Daily use of chlorhexidine gel in addition to regular brushing with low fluoride toothpaste did not provide additional reductions in early childhood caries


Early childhood caries (ECC) remains a challenge for many communities. Chlorhexidine (CHX) is a common oral antiseptic with effective bactericidal activity against mutans streptococci (MS) and early colonisation of the oral cavity by MS has been identified as a risk factor for ECC. The aim of this study was to test whether the daily application of CHX from the time of tooth eruption would reduce MS colonisation and prevent ECC.

The study was conducted in a deprived area of Queensland Australia. Children were randomised to receive either twice daily toothbrushing with low fluoride toothpaste and once daily 0.12% CHX gel (n = 110) or twice daily toothbrushing with a low fluoride toothpaste only (study controls) (n = 89). The mothers in the CHX group were instructed to apply a pea-sized amount of the CHX gel on a clean index finger and smear it evenly on the child’s teeth after the evening toothbrushing. All mothers were instructed to brush twice daily with a smear of low-dose fluoride dentifrice (304% fluoride). Microbial samples were obtained from each child and mother. Telephone contacts were made to the mothers at ages of approximately 6, 12, and 18 months by oral health therapists. Children received a clinical examination at 24 months of age. The primary outcome was caries incidence and the secondary outcome was percentage of children with mutans streptococci (MS).

At 24-months,

  • 61/110 children (55.5%) in the CHX group and 58/89 (65%) underwent clinical examination.
  • caries prevalence was 5% (3 of 61) in the CHX group, and 7% (4 of 58) in the controls [differences not statistically significant (P = 0.7)].
  • The percentage of children brushing twice daily in the CHX group (80%) was significantly higher compared with the study controls (67%, P < 0.001
  • Only about 20% of the children applied the CHX gel on a daily basis as instructed.
  • Community water fluoridation was introduced into Queensland’s water supply approximately 18 months after commencement of the study.

The authors concluded

This study demonstrates that daily application of chlorhexidine (0.12% gel) did not give additional benefits over twice daily toothbrushing with low-dose fluoride (304%) children’s toothpaste in reducing early childhood caries.


While the study was appropriately powered to cope with a significant drop out levels bearing in mind the type of hard to reach communities being studies, the dropout rates need to be borne in mind when considering the findings. A Cochrane review of Chlorhexidine compared to topical fluorides for caries prevention is currently underway (Eberhard et al).


Pukallus ML, Plonka KA, Barnett AG, Walsh LJ, Holcombe TF, Seow WK. A randomised, controlled clinical trial comparing chlorhexidine gel and low-dose fluoride toothpaste to prevent early childhood caries. Int J Paediatr Dent. 2012 Jun 19. doi: 10.1111/j.1365-263X.2012.01248.x. [Epub ahead of print] PubMed PMID: 22713081.

Eberhard J, Sandmann T, Marinho VCC, Dommisch H, Jepsen S, Stiesch M, Geurtsen W. Chlorhexidine versus topical fluoride treatment for the prevention and management of dental caries in children and adolescents (Protocol). Cochrane Database of Systematic Reviews 2012, Issue 7. Art. No.: CD009962. DOI: 10.1002/14651858.CD009962.


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Derek Richards

Derek Richards is a specialist in dental public health, Director of the Centre for Evidence-Based Dentistry and Specialist Advisor to the Scottish Dental Clinical Effectiveness Programme (SDCEP) Development Team. A former editor of the Evidence-Based Dentistry Journal and chief blogger for the Dental Elf website until December 2023. Derek has been involved with a wide range of evidence-based initiatives both nationally and internationally since 1994. Derek retired from the NHS in 2019 remaining as a part-time senior lecturer at Dundee Dental School until the end of 2023.

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