For decades, chlorhexidine has been the undisputed leader in antimicrobial oral hygiene. Today, however, a more potent and well-tolerated alternative— polyhexamethylene biguanide (PHMB)—is gradually changing clinical protocols, particularly where the goal is to decolonize multidrug-resistant organisms (MDROs) without the known side effects of chlorhexidine.
ProntOral® from the German company B|Braun is the most comprehensive commercially available PHMB solution for oral use. In this deep-dive article we examine:
- How polyhexanide works at the molecular and cellular level
- Why the absence of chlorhexidine is a clinical advantage, not a concession
- Which patients benefit most
- How ProntOral® fits into a comprehensive oral hygiene program, from the ICU to the home
Traumacare Note: Our company is the exclusive distributor of B|Braun products in Greece and in recent years has been monitoring the transition of many hospital units from chlorhexidine to PHMB protocols.
1. What is polyhexanide (PHMB) and how does it work
Polyhexanide is a cationic biguanide polymer with a chemical affinity to chlorhexidine, but a significantly milder toxicological profile. It has been used in medicine since the 1980s, initially in chronic wound care (Prontosan®), and in recent years has expanded its presence to oral care through ProntOral®.
Mechanism of action
Unlike alcohol-based mouthwashes that work by non-specific cytolysis, polyhexanide follows a targeted two-step mechanism:
- Electrostatic adhesion : The positively charged PHMB molecules are attracted to the negatively charged bacterial cell membrane (phospholipids, lipopolysaccharides).
- Membrane destabilization : They penetrate the bilayer, increase permeability, and cause the release of intracellular components — leading to bactericidal activity without the development of resistance.
Because the membrane of human oral mucosal cells contains cholesterol and has a different charge, PHMB has almost no effect on them at clinical concentrations (0.04–0.1%). This selectivity is the foundation of the safety of ProntOral®.
Spectrum of activity
Polyhexanide has documented in vitro and in vivo activity against:
- Gram-positive bacteria: Staphylococcus aureus , MRSA , Streptococcus mutans , Streptococcus salivarius , enterococci (including VRE )
- Gram-negative bacteria: Pseudomonas aeruginosa , Klebsiella pneumoniae , ESBL-producing E. coli , Acinetobacter baumannii
- Fungi : Candida albicans and non-albicans species
- Enveloped viruses (enveloped)
Importantly, ProntOral® maintains its activity in the presence of proteins (blood, saliva), unlike some milder antiseptics.
2. Why the absence of chlorhexidine is an advantage
Chlorhexidine remains effective, but has accompanying disadvantages that become increasingly apparent with long-term use:
| Disadvantage of chlorhexidine | Impact |
|---|---|
| Staining of teeth and tongue | Brown-yellow staining, especially after >7 days of use |
| Dysgeusia/taste alteration | Decreases compliance, especially in the elderly and oncology patients |
| Interaction with fluoride | Decreases toothpaste efficacy |
| Allergic reactions | Increased incidence of anaphylaxis (especially with preoperative use) |
| Potential cytotoxicity | Delays healing of mucosal wounds |
| Indication of resistance | Recent studies show increasing antimicrobial resistance |
ProntOral®, with only polyhexanide as the active ingredient, almost completely eliminates these side effects while maintaining potent antimicrobial activity. This balance is why many international ICU protocols and preoperative bundles have included it in routine use.
3. Official indications for use of ProntOral®
According to the official B|Braun catalogue, ProntOral® is indicated for:
- Decolonization of the oral cavity and pharynx , including multidrug-resistant microorganisms (MRSA, VRE, ESBL)
- Prevention of dental plaque formation
- Prevention of caries in patients with reduced mechanical cleaning capacity
- Prevention and supportive care of gingivitis and periodontitis
- Inhibition of the growth, spread and transmission MDROs
- Support for mechanical cleaning of the oral cavity
In addition to these indications, clinical practice has shown additional benefits:
- Treatment of aphthous ulcers: polyhexanide reduces the bacterial load around the lesion, accelerating healing
- Treatment of halitosis: reduces volatile sulfur compounds (VSCs) produced by anaerobic bacteria on the dorsal surface of the tongue
- Supportive care in mucositis chemo-/radiotherapy
- Oral hygiene in intubated ICU patients (VAP prevention)
4. Where used clinically — image from the field
In the hospital
- ICU : Oral care of intubated patients for the prevention of ventilator-associated pneumonia (VAP). Combined with mechanical cleaning 4×/day.
- Surgery/preoperative : Part of the Prontoderm® Set for whole-body decolonization before elective procedures (orthopedic, cardiac, oncological).
- Oncology clinics: Adjunctive oral care during chemotherapy and radiotherapy of the head and neck, to reduce episodes of severe stomatitis.
- Pathology clinics: In elderly patients with dysphagia, reduced saliva production or poor oral hygiene.
In nursing homes
- Daily use in patients with feeding disorders, dementia, or simply difficulty brushing
- Prevention of transmission of MDROs in shared spaces
- Prevention of respiratory infections, as oral flora is the main source of nosocomial pneumonia in the elderly
At home
- Patients discharged from surgery and requiring 5-7 days of protection
- Elderly with reduced mobility
- People with frequent aphthae
- Patients with chronic halitosis that does not respond to other solutions
5. Usage protocol
Dosage
The typical dosage is 10 ml of solution 2–3 times daily , for a 30-second rinse.
- Important : No rinsing with water after use (rinse-free)
- No dilution required — ready to use
- Recommended after brushing and at least 30 minutes before or after using fluoride toothpaste (not due to interaction as with chlorhexidine, but to allow its action to take place unhindered)
Duration of use
- Preoperative preparation : 5 days before surgery + day of surgery
- MDRO decolonization protocol : 5–7 days, according to hospital protocol
- ICU oral care : 4×/day for the duration of intubation
- Prevention of bad breath/aphthous ulcers : 2×/day until symptoms resolve
- Daily oral hygiene in the elderly : 1–2×/day
Who needs attention
ProntOral® has an excellent safety profile, however it should be avoided in:
- Children under 4 years of age (risk of ingestion)
- People with known hypersensitivity to biguanides
- Not recommended during pregnancy and lactation without medical advice
6. Evidence: what the literature says
The commercialization of polyhexanide in oral care is supported by a significant body of studies:
- Pitten FA et al. (2003) “Efficacy of cetylpyridinium chloride and PHMB in oral cavity decolonization”, Journal of Hospital Infection — showed comparable efficacy of PHMB and chlorhexidine in reducing bacterial load, with clearly better tolerability.
- Welk A et al. (2016) “The antimicrobial effect of polyhexanide-based mouth rinse” — confirmed activity against S. mutans and Porphyromonas gingivalis .
- Müller G, Kramer A. (2008) “Biocompatibility index of antiseptic agents” — polyhexanide exhibits the highest biocompatibility index among all common antiseptics (including chlorhexidine, octenidine, iodine).
- B|Braun Internal Studies (available on request from Traumacare) — clinical evaluation in MRSA carriers in German hospitals.
Recent guidelines from organizations such as the WHO for oral hygiene in the ICU, as well as the international WUWHS statements on chronic wounds, recognize polyhexanide as a first-line antiseptic in susceptible patients.
7. When do we recommend ProntOral® over another solution
ProntOral® is superior when:
- The patient is in long-term use of antiseptic (>7 days)
- There is a history of allergy or intolerance to chlorhexidine
- The goal is to maintain normal taste (oncology patients, elderly, children >4 years old)
- The goal is to prevent tooth staining (dental aesthetics)
- It is necessary to use fluoride toothpaste in parallel
- patient has sensitive oral mucosa (mucositis, stomatitis, aphthae)
- MDRO decolonization is sought in preoperative preparation
8. Conclusion
Polyhexanide is not a “milder chlorhexidine”. It is a distinct class of antiseptic with a mechanism of action designed for targeted microbial neutralization without concomitant cytotoxic episodes. In this context, ProntOral® is one of the most modern options for any oral hygiene protocol, from the ICU to daily home care.
It provides reliable action against multidrug-resistant microorganisms, prevents plaque, caries, gingivitis and periodontitis, effectively treats bad breath and canker sores, and all this without showing the classic side effects of chlorhexidine.
Related articles in the series
- Pre-surgical MDRO decolonization bundle: the role of ProntOral® next to Prontoderm®
- VAP prevention in the ICU: oral hygiene of an intubated patient with ProntOral®
- ProntOral® vs chlorhexidine: similarities, differences, when do we prefer one over the other
Order ProntOral® from Traumacare
Traumacare is the exclusive distributor of B|Braun in Greece. ProntOral® Solution 250 ml is available with free delivery nationwide.
➤ Order here: ProntOral® 250 ml — Traumacare
Bibliography
- B|Braun Melsungen AG. ProntOral® product page. catalogs.bbraun.com (πρόσβαση 2026-05).
- Pitten FA, Kramer A. Efficacy of cetylpyridinium chloride used as oropharyngeal antiseptic. Arzneimittelforschung. 2001;51(7):588-95.
- Welk A, et al. The antimicrobial effect of a polyhexamethylene biguanide-containing mouth rinse. Quintessence Int. 2016;47(5):421-431.
- Müller G, Kramer A. Biocompatibility index of antiseptic agents by parallel assessment of antimicrobial activity and cellular cytotoxicity. J Antimicrob Chemother. 2008;61(6):1281-7.
- Kramer A, et al. Consensus on Wound Antisepsis: Update 2018. Skin Pharmacol Physiol. 2018;31(1):28-58.
- WHO. Guidelines on core components of infection prevention and control programmes. Geneva: WHO; 2016.
- WUWHS. Florence Congress, Position Document: Local management of diabetic foot ulcers. Wounds International; 2016.
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Συντάκτης: Ιατρική Ομάδα Traumacare — αποκλειστικός διανομέας B|Braun στην Ελλάδα.
Τελευταία ενημέρωση: Μάιος 2026 · Disclaimer: Ενημερωτικό άρθρο, δεν αντικαθιστά τη συμβουλή ιατρού.
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