Mouthwash

Mouthwash

Also called: Prescription Mouth Rinses, Mouth Rinses, Dental Mouth Rinses, Cosmetic Mouth Rinses

Summary

Mouthwash is an over-the-counter or prescription liquid that patients usually swish in their mouth and then spit out. There are many different types of mouthwashes that claim to serve different functions.

Mouthwashes are usually classified into one of two categories:

  • Cosmetic mouthwashes. Most over-the-counter commercial mouthwashes fall into this category. In most cases, they are designed to mask bad breath (halitosis), rinse debris from the teeth and gums and temporarily reduce the amount of bacteria in the mouth.

  • Therapeutic mouthwashes. These offer the same benefits as cosmetic rinses, but also help prevent or treat certain oral health conditions, such as the build-up of dental plaque. This includes prescription antiplaque and antigingivitis rinses, as well as rinses that contain fluoride (which strengthens the teeth and protects them from decay). Some may also provide relief from oral pain.

Cosmetic mouthwashes have a limited effect on dental health. Although manufacturers tout over-the-counter mouthwashes as an effective way to promote oral health, dental experts generally do not believe that they offer significant benefits over simple flossing and brushing with a toothpaste containing fluoride. In addition, cosmetic mouthwash masks, rather than eliminates, bad breath. Its effects are temporary and usually do not last more than three hours.

Patients should consult their dentist about whether they should use a mouthwash and what type may be most appropriate for them. A dentist may recommend or prescribe certain types of mouthwashes for patients at high risk of tooth decay, periodontal (gum) disease and dry mouth (xerostomia). In addition, the use of mouthwash may be recommended following oral surgery or periodontal treatment.

While mouthwashes are generally safe, some can cause side effects in patients who use them. For example, many over-the-counter mouthwashes contain high levels of alcohol that may range from 18 percent to 26 percent. Overuse of these rinses can create a burning sensation in the cheeks, teeth and gums. Additional side effects may appear as the result of use of certain types of prescription-strength mouthwashes.

Mouthwashes are generally not recommended for use in children 12 and younger. There is the risk that children may swallow mouthwash instead of spitting it out. This can lead to alcohol poisoning or fluoride overdose, which require emergency medical attention.

About mouthwash

Mouthwash is a liquid solution that is swished around inside the mouth to cover the teeth, gums and tongue, and then is spit out. Some types of mouthwashes help to temporarily mask bad breath (halitosis) as well as rinse the area of debris and bacteria. Others are intended to coat the teeth with fluoride to strengthen them and help prevent decay. Mouthwash may be available in over-the-counter or prescription forms.

Mouthwash is intended to be a supplement to (not a replacement for) good oral hygiene practices, such as daily brushing and flossing. It is typically used after brushing and flossing and is not diluted.

When mouthwash is used, patients should follow the directions provided by their dentist or on the product packaging. Mouthwash should be swished around vigorously so that it rinses the front and sides of the mouth equally. In some cases, patients may be directed to gargle. This involves raising the chin and saying “ahhh” while holding liquid in the mouth and keeping the throat closed. This type of rinsing is especially effective at reaching the back of the tongue, where bacteria may accumulate.

In most cases, patients are urged to swish for about 30 seconds before spitting out the mouthwash. Typically, patients should avoid eating, drinking or rinsing the mouth for up to several hours after using mouthwash, depending on the type used.

Active ingredients in mouthwash can vary, and each provides a different function. Some common ingredient types include:

  • Antimicrobials (e.g., cetylpyridinium chloride, chlorhexidine, sanguinarine, phenolic compounds). These ingredients help reduce the amount of bacteria in the mouth.

  • Deodorizing and oxidizing agents (e.g., sodium bicarbonate and chlorine dioxide, respectively). These help to mask and neutralize bad odors.

  • Oxygenating agents (e.g., hydrogen peroxide). Helps to kill anaerobic germs (those that live without oxygen) by adding oxygen to the area.

  • Fluoride. Strengthens teeth and prevents tooth decay.

  • Astringents (e.g., citric acid, zinc chloride). These provide a pleasant taste and shrink oral tissues.

  • Pain-relieving agents (e.g., anodynes). These provide pain relief.

  • Buffering agents. These ingredients may relieve soft-tissue pain, reduce acidity and dissolve build-up of film on the lining of the mouth.

  • Antitartar (e.g., zinc citrate) agents. Reduce tartar build-up in the mouth.

Inactive ingredients in mouthwashes include those that dilute and sustain the active ingredients (e.g., water, alcohol), as well as those that add flavor or color. Most commercial mouthwashes contain a significant amount of alcohol as an inactive ingredient.

When selecting over-the-counter dental care products such as mouthwash, patients are advised to look for the American Dental Association Seal of Acceptance. This indicates a product is safe and effective.

Types and differences of mouthwash

Mouthwashes may be classified as cosmetic, therapeutic or a combination of the two.

Cosmetic mouthwashes (sometimes called antiseptics) are available over the counter. They are typically made up of phenol-related essential oil compounds that contain active ingredients such as thymol, methyl salicylate, menthol and eucalyptol. Many contain a significant amount of alcohol, although some are available without alcohol.

Most cosmetic mouthwashes perform the following functions:

  • Temporarily mask bad breath (halitosis)
  • Rinse away oral debris
  • Temporarily reduce bacterial levels in the mouth
  • Provide a pleasant, refreshing taste

Manufacturers often claim these types of mouthwashes are an effective way to promote oral health, but dental experts disagree about their effectiveness in reducing dental plaque. An antiseptic mouthwash may kill germs, but does so temporarily because bacteria can develop quickly in the mouth. In fact, some experts believe that rinsing the mouth with water may be as effective as using a cosmetic mouthwash.

Some recent studies have contended that an oral rinse can be as effective as flossing in reducing plaque. However, the American Dental Association (ADA) states that these claims have not been adequately substantiated. Flossing continues to be an important method of removing debris that becomes stuck between teeth and may be difficult to rinse away. Even if these mouthwashes do reduce plaque, they should be used in addition to, not in place of, proper brushing and flossing.

In addition, cosmetic mouthwashes mask rather than eliminate bad breath. The odor-masking properties of these mouthwashes last for up to three hours. Patients with persistent bad breath are advised to contact their dentist or physician. Chronic halitosis may indicate a dental condition (e.g., oral infections, dry mouth) or medical condition (e.g., diabetes, respiratory tract infection) that needs treatment.

Therapeutic mouthwashes offer most of the benefits of cosmetic rinses, but contain an added active ingredient that helps prevent or treat certain oral health conditions. These types of rinses are regulated by the U.S. Food and Drug Administration (FDA) and voluntarily approved by the ADA. They usually fall into one of two categories:

  • Antiplaque/antigingivitis rinse. This type of therapeutic mouthwash has been shown to control bacterial plaque and to reduce and inhibit gingivitis. Many of these rinses contain chlorhexidine gluconate and are available by prescription only. They may have an unpleasant taste or may leave a bitter aftertaste in the mouth. These solutions usually include alcohol, although they may be available without alcohol. They are recommended for short-term use only (e.g., six months or less).

  • Anticavity fluoride rinse. These rinses include fluoride, which helps strengthen teeth and prevent decay. They are available over-the-counter and by prescription (for a higher-concentration level of fluoride). People at high risk of tooth decay, as well as patients with orthodontic appliances, may be advised to regularly use these types of rinses in addition to their daily oral hygiene regimen.

In lieu of commercial mouthwashes, a simple saltwater mouth rinse can be made at home. This involves mixing 1/2 teaspoon salt in 8 ounces of water. It is less irritating than alcohol-based rinses and can be used to cleanse oral tissue.

Conditions treated/prevented with mouthwash

Patients should consult their dentist about whether they should use mouthwash, and what type may be appropriate for them. Certain oral health conditions may preclude use of mouthwashes. For example, overuse of antiseptic mouthwashes in patients with thrush may upset the normal balance of microorganisms in the mouth.

In most cases, mouthwashes are not recommended for use in children age 12 and younger. Children may swallow the mouthwash rather than spit it out, which can be harmful, especially if the mouthwash contains fluoride or alcohol.

There are instances where a dentist may suggest using mouthwash as part of a daily oral health routine, especially for patients with a high risk of tooth decay, periodontal (gum) disease and gum inflammation.

Mouthwash also may be recommended for patients who undergo oral surgery or treatment for periodontal disease (e.g., scaling, root planing). For example, patients may be urged to temporarily use mouthwash to prevent bacteria build-up on the teeth instead of brushing and flossing after such procedures. This gives the gums a chance to heal from irritation that may have occurred as part of these treatments.

In addition, mouthwash may be recommended for patients with the following conditions:

  • Dry mouth (xerostomia). A lack of saliva can increase the risk of tooth decay. Regular daily use of mouthwash can help keep the oral cavity clean and moist. Some rinses can encourage saliva production. Dry mouth may have a variety of causes, including certain medical conditions (e.g., Sjögren’s syndrome), treatments (e.g., radiation to the head or neck) or as a side effect of many different types of medications.
  • Inability to perform regular oral hygiene. Mouthwash can help maintain oral hygiene in people with physical impairments or medical conditions that prevent them from adequately brushing or flossing their teeth.
  • Braces, dental appliances. Mouthwashes may help clean areas of the mouth that are difficult to reach with brushingor flossing.
  • Canker sores. Painful open lesions inside the mouth. A dentist may recommend or prescribe certain types of mouthwash to cleanse the area and help reduce the pain and irritation of canker sores.
  • Immune system deficiency. People with immune system problems are at greater risk of oral infections and inflammation. Mouthwash can provide added protection against these problems.

Side effects and concerns with mouthwash

While mouthwashes are generally safe, some can cause side effects in patients who use them. Many over-the-counter mouthwashes contain high levels of alcohol that may range from 18 percent to 26 percent. This is a higher concentration of alcohol than is contained in some alcoholic beverages, such as beer or wine. Habitual use of these rinses can create a burning sensation in the cheeks, teeth and gums.

The alcohol in mouthwash may also contribute to dry mouth, which can increase a patient’s risk of tooth decay. Concerns have been raised about the risk of oral cancer due to alcohol contained in mouthwashes. However, there is currently no clear evidence that supports this.

Overuse of certain types of mouthwash (e.g., antiseptic mouthwashes) can upset the natural balance of bacteria in the mouth, and lead to bacterial overgrowth and conditions such as black hairy tongue.

Over-the-counter and prescription mouthwash can have a variety of side effects. Generally, these are more likely to occur with prescription strength rinses, but may also occur with over-the-counter mouthwash. Side effects include:

  • Staining of teeth and/or dental restorations
  • Taste disorder (dysgeusia)
  • Build-up of tartar on the teeth
  • Mouth and tongue irritation or numbness
  • Mucosal erosions
  • Retention of sodium
  • Swollen glands on the side of the face or neck
  • Sensitivity of tooth roots
  • Mouth ulcers

Patients should inform their dentist about any side effects they continue to experience as the result of using a mouthwash. A dentist may be able to recommend alternative treatments, based on a patient’s dental needs.

There have been some concerns that the oils in mouthwashes may damage dental restorations, such as braces, dentures or tooth fillings. However, studies have shown that these oral rinses are gentle on restorations and do not cause damage.

Swallowing too much mouthwash can have serious side effects that require emergency medical treatment. Most commercial mouthwash contains alcohol, which may be lethal when consumed in large quantities by children. Many rinses also contain sodium fluoride, which can lead to fluoride toxicity when taken excessively or swallowed. Symptoms of mouthwash overdose include:

  • Breathing problems, such as deep breathing (which may be rapid), rapid shallow breathing, slowed breathing or cessation of breathing.
  • Gastrointestinal problems, such as abdominal pain, diarrhea, and nausea and vomiting.
  • Nervous system problems, such as coma, dizziness or drowsiness.
  • Bluish skin (lips and fingernails).
  • Collapse.
  • Convulsions.
  • Decreased blood pressure (hypotension).
  • Decreased urination.
  • Excessive sweating.
  • Excessive thirst.
  • Listing from side to side or inability to walk normally.
  • Slurred speech.

Questions for your doctor about mouthwash

Preparing questions in advance can help patients have more meaningful discussions regarding their conditions. Patients may wish to ask their doctor the following mouthwash-related questions:

  1. Should I use a mouthwash? What are the pros and cons of using mouthwashes?
  2. What type of mouthwash should I use?
  3. What are the advantages and disadvantages of using a saltwater rinse?
  4. Do you recommend a prescription mouthwash to help treat my oral health condition?
  5. What side effects are associated with these mouthwashes?
  6. Are there alternative treatments for me that do not have these side effects?
  7. What side effects or changes in my condition should I bring to your attention? At what signs should I seek immediate medical attention?
  8. How much mouthwash would I have to accidentally swallow before my health would be at risk?
  9. Is it possible that using too much mouthwash could disrupt the natural balance of bacteria in my mouth?
  10. Should I use a mouthwash instead of brushing or flossing following my scaling and root planing procedure?
  11. How old should my child be before he/she can safely use mouthwash?
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