Oral Health Topics
- There are two main types of mouthwash: cosmetic and therapeutic.
- Therapeutic mouthwashes are available both over-the-counter and by prescription, depending on the formulation.
- There are therapeutic mouthwashes that help reduce or control plaque, gingivitis, bad breath, and tooth decay.
- Children younger than the age of 6 should not use mouthwash, unless directed by a dentist, because they may swallow large amounts of the liquid inadvertently.
- A company earns the ADA Seal of Acceptance by providing scientific evidence that demonstrates the safety and efficacy of its product, which the ADA Council on Scientific Affairs carefully evaluates according to objective requirements.
While not a replacement for daily brushing and flossing, use of mouthwash (also called mouthrinse) may be a helpful addition to the daily oral hygiene routine for some people. Like interdental cleaners, mouthwash offers the benefit of reaching areas not easily accessed by a toothbrush. The question of whether to rinse before or after brushing may depend on personal preference; however, to maximize benefit from the oral care products used, manufacturers may recommend a specific order for their use, depending on ingredients. For example, some dentifrice ingredients (like calcium hydroxide or aluminum hydroxide) can form a complex with fluoride ions and reduce a mouthwash’s effectiveness. Therefore, vigorous rinsing with water may be recommended after brushing and before rinsing if these ingredients are present.1
Mouthwash is not recommended for children younger than 6 years of age. Swallowing reflexes may not be well developed in children this young, and they may swallow large amounts of the mouthwash, which can trigger adverse events—like nausea, vomiting and intoxication (due to the alcohol content in some rinses)1, 2 Check the product label for specific precautions and age recommendations.
Types of Mouthwash
Broadly speaking, there are two types of mouthwash: cosmetic and therapeutic. Cosmetic mouthwash may temporarily control bad breath and leave behind a pleasant taste, but have no chemical or biological application beyond their temporary benefit. For example, if a product doesn’t kill bacteria associated with bad breath, then its benefit is considered to be solely cosmetic. Therapeutic mouthwash, by contrast, has active ingredients intended to help control or reduce conditions like bad breath, gingivitis, plaque, and tooth decay.
Active ingredients that may be used in therapeutic mouthwash include:
- Cetylpyridinium chloride;
- Essential oils;
Cetylpyridinium chloride may be added to reduce bad breath.3
Both chlorhexidine and essential oils can be used to help control plaque and gingivitis.4, 5
Fluoride is a proven agent in helping to prevent decay.6
Peroxide is present in several whitening mouthwashes. Therapeutic mouthwash is available both over-the-counter and by prescription, depending on the formulation. For example, mouthwashes containing essential oils are available in stores, while those containing chlorhexidine are available only by prescription.
Some of the conditions mouthwashes are designed to address are discussed below:
Volatile sulphur compounds (VSCs) are the major contributing factor to bad breath or halitosis. They arise from a variety of sources (e.g., breakdown of food, dental plaque and bacteria associated with oral disease).3 Cosmetic mouthwashes can temporarily mask bad breath and provide a pleasing flavor, but do not attack bacteria or VSCs. Mouthwashes with therapeutic agents like antimicrobials, however, may be effective for more long-term control of halitosis. Antimicrobials in mouthwash formulations include chlorhexidine, chlorine dioxide, cetylpyridinium chloride, and essential oils (eucalyptol, menthol, thymol and methyl salicylate). Other agents used in mouthwashes to inhibit odor-causing compounds include zinc salts, ketone, terpene, and ionone.1
Although the combination of chlorhexidine, cetylpyridinium chloride plus zinc lactate has been shown to significantly reduce bad breath, it also may significantly contribute to tooth staining.3, 7
Plaque and Gingivitis
When used in mouthwashes, antimicrobial ingredients like cetylpyridinium, chlorhexidine, and essential oils have been shown to reduce plaque and gingivitis when combined with daily brushing and flossing.5, 8 While some studies have found that chlorhexidine achieved better plaque control than essential oils no difference was observed with respect to gingivitis control. Cetylpyridinium and chlorhexidine may cause brown staining of teeth, tongue, and/or restorations.4
Fluoride ions, which promote remineralization, may be provided by certain mouthwashes. A Cochrane systematic review found that regular use of fluoride mouthwash reduced tooth decay in children, regardless of exposure to other sources of fluoride (i.e. fluoridated water or toothpaste containing fluoride).9
Topical Pain Relief
Mouthwashes that offer pain relief most commonly contain topical local anesthetics such as lidocaine, benzocaine/butamin/tetracaine hydrochloride, dyclonine hydrochloride, or phenol.1 In addition, sodium hyaluronate, polyvinylpyrrolidine and glycyrrhetinic acid may act as a barrier to relieve pain secondary to oral lesions, like aphthous ulcers.1
Mouthwash may contribute to extrinsic stain reduction when either carbamide peroxide or hydrogen peroxide are among the active ingredients. Products that rely on carbamide peroxide typically contain 10 percent carbamide peroxide and may be dispensed by dentists to their patients for use at home.10 Mouthwashes that claim to whiten teeth also may contain 1.5 to 2 percent hydrogen peroxide.1 One study found that 12 weeks use of mouthwash containing hydrogen peroxide in this concentration range achieved similar color alteration as that achieved by 2 weeks use of 10 percent carbamide peroxide whitening gel.11
Xerostomia is a reduction in the amount of saliva bathing the oral mucous membranes. Since the lack of saliva increases the risk of caries, a fluoride-containing mouthwash may be helpful to those managing this problem. However, since alcohol can be drying, it may be prudent to recommend an alcohol-free mouthwash.12 Mouthwashes containing enzymes, cellulose derivatives and/or animal mucins can mimic the composition and feel of saliva and may provide additional relief from symptoms associated with xerostomia.1
Oral Cancer Concern
Alcohol consumption as well as alcohol and tobacco use are known risk factors for head and neck cancers.13 Resulting from this has been the question of whether use of alcohol-containing mouthwash increases risk of these cancers.14 A recent systematic review and meta-analysis failed to find an association between mouthwash use and oral cancer, use of alcohol-containing mouthwash and oral cancer, or mouthwash dose response and oral cancer.15
- Use prescription mouthwashes as directed (i.e., dose, frequency, time in mouth). If a dose is missed, use the rinse as soon as possible; doubling the dose will have no therapeutic effect.1
- With over-the-counter products, look for mouthwashes that have the ADA Seal of Acceptance. The Seal shows that a product is safe and effective for the purpose claimed.
- Using a mouthwash does not take the place of optimal brushing and flossing. Mouthwashes may offer additional benefit in terms of reducing the risk of bad breath, cavities, or gum disease; or for relief of dry mouth or pain from oral sores.
ADA Seal of Acceptance
Look for the ADA Seal—your assurance that the product has been objectively evaluated for safety and efficacy by an independent body of scientific experts, the ADA Council on Scientific Affairs. A company earns the ADA Seal for mouthwash by producing scientific evidence demonstrating the safety and efficacy of its product, which is evaluated according to the objective requirements related to their claims.
To qualify for the Seal of Acceptance, the company must provide evidence to support the claims associated with their products. For example:
- Manufacturers of mouthwashes that contain fluoride for reducing decay must either demonstrate effectiveness in clinical studies, or show that the formula is the same as a similar product that has been clinically proven.
- Manufacturers that claim their mouthwash controls gingivitis must substantiate this assertion by demonstrating a statistically significant reduction in gingival inflammation.
- Manufacturers that claim their mouthwash controls bad breath must provide data demonstrating that it reduces oral malodor over a meaningful period of time.
For all types of mouthwash, manufacturers must demonstrate the product is safe and does not damage oral tissues or cause any internal problems.
- Mariotti AJ, Burrell, K.H. Mouthrinses and Dentifrices. 5th ed. Chicago: American Dental Association and Physician's Desk Reference, Inc.; 2009.
- Weyant RJ, Tracy SL, Anselmo TT, et al. Topical fluoride for caries prevention: executive summary of the updated clinical recommendations and supporting systematic review. J Am Dent Assoc 2013;144(11):1279-91.
- Blom T, Slot DE, Quirynen M, Van der Weijden GA. The effect of mouthrinses on oral malodor: a systematic review. Int J Dent Hyg 2012;10(3):209-22.
- Van der Weijden FA, Van der Sluijs E, Ciancio SG, Slot DE. Can Chemical Mouthwash Agents Achieve Plaque/Gingivitis Control? Dent Clin North Am 2015;59(4):799-829.
- Araujo MW, Charles CA, Weinstein RB, et al. Meta-analysis of the effect of an essential oil-containing mouthrinse on gingivitis and plaque. J Am Dent Assoc 2015;146(8):610-22.
- Fejerskov O, Thylstrup A, Larsen MJ. Rational use of fluorides in caries prevention. A concept based on possible cariostatic mechanisms. Acta Odontol Scand 1981;39(4):241-9.
- Fedorowicz Z, Aljufairi H, Nasser M, Outhouse TL, Pedrazzi V. Mouthrinses for the treatment of halitosis. Cochrane Database Syst Rev 2008(4):CD006701.
- Sharma N, Charles CH, Lynch MC, et al. Adjunctive benefit of an essential oil-containing mouthrinse in reducing plaque and gingivitis in patients who brush and floss regularly: a six-month study. J Am Dent Assoc 2004;135(4):496-504
- Marinho VC, Higgins JP, Logan S, Sheiham A. Topical fluoride (toothpastes, mouthrinses, gels or varnishes) for preventing dental caries in children and adolescents. Cochrane Database Syst Rev 2003(4):CD002782.
- Hasson H, Ismail AI, Neiva G. Home-based chemically-induced whitening of teeth in adults. Cochrane Database Syst Rev 2006(4):CD006202.
- Torres CR, Perote LC, Gutierrez NC, Pucci CR, Borges AB. Efficacy of mouth rinses and toothpaste on tooth whitening. Oper Dent 2013;38(1):57-62.
- Kerr AR, Corby PM, Kalliontzi K, McGuire JA, Charles CA. Comparison of two mouthrinses in relation to salivary flow and perceived dryness. Oral Surg Oral Med Oral Pathol Oral Radiol 2015;119(1):59-64.
- Chi AC, Day TA, Neville BW. Oral cavity and oropharyngeal squamous cell carcinoma - an update. CA Cancer J Clin 2015;65(5):401-21.
- Weaver A, Fleming SM, Smith DB. Mouthwash and oral cancer: carcinogen or coincidence? J Oral Surg 1979;37(4):250-3.
- Mariotti AJ, Burrell, K.H. Mouthrinses and Dentifrices. Third ed. Chicago: American Dental Association; 2003.
Prepared by: Center for Scientific Information, ADA Science Institute
Last Updated: March 31, 2017
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