MAXIMIZE the Benefits of MOUTHRINSE
Reducing the oral cavity's bacterial load is essential to
maintaining health. Here's how antimicrobial
mouthrinses can help. By Kathleen O. Hodges, RDH, MS
Antimicrobial mouthrinses can be an effective
adjunct to self–care routines for patients
experiencing a number of oral health problems, including gingivitis,
caries, and enamel erosion. There is no shortage in
selection when considering the best mouthrinse for individual
patient needs. Antimicrobial rinses typically contain chlorhexidine
gluconate, essential oils, cetylpyridium chloride, or stannous
fluoride. By understanding the mechanism of action of
these antimicrobials, dental hygienists will be well prepared to
provide effective recommendations for their patients.
Chlorhexidine gluconate (CHX) mouthrinse has great substantivity,
meaning it is retained in the oral cavity for extended
periods of time and provides a slow and sustained release of
the active ingredient. As a result, CHX mouthrinse is known
the "gold standard" of mouthrinses.1–3 Research conducted
in the 1980s found that CHX was the most effective agent
against supragingival plaque and gingivitis, with reported
plaque reductions of 50% to 55% and gingivitis reductions of
45%.1–3 In the United States, CHX commercial rinse preparations
are available by prescription only in a 0.12% concentration
with 11.6% alcohol and a pH of 5.5 to 6.0. It can also be
compounded at a pharmacy where inactive ingredients may
be adjusted. An alcohol-free version is also available that has
been approved by the federal Food and Drug Administration
(FDA) as therapeutically equivalent to traditional CHX rinses.4
A lipophilic broad-spectrum antimicrobial agent, CHX disrupts
cells osmotic equilibrium, which leads to cell death. CHX's
pronounced substantivity results from its absorption into oral
mucosa, hydroxyapatite, and salivary glycoprotein. Approximately
30% is retained in the oral cavity after rinsing, and it
remains effective for 8 hours to 12 hours.5 FDA approval of
CHX mouthrinse is limited to gingivitis, however, it is also used
in the treatment of oral candidiasis, aphthous stomatitis, linear
gingival erythema, necrotizing ulcerative periodontitis, and
HIV/AIDS care.1–3 In addition, CHX helps prevent respiratory
infections, reduces bacteria in the edentulous, and supports
oral health in those undergoing chemotherapy.1–3 Evidence has
not shown that CHX mouthrinse is effective in the treatment of
periodontitis, however, the rinses's efficacy in reducing gingivitis
may enhance prevention of chronic periodontitis.
Patients should not rinse, eat, or brush immediately after
using a CHX mouthrinse to prevent the loss of substantivity.1–3
Patients should be advised of the rinse's side effects, including
bitter taste, staining, increased calculus formation, and altered
taste sensation. Modern CHX mouthrinses have improved
taste through the addition of flavoring, and the calculus formation
and staining can be controlled by effective self-care
and professional treatment. Best used after meals to prevent
interference with taste, patients should also wait at
least 30 minutes after toothbrushing to prevent interaction
between sodium lauryl
sulfate and other elements
Patients' insurance coverage for prescription medication should be considered when recommending CHX because
ease of purchase and cost effectiveness both
influence compliance. Over–the–counter (OTC)
products may be a better choice when access
and cost are factors.
Short–term CHX mouthrinse is also used to
treat rampant caries and is recommended for
those at high caries risk. Suggested use is typically
to rinse with 10 ml daily for 1 week each
month.6 However, a 2011 summary of evidence–
based clinical recommendations concluded
that CHX rinse is not effective in coronal
or root caries prevention7. The effects of CHX,
essential oils, and fluoride on three root caries
pathogens were investigated in an artificial
mouth model. CHX created the most significant
inhibition results, as well as the best
inhibitory action against Streptococcus mutans,
Lactobacilli, and Candida albicans when compared
to sodium fluoride.8
Phenolic compounds, such as essential oils,
reduce plaque and gingivitis. Essential oil
mouthrinses usually contain a combination of
thymol, eucalyptol, menthol, and menthyl salicyclate.
Essential oils decrease plaque formation
and bacterial adhesion. Side effects
include burning, objectionable taste, and tooth
staining. Chemical irritation and desquamative
oral mucosa can occur with prolonged rinsing.
The mouthrinse usually contains 21.6% to
26.95% alcohol at a pH of 5.0; nonalcohol
compounds are available, however, they are
not antiseptics. The antiseptic is contraindicated for alcoholics or recovering alcoholics (as are all rinses with alcohol; it is recommended that patients check with their abuse counselor9) and patients with oral cancer. While alcohol
use is a risk factor for oral cancer, evidence has
not demonstrated an increased risk of oral and
pharyngeal cancers with the use of alcoholcontaining
mouthrinses. Essential oil mouthrinses are often used when CHX mouth rinses
are contraindicated due to taste, cost, esthetics,
ease of purchase, or mode of application.
Cetylpyridium chloride (CPC) is a quarternary
ammonia compound used at 0.05% or 0.07%
with or without other ingredients, such as
domiphen bromide. CPC's mechanism of
action is similar to CHX's in that positive ions
bind to the negatively charged cell wall—
affecting permeability and loss of cellular contents.
Long–term clinical results generally show
that CPC is less effective than CHX and essential
oils due to its lack of substantivity and rapid
clearance from the oral cavity.10 Burning, soft
tissue irritation, and slight staining have been
cited as side effects. Alcohol content varies from
0% to 18% and the pH is 5.5 to 6.5.
Stannous fluoride rinses are another alternative.
Pizzo et al11 evaluated the use of amine
fluoride/stannous fluoride (ASF) and CHX on
plaque regrowth and found that CHX was
more effective, however, ASF had fewer side
effects. The authors suggest that ASF might
be a substitute for CHX mouthrinse when side
effects are of concern. Stannous fluoride is also
a proven caries prevention agent.
Delmopinol hydrochloride is not an antimicrobial
but rather it inhibits bacterial adhesion to
the tooth and mucosa, and cohesion between
cells. As a result, the rinse improves the efficacy
of patient removal of plaque biofilms, in addition
to disrupting cariogenic and periodontal
pathogens. The rinse contains 1.5% alcohol.
Delmopinol mouthrinse is recommended as a
precursor to CHX, as well as an appropriate
addition to a self–care regimen after treatment
with a CHX rinse is complete.12
Gunsolley10 evaluated the efficacy of antiplaque,
antigingivitis mouthrinses and the clinical relevance
of the evidence. Three systematic reviews
and one meta–analysis were found. Strong evidence
supported the efficacy of CHX and essential
oils as antiplaque, antigingivitis mouthrinses
while the evidence for CPC was weaker due to
few clinical trials testing the same formulations.
One meta–analysis of delmopinol concluded it
was an effective antiplaque, antigingivitis agent.
Gunsolley et al concluded that the clinical
effects of CHX and essential oil mouthrinses met
or exceeded reductions over time when compared
to placebo groups.
Studies have evaluated the effects of mouthrinses on other oral problems. In a systematic
review on breath malodor, evidence showed
that CHX was effective, as well as a CPC/zinc
combination.13 A CHX/ CPC/ zinc lactate
mouthrinse was effective in reducing breath
malodor and both CHX and CPC were recognized
as effective, although more randomized
control trials containing additional subjects
with longer intervals and follow–up periods
are needed.13 ASF mouthrinse was compared
to CHX rinse for malodor in a single use in
vivo. ASF was found to be more effective.14
Eick et al15 studied the in vitro effect of CHX,
essentials oils, and ASF against periodontopathic
microorganisms and concluded all
were active against the microbes, and that
long–term use would not result in emergent
antimicrobial resistance. Featherstone et al16
tested an intervention of a fluoride dentifrice
(1,100 ppm NaF), 0.12% CHX rinse, and
0.5% NaF rinse and concluded that targeted
antibacterial and fluoride therapy based on
salivary microbial and fluoride levels altered
caries risk factors for the better. A systematic
review on Staphylococcus aureus in lower respiratory
tract infections and cross infections
to other patients concluded that CHX in
mouthrinses, gels, and sprays had some
effect, but more randomized controlled trials
were needed.17 In a study on Streptococci and
complete dentures, CHX showed the most
antimicrobial action when compared to CPC
and a nonantimicrobial rinse.18
Antimicrobial mouthrinses are effective adjuncts
to self–care regimens. The American Dental
Association Seal of Acceptance provides added
credibility to product claims, but is only available
for OTC products. Oral health professionals
need to target their recommendations to
patient conditions and needs. Patients need to
understand that antimicrobial mouthrinses are
an addition to an appropriate self–care regimen
and regular professional care. Antimicrobial
mouthrinses can be especially effective among
patients with poor self–care and those who
need assistance reducing the bacterial load,
which is key to both improving oral and systemic
- Banting D, Bosma M, Bollmer B. Clinical effectiveness of a 0.12% chlorhexidine mouthrinse over two years. J Dent Res. 1989;68:1716—1718
- Gjermo P. Chlorhexidene and related compounds. J Dent Res.1989;68:102.
- Grossman E, Reiter G, Sturzenberger OP, De La Rosa M, Dickinson TD, Ferretti GA. Six–month study of the effects of a chlorhexidine mouthrinse on gingivitis in adults. Periodontal Res.. 1986;21:33—43.
- Dimensions of Dental Hygiene. Sunstar Butler Launches first and only FDA approved alcohol–free CHX rinse. Available at: www.dimensionsofdentalhygiene.com/Print.aspx?id=757. Accessed October 20, 2012.
- Bonesvoll P, Lökken P, Rölla G, Paus PN. Retention of chlorhexidine in the human oral cavity after mouth rinses. Arch Oral Biol..
- Jenson L, Budenz AW, Featherstone JDB, Ramos–Gomez, FJ, Spolsky, VW, Young DA. Clinical protocols for caries management by risk assessment.J Calif Dent Assoc.2007;35:714—723.
- Rethman MP, Beltran–Acquilar ED, Billings RJ, et al. Nonfluoride caries–preventive agents: executive summary of evidence–based clinical recommendations. J Am Dent Assoc. 2011;142:1065—1071.
- Zheng CY, Wang ZH. Effects of chlorhexidine, listerine and fluoride listerine mouthrinses on four putative root–caries pathogens in the biofilm. Chin J Dent Res. 2011;14:135—140.
- DePaola LG, Spolarich AE. Safety and efficacy of antimicrobial mouthrinses in clinical practice. J Dent Hyg. 2007;81(Suppl):13—25.
- Gunsolley JC. Clinical efficacy of antimicrobial mouthrinses. J Dent. 2010;38(Suppl):S6–10.
- Pizzo G, Guiglia R, La Cara M, Giuliana G, D'Angelo M. The effects of an amine fluoride/stannous fluoride and an antimicrobial host protein mouthrinse on supragingival plaque regrowth. J Periodontol. 2010 Aug 20. [Epub ahead of print].
- Bruhn A. Biofilm barrier. Dimensions of Dental Hygiene. 2011;9(9):19—22.
- Feng X, Chen X, Cheng R, Sun L, Zhang Y, He T. Breath malodor reduction with use of a stannous–containing sodium fluoride dentifrice: a meta–analysis of four randomized and controlled clinical trials. Am J Dent. 2010;23:27B—31B.
- Wilhelm D, Gysen K, Himmelmann A, Krause C, Wilhelm KP. Short–term effect of a new mouthrinse formulation on oral malodour after single use in vivo: a comparative, randomized, single–blind, parallel–group clinical study. J Breath Res. 2010;3:036002.
- Eick S, Goltz S, Nietzsche S, Jentsch H, Pfister W. Efficacy of chlorhexidine digluconate–containing formulations and other mouthrinses against periodontopathogenic microorganisms. Quintessence Int. 2011;42:687—700.
- Featherstone JD, White JM, Hoover CI, et al. A randomized clinical trial of anticaries therapies targeted according to risk assessment (caries management by risk assessment). Caries Res. 2012;46:118—129.
- Lam OL, McGrath C, Bandara HM, Li LS, Samaranayake LP. Oral health promotion interventions on oral reservoirs of staphylococcus aureus: a systematic review. Oral Dis. 2012;18:244—254.
- André RF, Andrade IM, Silva–Lovato CH, Paranhos Hde F, Pimenta FC, Ito IY. Prevalence of mutans streptococci isolated from complete dentures and their susceptibility to mouthrinses. Braz Dent J. 2011;22:62—67.
From Dimensions of Dental Hygiene. November 2012; 10(11): 23–24.