The Role of Antimicrobial Mouth Rinses in Infection Prevention

Mary Govoni, CDA, RDA, RDH, MBA 

The Role of Antimicrobial 

Mouth Rinses in Infection 

Prevention 

Educational Objectives 

Upon completion of reading these article, the clinician will be able to: 

1. Differentiate between the various types of mouth rinses marketed as “antimicrobial” or 

“therapeutic” 

2. Identify the active ingredients in antimicrobial mouth rinses and their mechanism of 

action 

3. Determine whether utilizing a pre-procedural mouth rinse for all or some patients is 

valuable to patients and dental team members.

Introduction 

Mouth rinses have been studied extensively for their potential benefits to patients for disease 

prevention, as well as the benefit to dental health professionals for their potential to reduce 

exposure to oral microorganisms during dental procedures. 

The studies have focused on three key areas. The first is the role of antimicrobial rinses in 

treatment and prevention of periodontal disease by killing or inhibiting the growth of bacteria that 

cause gingivitis and periodontitis. Second is their role in the prevention of bacteremia, by 

reducing the number of microorganisms in the oral cavity which might be introduced into the 

bloodstream during dental procedures. The third is infection prevention and safety for the dental 

team and patients by reducing the number of microorganisms in saliva that may become 

airborne during dental procedures. 

In addition, the types of antimicrobial agents in the mouthrinses have also been studied and 

compared for their effectiveness in reducing microorganisms, as well as potential side effects of 

using the rinses. This course will examine the uses of antimicrobial mouth rinses prior to dental 

procedures and the potential benefits to both patients and dental health professionals. In order 

to understand the value of antimicrobial mouthrinses, it is important to understand the types of 

rinses available and their mechanism of action. 

Types of Mouth Rinses 

Mouth rinses are available in over-the-counter (OTC) formulations as well as in prescription-only 

formulations. Oral rinses can be categorized by their ingredients or mode of action. For 

example, many OTC mouth rinses are meant to be cosmetic – to freshen breath, or whiten 

teeth. They contain active ingredients, such as flavoring oils and/or hydrogen peroxide, which is 

a whitening agent. Other OTC rinses are categorized as therapeutic, meaning that they contain 

an ingredient that is meant to protect against disease, such as caries or gingivitis. These rinses 

may contain fluoride or other ingredients, such as chlorhexadine (CHX) or cetylpyridinium 

chloride (CPC), or essential oils, which we will discuss later. Many of the OTC oral rinses are a 

combination of both cosmetic and therapeutic characteristics, while the prescription rinses 

typically contain one key active ingredient, such as fluoride or CHX. Table 1 compares the 

characteristics of cosmetic and therapeutic oral rinses. 

Therapeutic oral rinses are regulated by the Food and Drug Administration (FDA), whether they 

are OTC or prescription-only. In order to make a claim that a product has therapeutic value, it 

must go through rigorous testing by the FDA to prove its safety and efficacy. The FDA has taken 

action against some manufacturers of mouth rinses for unsubstantiated claims of effectiveness 

in preventing plaque formation and antimicrobial activity. These rinses are approved as 

antimicrobial “drugs”, since they act chemically to kill bacteria. In addition to FDA approval, OTC 

therapeutic oral rinses may also receive the Seal of Acceptance from the American Dental 

Association (ADA), which is a voluntary acceptance or approval for products that have met 

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certain safety and efficacy requirements. Additional information regarding the FDA approval 

process is available at: http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ 

DeviceApprovalsandClearances/default.htm. And information regarding the ADA Seal program 

is available at: http://www.ada.org/sealprogramproducts.aspx. 

It should be noted that the FDA has also approved a rinse that forms a physical barrier on teeth 

– a surfactant – that prevents the attachment of plaque bacteria on tooth surfaces, making it 

easier to remove. This type of rinse, which contains Delmopinol, is approved by the FDA as a 

medical device, since its action is physical rather than chemical. It is available as an OTC rinse. 

While the studies show positive results with this type of rinse,, its action is not one that would 

lend itself to use as a pre-procedural mouthrinse, since it does not kill microorganisms. 

Since many therapeutic mouthrinses claim to kill or inhibit the growth of microorganisms that 

cause periodontal disease, some may be further categorized as antimicrobial oral rinses. These 

types of rinses typically contain one of three active ingredients: chlorhexadine gluconate (CHX), 

cetylpyridinium chloride (CPC) or essential oils – containing rinses. The essential oil rinses, 

sometimes referred to as phenolics, may contain ingredients such as thymol, menthol, 

eucalyptol, or eugenol; alone or in combination. These antimicrobial oral rinses have been 

studied extensively for safety and efficacy with regard to treatment and prevention of periodontal 

disease, their potential for reducing bacteremia during dental procedures and for their potential 

for reducing the number of microorganisms in the splash, splatter or aerosol of saliva during 

dental procedures. The research strongly supports the incorporation of antimicrobial mouth 

rinses into the oral hygiene protocol for patients who have gingivitis and periodontitis., In 

addition, these rinse agents are often used as irrigating solutions during dental hygiene 

procedures, such as ultrasonic scaling. Table 2 lists common brands of therapeutic rinses and 

their active ingredients. 

Comparison of Active Ingredients in Therapeutic Oral Rinses 

Chlorhexadine gluconate (CHX) is an antiseptic – a cationic bis-biguanide that is used for 

numerous applications. In dentistry it is used as a dental unit waterline disinfectant, as a gelatinlike 

chip for placement into periodontal pockets at high concentration of 36% and as a mouth 

rinse at lower concentration of 0.12% in the United States. The CHX oral rinse is a prescriptiononly 

product that has been widely prescribed for periodontal patients for a number of years and 

its effectiveness is well documented. 

It is effective on both gram-positive and gram-negative bacteria, which is particularly beneficial 

in prevention of plaque formation, which is normally composed of gram-positive bacteria and is 

a key factor in the development of gingivitis and its progression to periodontitis, in which grampositive 

bacteria and gram-negative bacteria are present. Chlorhexadine gluconate works by 

adsorption into the pellicle on tooth enamel, to the hydroxyapatite of the enamel, to plaque 

bacteria and mucous membranes, which provides a long-lasting bacteriostatic and bactericidal 

effect, inhibiting bacterial colonization of plaque. CHX rinses come in both alcohol and alcoholwww.ColgateOralHealthNetwork.com 


free formulas. Alcohol is not an active ingredient in the rinse, but is a solubilizer or delivery 

vehicle for the other ingredients. Some patients are sensitive to the burning sensation of 

alcohol-containing mouth rinses, especially if they experience xerostomia. In addition, patients 

who have issues with alcohol abuse are not candidates for use of alcohol-containing mouth 

rinses. Long term use of CHX oral rinses has been shown to cause brownish discoloration of 

the teeth and some restorations, as well as some staining of the tongue and gingiva. It should 

be noted, however, that heavy staining on teeth has been shown to be associated with 

unremoved plaque, which can be decreased with improved oral hygiene. It can also cause a 

change in taste perception for some patients. 

Cetylpyridinium chloride (CPC) is also an antiseptic – a cationic quaternary ammonium 

compound which is used in products such as toothpaste, nasal sprays, and more recently in 

mouth rinses in a .45% to 10% concentration. CPC rinses are more recent additions to the 

antimicrobial therapeutic rinse category and have also been extensively studied for their 

effectiveness, which is said to be comparable to CHX rinses. In addition to the concentration of 

the CPC in a therapeutic rinse, it is important that the other ingredients in the rinse, such as 

solubilizers (sometimes alcohol), preservatives and stabilizers do not have a negative effect on 

the bioavailability of the CPC. Higher bioavailability is will increase the effectiveness of the rinse. 

CPC rinses have been shown to prevent the formation of plaque and reduce gingivitis, a 

precursor to periodontitis, by penetrating the cell walls of bacteria, which causes leakage and 

eventually death of the bacteria. Like CHX, CPC is a long-acting agent, shown to be bioactive in 

the mouth for up to 12 hours after using the rinse due to its ability to adhere to the teeth. CPC 

mouth rinses are also available in both alcohol and alcohol-free formulas. A distinct advantage 

of CPC mouthrinses is that they are OTC products, making them more readily available to 

patients. 

Essential Oils formulations are OTC rinses. The essential oil formulation that has been 

approved by the FDA as a therapeutic oral rinse is that of Listerine®, with a composition of 

eucalyptol, menthol, methyl salicylate, and thymol which are delivered in an alcohol base. 

Rinses with essential oils as their active ingredients are able to disrupt cell membranes and also 

inhibit the enzyme activity of cells, which makes the products bacteriostatic or bactericidal. 

Because alcohol is the delivery vehicle for this formulation, patients may experience burning 

and it is not the most appropriate choice for patients with xerostomia or who are alcohol 

abusers. Essential oils rinses have not been proven to have the adhesive properties of CHX and 

CPC products, therefore they have more limited bioavailability. 

Mouthrinses and Prevention of Bacteremia 

Antimicrobial mouth rinses used by the patient before a dental procedure can decrease the 

number of microorganisms introduced into the patient's bloodstream during invasive dental 

procedures. The scientific evidence is not clear, however, that reducing the number of 

microorganisms through mouth rinsing directly reduces the incidence of bacteremia. In its 1997 



guidelines for antibiotic prophylaxis, the American Heart Association (AHA) recommended the 

use of pre-procedural mouth rinses for patients at risk for bacteremia during dental procedures. 

In its most current guidelines, the AHA does not mention pre-procedural mouth rinsing. In 

addition, the American Academy of Orthopaedic Surgeons (AAOS) also states in their 2012 

guidelines on Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental 

Procedures that the evidence is inconclusive to support the use of topical antimicrobials (mouth 

rinses) to prevent orthopaedic implant infections. Further study is needed to determine the 

effectiveness of pre-procedural mouth rinsing for reducing dental procedure-induced bacteremia 

and the incidence of bacteremia in patients who have underlying risks. 

Mouth Rinses for Environmental Infection Control 

The third issue related to pre-procedural mouth rinsing is that of reducing the number of bacteria 

in the saliva during dental procedures that involve the creation of aerosols, spatter and spray. 

These procedures include the use of a high and slow speed handpieces, air/water syringes and 

ultrasonic scalers. The most effective way to reduce the aerosol and spatter contamination is to 

use a dental dam. But a dental dam would interfere with hygiene procedures, such as ultrasonic 

scaling and polishing. And the use of dental dam for restorative procedures may take additional 

time and instrumentation that many practices choose not to adapt into their protocols. In this 

case, a pre-procedural antibacterial mouth rinse is a simple way to decrease the potential for 

aerosol contamination in the treatment rooms. 

While the Centers for Disease Control and Prevention (CDC) does not specifically recommend 

pre-procedural mouthrinses as an infection prevention protocol, there is evidence that using an 

antimicrobial mouthrinse prior to procedures can reduce the potential for is contamination of 

equipment and environmental surfaces. According to the CDC, the spray from dental 

procedures typically contains large-particle spatter or spray of water, saliva, blood, 

microorganisms and other debris (tooth, restorative material, calculus). The spatter has been 

shown to travel only short distances from the patient’s mouth, which would potentially 

contaminate equipment (e.g. bracket tray), operatory surfaces (counter tops or other work 

surfaces) and the dental team members and patients. Aerosol, on the other hand is composed 

of much smaller particles and can remain airborne for long periods of time and can pose an 

inhalation risk for dental team members. It is important to note, however, that there is no 

evidence of transmission of bloodborne pathogens, such as hepatitis B or C or HIV/AIDS 

through exposure to aerosol or spatter in dentistry. The use of pre-procedural mouthrinses is an 

additional safeguard that could be employed by dental practices for protection against other 

types of microorganisms, such as the influenza virus. But dental teams should utilize dental 

dams and high volume evacuation as their first line of defense against spatter and 

aerosolization of saliva and blood during dental procedures. It is also important to note that the 

use of pre-procedural mouthrinses does not preclude the need for environmental cleaning and 

disinfection of equipment and surfaces following treatment. Although the mouthrinse may 



decrease the number of microorganisms, it does not reduce the spatter, unless high-volume 

suction or dental dam is used. 

Since hygiene procedures are the least likely to have high volume evacuation utilized, and the 

use of dental dam is not appropriate, pre-procedural mouthrinses make the most sense for use 

prior to hygiene procedures. Not only can the mouthrinse reduce microorganisms, but it 

provides an excellent opportunity for the hygienist to introduce the concept of utilizing an 

antimicrobial mouthrinse as part of routing oral health care for the patients. The hygienist has an 

opportunity to educate the patients about the benefits of antimicrobial rinses in controlling 

plaque formation and treating periodontal disease. The education process can also include 

information about the most appropriate antimicrobial rinse for each patient, such as alcohol-free 

formulas, and the long lasting effects of CPC and CHX mouthrinses. Having the patient utilize 

the antimicrobial mouthrinse prior to a procedure is a strong endorsement of the belief in the 

therapeutic value of using the rinse and opens the door for additional dialogue with the patient 

about their oral health and the need to control oral microorganisms that can cause disease. It 

also provides the opportunity for the hygienist to differentiate between cosmetic and therapeutic 

mouthrinses, the research that supports the use of therapeutic mouthrinses and the benefits to 

the patient. 

Implementation of a Pre-Procedural Mouthrinse Protocol: 

If a practice implements a pre-procedural mouthrinse protocol, the first step is to decide if the 

protocol will apply to all procedures or just to hygiene procedures. Although the data indicates 

that the most benefit is gained when no dental dam or high volume evacuation is utilized, the 

patient and the team can certainly benefit from the rinse being used for all hygiene, restorative 

and surgical procedures. Again, this makes a positive statement to patients regarding the 

benefit of antimicrobial mouthrinses. The next step is evaluating products and determining 

which product or products are most appropriate to use. As mentioned earlier, the three types of 

products that are classified by the FDA and therapeutic, antimicrobial rinses are those that 

contain CPP, CHX and Essential Oils. If a practice wishes to select a product that will work will 

all types of patients, including those with xerostomia and who have alcohol abuse issues, than 

an alcohol-free product is the most appropriate. There are alcohol-free formulations of most 

FDA approved antimicrobial mouthrinses. Table 3 lists commonly recommended or prescribed 

products with alcohol-free formulas. Another consideration is the potential for staining of the 

teeth which is a common occurrence with CHX and CPC rinses, although CPC rinses have 

been shown to cause less severe staining. If a patient has anterior composite restorations, 

especially older restorations, there may be some staining that occurs when the rinse is utilized. 

For a hygiene procedure, however, the stain will be easily removed if the teeth are polished. 

Other considerations may be the flavor, cost and availability. CPC and essential oil mouthrinses 

are available as OTC products, whereas CHX rinses are prescription-only. If the hygienist or 

other dental team member wants to reinforce the use of the antimicrobial rinse for the patient on 

a daily basis at home, this may be a consideration for some patients and possibly for the 



practice, since the OTC products may be less expensive to utilize in the office than prescription 

products. 

Once the type and brand of mouthrinse has been selected, the team should develop a protocol 

for introducing the mouth rinsing procedure into the practice. The team should decide whether 

to utilize the mouthrinse for all operative and hygiene procedures or only for hygiene 

procedures. The patients should be informed and educated about the benefits of utilizing the 

mouth rinse and given information about the product used. This information is readily available 

from the product manufacturer. 

It may also be beneficial to provide samples if it is an OTC rinse, or to have prescription-only 

products available to dispense to patients. OTC products could be sold in the practice as well, 

which can make it convenient for patients and potentially increase their compliance with using 

the rinses at home. If a practice chooses not to dispense prescription-only rinses, it is 

recommended to have prescribing information readily available in the practice management 

software or pre-printed prescriptions to give to the patients. 

The pre-procedural rinse is administered to the patient soon after they are seated and the 

appropriate explanations are given. The patient is given a disposable cup with the appropriate 

amount of rinse, instructed to swish for the time recommended on the product, and can then spit 

it out in the sink in the operatory or it can be evacuated with the suction. 

Conclusions: 

The therapeutic value of antimicrobial mouthrinses has been well documented by current 

research for the control of plaque formation and in treating gingivitis and periodontitis. While 

there is no compelling evidence that suggests that utilizing pre-procedural mouthrinses is 

effective in controlling the introduction of microorganisms into the bloodstream during dental 

procedures and potentially preventing bacteremia, there is also no compelling evidence that 

suggests that this practice is harmful to patients, if the appropriate rinse is used. The evidence 

is also not conclusive that the use of a pre-procedural mouthrinse can prevent the transmission 

of an infectious disease by decreasing the number of microorganisms in the spatter and aerosol 

produced during dental procedures. But decreasing the number if microorganisms that can 

potentially contaminate equipment and surfaces in a treatment room through spatter, and in the 

aerosol produced, can help provide a safer environment for both the patients and the dental 

team members. The true value of using a pre-procedural antimicrobial mouthrinse may be in the 

example that it provides for patients and the reinforcement that they may receive about the 

usefulness of these rinses in their every-day home care. If the dental team believes in the 

therapeutic value of the rinses they can, by their example, reinforce this concept with their 

patients on a regular basis. 



Table 1 

Type of Rinse 

Cosmetic 

Therapeutic 

Characteristics 

over the counter (OTC) 

controls bad breath – temporarily 

refreshes the mouth 

helps to remove food and debris before or after 

brushing 

over the counter (OTC) or prescription 

controls bad breath – temporarily 

refreshes the mouth 

helps to remove food and debris before or after 

brushing 

regulated by the FDA 

contain an added ingredient that helps to protect 

against some oral disease (e.g.caries or periodontal 

disease) 

may have voluntary Seal of Acceptance from ADA 

Table 2 

Oral Rinse Manufacturer Active Ingredient How Sold 

Peridex 3M ESPE CHX Prescription 

Periogard Colgate CHX Prescription 

Paroex Sunstar Butler CHX Prescription 

Oris Dentsply CHX Prescription 

Crest Pro Health Procter & Gamble CPC OTC 

Colgate Total Advanced 

Pro-Shield 

Colgate CPC OTC 

Listerine Johnson & Johnson Essential Oil OTC 

Table 3 



Preventive antibiotics prior to a dental procedure are advised for patients with: 

1.artificial heart valves 

2.a history of infective endocarditis 

3.certain specific, serious congenital (present from birth) heart conditions, including 

I.unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative 

shunts and conduits 

II.a completely repaired congenital heart defect with prosthetic material or device, whether placed by 

surgery or by catheter intervention, during the first six months after the procedure 

III.any repaired congenital heart defect with residual defect at the site or adjacent to the site of a 

prosthetic patch or a prosthetic device 

4.a cardiac transplant that develops a problem in a heart valve. 

American Heart Association 2007 

Table 4 

Brand Name 

Colgate Total Advanced Pro-Shield 

Crest Pro Health Rinse 

GUM CHX Rinse 

Paroex 

Periogard Alcohol Free 

Formula 

CPC 

CPC 

CHX 

CHX 

CHX 



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Author Bio 

Mary Govoni brings over 40 years of experience in dentistry to the team. She is a Certified 

Dental Assistant, a Registered Dental Assistant (MI) and a Registered Dental Hygienist, with 

experience in general and specialty practices both clinically and as an administrator. Mary is a 

former dental assisting educator and was a partner in a successful dental staffing service. 

For the past 20 years, Mary has focused on speaking and consulting with dental teams on 

infection prevention, OSHA and HIPAA compliance, ergonomics, chairside efficiency and team 

communication and development. Mary has published numerous articles in professional 

journals, such as RDH Magazine, Dental Economics, The Dental Assistant, Dental Products 

Reports, and is featured monthly in Dental Economics. She is a life member and Past President 

of the American Dental Assistants Association, and serves on the ADAA Editorial Board as well 

as the Corporate Council for Dimensions of Dental Hygiene. Mary is also a consultant to the 

American Dental Association Council on Dental Practice (ADA) and a featured speaker on the 

Continuing Education and Lifelong Learning Seminar Series. 

Author Contact Information 

Mary Govoni 

2435 Seville Drive 

Okemos, MI 48864 

517-214-8223 office 

866-628-4149 fax 

mary@marygovoni.com 

www.marygovoni.com 

@Mary Govoni

The Role of Antimicrobial Mouth Rinses in Infection Prevention

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