir.35
It could also be anticipated that chlorhexi-
dine gluconate accelerates formation of
acquired pellicles and therefore accumula-
tion of polyphenols on the chlorhexidine
gluconate itself and subsequently on the
tooth surfaces. This aspect of mechanism
for staining needs further investigations.
Nevertheless, based on the results of this
study, the first 3 days seem to be the most
critical for chlorhexidine gluconate mouth-
rinse–induced staining.
One difficulty in conducting clinical sci-
entific research is that the actual investi-
gation itself may influence the behaviors
of the individuals under observation (the
Hawthorne effect).21,22 If the Hawthorne
effect does occur, it will bias the estimates
of prevalence obtained from the cohort
away from the correct values obtained.
In this case, the most reliable and useful
results are those obtained from comparative
analyses. However, knowing the well-estab-
lished beneficial effects of chlorhexidine
gluconate and not prescribing it for the
study cohort or involving a healthy group of
subjects and letting them use chlorhexidine
gluconate only for the sake of comparison
would not be ethically viable. Therefore, the
Hawthorne effect would be very unlikely and
almost impossible to cope with in practice,
so the possibility would have to be ignored.
For this reason, both short- and long-term
221
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Bagis et al
results were of interest, as we anticipated
that the early observations in the first week
would affect the individuals’ oral hygiene
regimes, possibly further decreasing the
staining effect of the chlorhexidine gluco-
nate. Multicenter studies may verify the
findings of this current study.
The use of chlorhexidine gluconate
mouthrinse prior to or during periodontal
therapy has been reported to cause stain-
ing in earlier clinical studies.12,36–38 From this
perspective, this study carries confirma-
tory value. However, these former stud-
ies were based on only visual inspection.
Consequences of chlorhexidine gluconate
staining may result in additional prophylac-
tic cleaning sessions or mismatch in color
between the natural dentition and neigh-
boring restorations. The set of numeric
data obtained as a function of location and
time could be considered the significance
of this study that may serve as baseline
indicators when bleaching or restorative
action eventually needs to be undertaken
subsequent to chlorhexidine gluconate use.
Such baseline information may help clini-
cians communicate with the patient, as well
as eliminate overtreatment. The results also
indicate no justification for short-term use
of chlorhexidine gluconate based solely on
esthetic concerns.
CONCLUSION
The results of this study suggest that stain-
ing was significantly higher after 3 days of
chlorhexidine gluconate mouthrinse use
when compared to the baseline situation,
but it remained nonsignificant up to 3
weeks of use. Whiteness, redness, and
yellowness of the evaluated teeth did not
show significant difference at 3 days or 1,
2, and 3 weeks. The highest visible stain-
ing occurred on the first molars for all time
points.
222
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