Scholars Journal of Dental Sciences (SJDS) ISSN 2394-496X (Online)

Sch. J. Dent. Sci., 2015; 2(2B):186-191 ISSN 2394-4951 (Print)

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Review Article
Mouthwashes and Their Use in Different Oral Conditions
Amit Parashar
Department of Periodontics, KLE VK Institute of Dental Sciences, Belgaum, Karnataka, India.

*Corresponding author
Dr Amit Parashar , MDS,FAGE,FPFA
Email: [email protected]

Abstract: Mouthwashes are medicated solutions used for gargling and rinsing the mouth. Many oral conditions require
the use of a mouthwash, which can vary from oral malodour to periodontal disease to treatment of secondary infections
like oral mucositis. A mouthwash may be recommended as an antimicrobial, a topical anti-inflammatory agent, a topical
analgesic or for caries prevention. Many different mouthwashes are available now a day. Selection of an appropriate
mouthwash depends on patient’s oral condition, disease risk and efficiency and safety of mouthwash. The main objective
of this review is to help the oral health care professionals to make the correct selection of mouthwash while dealing with
different conditions of oral cavity.
Keywords: Mouthwash, Oral condition.

INTRODUCTION effects should be taken into consideration before

Dental plaque is the main etiologic agent in the recommending a particular mouthwash.
development and progression of gingival and
periodontal diseases[1]. Principal means of preventing CHLORHEXIDINE
the development and progression of various periodontal Chlorhexidine is a symmetrical bisbiguanide
diseases is mainly through mechanical removal of synthetic antiseptic consisting of four chlorophenyl
plaque through regular tooth brushing[2]. But for rings and two biguanide groups connected by a
mentally or physically-handicapped patients who are hexamethylene bridge. The dicationic nature of
unable to brush their teeth themselves or other Chlorhexidine makes it extremely interactive with
individuals who lack the dexterity, skill or motivation anions, which is relevant to its efficacy, safety and side
for mechanical plaque removal, mouthwashes may aid effects. It is available in three forms, digluconate,
in controlling dental plaque and periodontal disease[3]. acetate and hydrochloride salts.
Mouthwashes should never be used as sole means of
oral hygiene but it should always be used in conjunction Chlorhexidine has broad spectrum
with mechanical plaque control measures. antimicrobial activity. It is effective against both Gram-
positive and Gram-negative bacteria including aerobes
The use of mouthwash to control plaque and anaerobes, yeasts, fungi and lipid enveloped
bacteria date back around 5000 years when the Chinese viruses[6-7]. It increases the permeability of cell
recommended the use of child’s urine for the control of membrane followed by coagulation of cellular
gingivitis[4]. Mouthwashes can be used for various macromolecules[8]. It has also shown to reduce the
preventative and therapeutic purposes viz. to treat oral adherence of Porphyromonas gingivalis to epithelial
infections, reduce inflammation, decrease halitosis and cells[9]. It does not interact with any microbial enzymes
to deliver fluoride locally for preventing caries. The use or receptors and hence does not lead to resistance from
of mouthwash is usually based on anecdotal evidence organisms[10].
rather than scientific evidence especially for over-the-
counter (OTC) products. This may often leads to the use Substantivity
of an inappropriate product and incorrect mode of The ability of drugs to adsorb onto or bind to
application, leading to a failed treatment outcome[5]. soft and hard tissues is known as Substantivity[11-13].
The patient's ability to perform good mechanical oral It ensures that the effect is sustained for a longer period
hygiene practices, dental status, gingiva and oral than just the time it is held in the mouth and thus it is
mucosa, other oral diseases (xerostomia), and the suitable for plaque inhibition[12, 14]. Substantivity is
efficacy of a mouthwash and its potential adverse influenced by concentration, pH, temperature and time
for which the solution is held in mouth[13].

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Safety Epstein et al. demonstrated that Benzydamine

Chlorhexidine is poorly absorbed in the significantly reduces the duration, incidence and
gastrointestinal tract and undergoes minimal metabolic severity of radiation-induced mucositis[24]. Therefore,
cleavage in the body. Therefore, it shows very low it is recommended for radiation-induced mucositis and
toxicity. Its oral LD50 is 1800mg/kg and i.v. LD50 is ulcerative lesions like recurrent apthous stomatitis.
22mg/kg. Animal studies have revealed that primary
route of Chlorhexidine excretion is through faeces. ESSENTIAL OILS
There is no evidence of carcinogenic substance Mouthwashes based on essential oils contain thymol,
formation and no teratogenic alterations have been eucalyptol and menthol in an alcohol solvent. They are
reported on its long term use[15,16]. broad spectrum antimicrobial agents which decrease
bacterial multiplication, aggregation and
Clinical usage pathogenicity[25]. They act by destruction of bacterial
Various preparations of Chlorhexidine cell and inhibition of bacterial enzymes. They also have
mouthwashes are available across the globe. The anti-inflammatory activity, prostaglandin inhibitory
Chlorhexidine mouthwash containing 0.2% activity and antioxidants activity. Sharma et al. stated
Chlorhexidine should be used 10ml volume per rinse that mouthwashes containing essential oils are effective
delivers 20mg of total dose of Chlorhexidine and those in reducing oral malodour and gingivitis[26].
preparations containing 0.12% Chlorhexidine to be used
15ml volume per rinse delivers 18mg They can be recommended as an adjunct to
Chlorhexidine[17]. Segreto et al stated that the effect of mechanical plaque control measures especially in
Chlorhexidine is dose dependent not just depending on patients with gingival inflammation even with regular
its concentration[18]. So, both of these formulations are tooth brushing and flossing. They are contraindicated in
effective. But the lower concentration of Chlorhexidine children because of risk of ingestion and in patients
minimizes its side effects while maintaining its benefits. suffering from dry mouth and oral mucosal disease
To ensure good compliance and efficacy, the accepted because of ethanol based irritation and dryness.
length of time for rinsing is 30 seconds[19]. Patients
should be advised to rinse just before going to bed and CETYLPYRIDINIUM CHLORIDE AND SODIUM
after breakfast, with at least 30 minutes interval after BENZOATE
tooth brushing. Cetylpyridinium chloride is a quaternary ammonium
compound with moderate plaque inhibitory
Side effects: Flotra et al reported various local side activity[27,28]. It acts by binding to bacterial cell
effects of Chlorhexidine mouthwash[20]. These local membrane because of its cationic nature thus causing
side effects are: disruption of cell membrane and leakage of intracellular
1. Brown discoloration of the teeth, restorative components. The reason behind their moderate plaque
materials and the tongue. inhibitory activity as compare to Chlorhexidine may be
2. Alter taste sensation especially for salt taste. their rapid desorption from the oral mucosa and may
3. Mucosal erosion with use of high also be related to their mono-cationic nature[12, 29,
concentration of Chlorhexidine rinse. 30]. The single cationic group binds to mucosa
4. Parotid swelling in rare cases. providing mucosal retention but leaving few unattached
5. Increased rate of supragingival calculus sites for its antibacterial action.
formation.
Sodium benzoate disperses carbohydrate, fat,
Staining: Various mechanisms for Chlorhexidine protein thereby weakens plaque attachment which can
staining were proposed[21-23]. They are: then be easily removed by toothbrushing.
1. Degradation of the Chlorhexidine to release
parachloraniline. TRICLOSAN
2. Non-enzymatic browning reactions (Maillard Triclosan (2, 4, 4'-trichloro-2'-hydroxydiphenyl
reactions). ether) is a non-ionic antiseptic compound shows anti-
3. Protein denaturation by Chlorhexidine with inflammatory property and has been used in many
metal sulphide formation. toothpastes and mouthwashes[31]. Various studies have
4. Precipitation of anionic dietary chromogens by shown that Triclosan reduces the inflammatory reaction
cationic antiseptics. on the gingiva by sodium lauryl sulphate and reduce the
severity and healing period of recurrent apthous
BENZYDAMINE HYDROCHLORIDE ulcers[32,33]. Gaffar et al stated Triclosan reduces the
Benzydamine hydrochloride is known for its levels of inflammatory mediators (prostaglandins and
analgesic, anaesthetic, anti-inflammatory and leukotrienes) by inhibiting both cyclo-oxygenase and
antimicrobial properties. The exact mechanism of lipoxygenase pathways[34]. Triclosan also increases the
action is not fully understood but it probably affects the binding ability of mouthwashes to the oral mucosa and
prostaglandin and thromboxane production and thus being available for a longer period of time.
decrease pro-inflammatory cytokine production.

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OXYGENATING AGENTS and viruses by causing protein denaturation and

Oxygenating agents such as Hydrogen peroxide, dissolution of lipids. Various studies have been done to
Sodium peroxyborate and peroxycarbonate act by determine the relationship between use of alcohol
liberating nascent oxygen to loosen debris, remove containing mouthwashes and the risk of developing oro-
stains and kill anaerobic micro-organisms. They are pharyngeal cancer.
bleaching agent having strong oxidising properties.
They are also broad spectrum antimicrobial agents[35]. McCullogh and Farah stated that there may be
Oxygenating agents containing mouthwashes are a direct association between the alcohol content of
recommended for acute ulcerative conditions, to relieve mouthwashes and the risk of development of oral
soreness caused by dentures, orthodontic appliances and cancer[40]. The risk of developing oro-pharyngeal
for stain removal[36]. cancer is nine times in smokers, five times in those who
also drink alcohol, and five times in those who neither
POVIDONE-IODINE CONTAINING smoke nor drink alcohol. While Cole et al)
MOUTHWASHES demonstrated no correlationship between the use of
Povidone-iodine is a broad spectrum antimicrobial alcohol containing mouthwashes and the risk of
having its affinity against bacteria, virus, fungi and development of oro-pharyngeal cancer[41]. Lachenmeir
protozoa. It is an iodophore in which iodine is loosely et al demonstrated acetaldehyde which is a toxic
bound to Povidone thereby delivering free iodine to metabolite of ethanol, is formed from alcohol
bacterial cell membrane. It reduces plaque formation containing mouthwashes and their concentration in
and decreases the severity of gingivitis and radiation saliva is similar to those found after alcohol
mucositis. It is contraindicated in individuals having consumption[42].
sensitivity to iodine and pre-existing thyroid
disorders[37]. Mouthwashes containing significant amount of
alcohol have number of disadvantages also. Firstly, they
ANTIBACTERIAL PEROXIDASE are not accidently swallowed by young children[43-44].
MOUTHWASHES Secondly, the use of alcohol containing mouthwashes
They contain enzymes like lysozyme, lactoferrin, may increase the alcohol content of exhaled air and
lactoperoxidase and glucose oxidase which act against could change the readings of the police breath test[45].
bacterial peroxidise. They restore antimicrobial activity Thirdly, alcohol containing mouthwashes have also
of saliva hence, useful in cases of dry mouth, gingival shown to reduce the hardness of composite and hybrid
inflammation and oral malodour[38]. Its long term use resin restorations and may also alter the colour of
might pose a risk of dental erosion because of its low composite restorations[46-47]. The use of alcohol
pH. containing mouthwashes should be restricted to short
term under supervision until long term studies are
FLUORIDE CONTAINING MOUTHWASHES available. The use of alcohol containing mouthwashes
These mouthwashes contain fluoride in various forms should be discouraged for long term use.
as either sodium fluoride (NaF) or acidulated phosphate
fluoride (APF). They promote remineralisation of CLINICAL IMPLICATIONS
enamel with fluorapatitie and fluor-hydroxyapatite, Mouthwashes can be used in various clinical
making enamel resistant to acid attack. Hence, they are conditions.
useful in patients with high risk of dental caries, They can be used as an adjunct to mechanical oral
patients having xerostomia after undergoing radiation hygiene procedure in conditions like:
therapy and those undergoing orthodontic therapy[39].  After subgingival scaling or root planing
They are contra-indicated in children less than six years  In patients having inadequate oral hygiene
of age because of risk of fluoride ingestion.  Post-scaling cervical hypersensitivity

SODIUM BICARBONATE They can be used to replace normal toothbrushing

It increases the salivary pH and suppresses the which is not possible in various conditions like:
growth of aciduric bacteria. Therefore, it is  After periodontal surgical procedures
recommended in patients with xerostomia and erosion.  After intermaxillary fixation
 During acute oral or gingival infection
ALCOHOL CONTENT OF MOUTHWASHES  For mentally or physically handicapped
Ethanol is used as a preservative and solvent in a patients
concentration range of 5 – 27 % in various
commercially available mouthwashes. It has
Mouthwashes for Different Oral Conditions (Table 1)
antimicrobial activity against various bacteria, fungi

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Table 1: Mouthwashes In Different Clinical Conditions [19].

Clinical Conditions Treatment Active Ingredients
Covering agent Polyvinylpyrrolidone
Anti-inflammatory Benzydamine hydrochloride
Antimicrobial Chlorhexidine 0.12%
Oral mucositis / oral sores Generic CHX 0.2%
(alcohol free) Povidone Iodine
Analgesic / Anti-inflammatory / Benzydamine hydrochloride / Chlorhexidine
Antimicrobial
Antimicrobial / Analgesic Benzocaine / Chlorhexidine
Antimicrobial without flavouring Generic CHX 0.2%
Chlorhexidine 0.12%
Halitosis Chlorhexidine 0.2%
Antimicrobial with flavouring Chlorhexidine 0.2%
Cetylpyridinium chloride, Triclosan with oil
Essential oils
Saliva substitute with antimicrobial Betaine / Olive oil / Xylitol / Fluoride
properties Various enzymes
Xerostomia Cetylpyridinium chloride, Triclosan with oil
Tooth protection - Fluoride Sodium fluoride 0.05%
Periodontal (gum) Antimicrobial with / without Chlorhexidine 0.2%
diseases flavouring Chlorhexidine 0.12%
Benzydamine hydrochloride

Oral mucositis: Xerostomia

Oral mucositis is a complication which can be Xerostomia / Dry mouth is not a disease but a
seen in patients after head and neck radiation therapy, sign of an underlying disease or side effect of
chemotherapy and in bone marrow transplant cases[48- medications and radiation therapy for head and neck
50]. Although the mechanism for development of oral cancer treatment. Various changes occur in saliva after
mucositis is much complex, but it may occur from head and neck radiation therapy like decreased salivary
direct effect of cytotoxic drugs on oral epithelial cells in flow, reduced pH and thick and pasty saliva hence,
cancer patients[51]. Maintenance of oral hygiene and excellent plaque control and oral hygiene measures are
plaque control measures are important factors in the essential[54-55]. Xerostomia is also a common sign in
management of oral mucositis[50]. 0.12% or 0.2% older age individuals. Various symptomatic treatment
Chlorhexidine mouthwashes can be used for this measures are available like salivary stimulation,
purpose but combination mouthwashes containing anti- avoidance of dry sticky food, saliva replacement
inflammatory, analgesic, antimicrobial properties and therapy and maintenance of good oral hygiene[55].
covering agents are much more useful. Various preparations of mouthwashes containing
Chlorhexidine, Cetylpyridinium chloride, Triclosan,
Halitosis: fluoride in non alcohol base preparations are
Breath malodour is a common complaint helpful[50,55].
among the general population which has a significant
socioeconomic impact. Scully and Greenman stated that Periodontal diseases
in 85% of cases, an oral cause can be found while Gingival and Periodontal diseases are one of
extraoral causes (ENT pathologies, systemic diseases, the most common diseases in the world[56,57].
metabolic or hormonal changes, hepatic or renal Mechanical plaque control measures (toothbrushing and
insufficiency, pulmonary diseases and GIT pathologies) flossing) are of utmost importance in prevention of
can be found in rest 15% of the cases[52]. Intraoral periodontal diseases. Chemical plaque control measures
causes mainly include tongue and tongue coating, like use of mouthwash preparations containing 0.12%
periodontal diseases, deep carious lesions and dry or 0.2% Chlorhexidine, Benzydamine chloride may also
mouth. A proper diagnosis is therefore essential and the aid in prevention of periodontal diseases[58].
treatment of oral malodour should preferably be cause
related. Use of mouthwashes is a common practice in CONCLUSION
patients with oral malodour. The active ingredients in Mouthwashes can be used for various conditions,
these mouthwashes are usually antimicrobial depending on the lesions present in the oral cavity. So,
compounds like Chlorhexidine, Cetylpyridinium the oral health practitioners should be aware of various
chloride, chlorine dioxide, hydrogen peroxide, essential etiologic factors and predisposing conditions affecting a
oils and Triclosan[53]. particular oral lesion. The use of mouthwash should be
limited to a smaller period of time depending on the

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