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This is a PatientPlus article. PatientPlus articles are written for doctors and so the language can be technical. However, some people find that they add depth to the articles found in the other sections of this website which are written for non-medical people.
Dentifrices and Mouthwashes
Post your experienceThe aim of promoting oral hygiene is to prevent dental caries and gingivitis or periodontitis.1 The most important factors for the prevention of both dental and periodontal disease are a good diet with a minimum of sugar and careful attention to oral hygiene.2,3 This generally involves:1
- Brushing teeth twice a day
- Flossing teeth three times a week
- Visit a dental practitioner or dental hygienist regularly
A dentist or dental hygienist will recommend the exact frequency of these measures according to the individual circumstances. Especially adapted toothbrushes are available for those who have difficulties in using regular brushes.4
Mouth washing also plays a role in patients who are unable to use a toothbrush or where a painful periodontal condition limits tooth brushing. It may also be used in patients with superficial infections of the mouth and can be beneficial in patients suffering from halitosis.
In addition to specific oral hygiene measures, the opportunity to re-iterate the "quit smoking" message should be taken as this group of patients have an increased risk of periodontal disease and oral cancer.1
Dentifrices are substances used for cleaning teeth: these may be in paste or powder form. Toothpastes are the paste form of dentifrices and have the dual function of cleaning teeth and delivering fluoride.
| Fluoridation The amount of fluoride in a given medium (water, toothpaste, salt) is expressed as parts per million Fluoride, ppmF. Fluoridation of toothpastes, mouth rinses, gels and tooth varnishes has been common practice for several decades, resulting in beneficial effects where these products have been used appropriately.5 However, the broader issue of fluoridation is a controversial one.6 The addition of fluoride to drinking water addresses issues of health inequalities but there are risks of dental fluorosis and evidence is equivocal regarding systemic benefits such as the reduction of hip fractures.7 The dentist will know what local levels are and can advise on the fluoride content needed in the toothpaste and the need for fluoride supplements. |
There are a number of different fluoride concentrations within toothpastes:
- Standard toothpaste: 1000-1450ppmF. Contain mild abrasives which give cleaning properties.
- Children's toothpaste: 500ppmF. Suitable until about 6 or 7 years old.
- Whitening toothpaste: 1500ppmF. Similar to standard toothpastes.
- High fluoride toothpaste: up to 2800ppmF - usually used on specialist recommendation only.
- Non-fluoride toothpastes: do not contain fluoride, rely on natural plant extracts.
- Antiseptic toothpastes are available although not widely in use for fear of the emergence of bacterial resistance.
Dentifrices also play a role in reducing dental calculus (also known as tartar: this is calcified plaque, the soft, sticky bacterial deposit that readily forms on exposed surfaces of teeth) through their pyrophosphates, zinc compounds and copolymer content.8
These are (usually flavoured) antiseptic solutions, also known as gargles, used for cleaning the mouth and freshening breath.
Saline mouthwash
- Use - superficial oral infections.
- Essence - this has a mechanical cleansing effect and if warmed, causes local hyperaemia.
- Examples - compound sodium chloride solution (prescribable: mix with equal amount of water) or home made: mix half teaspoon of salt in a glassful of warm water.
- Administration - use frequently and vigorously.
Fluoride mouthwashes
- Use - recommended for people who are at particular risk of dental decay (they contain around 1450ppmF).
- Administration - as directed on individual product.
Total mouthwashes
- Use - combine decay prevention with breath freshening properties.
- Administration - as directed on individual product.
Antiseptic mouthwashes
- Chlorhexidine gluconate9 - this helps inhibit plaque formation and is used in:
- The treatment of denture stomatitis
- The treatment of secondary infection in mouth ulceration
- The treatment and prevention of gum inflammation, particularly where tooth brushing is difficult (e.g. following oral surgery)
- Prevention of oral candidiasis in immunocompromised patients
- Prevention of bacteraemia in patients undergoing dental procedures requiring antibacterial prophylaxis
- It may reduce the incidence of alveolar osteitis following wisdom tooth extraction
- Oxidising agents such as hydrogen peroxide, used in Vincent's angina and has a mechanical cleansing effect.
- Povidone iodine is used for oral mucosal infections. Do not use for longer than 14 days as a significant amount of iodine may be absorbed. For this reason, avoid in pregnancy, breast-feeding mothers, patients on lithium therapy and with thyroid disorders.10 It may also interfere with tests for occult blood. Not for children under 6 years.
- Hexetidine11 is used for general oral hygiene and in the treatment of minor infections e.g. oral thrush and in the prevention and treatment of gingivitis. It can also be used in the management of sore throat and recurrent aphthous ulcers as well as for halitosis. Rarely, it may cause taste disturbance and transient anaesthesia. Not for children under 6 years. Use to rinse the mouth or to gargle and avoid swallowing large quantities.
- Thymol preparations come as mouthwash solution-tablets, which may be handy for travellers.
Mouthwashes are generally used 2-4 times a day, after meals. Refer to instructions on individual product for specific administration.
A word of caution about mouthwashes
These products are generally regarded as useful, easy products to use in oral hygiene. Whilst this is true, they are still medicinal products, a fact that is overlooked possibly due to their wide availability. Mouthwashes can have significant alcohol content and do not always come with child proof caps. There have been case reports of accidental ingestion by young children with two reported deaths. Their bright colourings and pleasant smell/taste make them attractive targets and patients who have young children should be reminded of this when being advised to use mouthwashes.
The alcohol content of mouthwashes has raised questions as to its possible role in the development of oropharyngeal cancers in individuals who use the product heavily.12,13 However, review of the evidence suggests that this association is an artefact of recall bias and that there is no association between the two.14
Babies and children
- Tooth brushing should start as soon as the teeth begin to come through (about 6 months): a moist flannel with a small smear of children's toothpaste may be a gentle way to start, progressing onto soft baby tooth brushes.15
- Until the age of 6 or 7, children should use children's toothpaste unless there is a particularly high risk of dental caries (use standard paste).1
- Regular supervised tooth brushing will ensure good future habits.
- When using mouthwash in children under 7 soak some on a cotton bud and apply directly (otherwise there is a risk of swallowing it).
- Most of the above mouthwashes are fine to use in children (some have lower age limits - check individual preparation and see above) but avoid hydrogen peroxide in concentrations of > 1.5% as this may cause tissue damage and mouth ulceration.
Elderly
Dentures should be cleaned regularly with a denture brush and plain soap.4 Using bleach on them may give rise to denture-associated oral ulceration.
Patients complaining of problems in the mouth usually present to their dentist. However, with NHS dental provision becoming increasingly patchy, they are more likely to turn to medical primary care services for help. Mouth and dental problems cover a very broad range of diseases that do not form part of the routine training of medical staff, so it is usually best dealt with by a dental general practitioner. However, you may find the following records helpful in the initial assessment and management of these patients:
- Dental and periodontal diseases (where you will find more information about oral healthcare)
- Problems in the mouth
- Oral ulceration
The referral criteria set out below are a simple summary guideline. More information is provided in the above records.
Referral to a dentist1
- Clinically apparent gingivitis (red swollen gums) not responding to simple treatment
- Periodontitis, especially if symptoms are aggressive (rapid and severe)
- Acute necrotizing ulcerative gingivitis (= "trench mouth" : bacterial infection of ulcerated gums)
Referral to the maxillofacial department
- Urgent: unexplained oral mucosal mass or ulceration lasting > 3 weeks
- Urgent: unexplained painful swollen / bleeding red and white patches of the mucosa
- Non-urgent: unexplained non-swollen, non-painful red and white patches that are not bleeding
The link provided in the further reading section can be used to find a local NHS dentist: names, locations and opening hours are provided. It also provides information regarding charges and a number of helpful links to related websites.

Document references
- Gingivitis and periodontitis - plaque-associated, Clinical Knowledge Summaries (2007)
- Harris R, Nicoll AD, Adair PM, et al; Risk factors for dental caries in young children: a systematic review of the literature. Community Dent Health. 2004 Mar;21(1 Suppl):71-85. [abstract]
- Sanders TA; Diet and general health: dietary counselling. Caries Res. 2004;38 Suppl 1:3-8. [abstract]
- Dental Health Foundation FAQ; Caring for my teeth (2005).
- Marinho VCC, Higgins JPT, Logan S, Sheiham A.; Topical fluoride (toothpastes, mouthrinses, gels or varnishes) for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2003, Issue 4. Art. No.: CD002782. DOI: 10.1002/14651858.CD002782.
- NICE; Citizens Council Report - Mandatory Public Health Measures.
- MRC; Press release (Sept 2002) calling for more research on effective fluoridation of water.
- Netuveli GS, Sheiham A; A systematic review of the effectiveness of anticalculus dentifrices. Database of Abstracts of Reviews of Effects (DARE), 2004.
- Patient Information - Eludril Mouthwash® (Chlorhexidine gluconate BP and Chlorobutanol hydrochloride EP) Pierre Fabre Limited, electronic Medicines Compendium
- Summary of Product Characteristics - Betadine® Gargle and Mouthwash (Povidone Iodine USP), Molnlycke Health Care. Updated Sept 2005 - electronic Medicines Compendium
- Summary of Product Characteristics - Oraldene®; Gargle (Hexetidine), McNeil Products Ltd. Updated January 2004 - electronic Medicines Compendium.
- Llewelyn J; Oral squamous cell carcinoma. Mouthwashes may increase risk. BMJ. 1994 Jun 4;308(6942):1508.
- Winn DM, Blot WJ, McLaughlin JK, et al; Mouthwash use and oral conditions in the risk of oral and pharyngeal cancer. Cancer Res. 1991 Jun 1;51(11):3044-7. [abstract]
- Cole P, Rodu B, Mathisen A; Alcohol-containing mouthwash and oropharyngeal cancer: a review of the epidemiology. J Am Dent Assoc. 2003 Aug;134(8):1079-87. [abstract]
- British Dental Association; Smile - patient resource.
Internet and further reading
- NHS UK; Information on availability of local services (including dentists).
DocID: 517
Document Version: 5
DocRef: bgp25220
Last Updated: 23 Jun 2008
Review Date: 23 Jun 2009
The authors and editors of this article are employed to create accurate and up to date content reflecting reliable research evidence, guidance and best clinical practice. They are free from any commercial conflicts of interest. Find out more about updating.
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