Mouthwash Health Concerns: Should You Stop Using Mouthwash?
It seems so logical on the surface. Your mouth smells bad due to bacteria in there. You use some tingly mouthwash and voila, bad breath gone, replaced with a clean feeling, and a bonus of minty breath.
Well, recent research has shed light on the concerns of this simple daily morning routine. It turns out that using mouthwash can do more harm than good. The benefit is fresh breath but the trade-off comes at the price of diabetes, cancer, and even an impact on your workout.
Whether you're a die-hard mouthwash user or just someone who wants to keep their pearly whites shining, this article will give you the lowdown on whether mouthwash is worth that rinse.
5 Health Concerns With Mouthwash
1. Increased Risk Of Diabetes
The mouth is incredibly interconnected to many parts of the body, an enduring theme in this article. One of those parts is the endocrine system.
A 2017 study looked at 946 overweight or obese adults between 40-65 years old who did not have diabetes or major cardiovascular disease. Over a 3-year period, the researchers found that those who used mouthwash 2 or more times a day had a "significantly elevated risk of pre-diabetes/diabetes." Those who used mouthwash less than twice a day didn't have a correlation.
Researchers also found that CHX had a significant impact on the body. CHX (chlorhexidine) is an antiseptic and antibacterial agent used in mouthwash to prevent and treat gingivitis and other oral infections. Common brands are Perogard, Peridex, Pareox, Corsodyl, Savacolm, Crest Pro-Health Multi-Protection Mouthwash with Chlorhexidine, and Colgate Peroxyl Mouth Sore Rinse with Chlorhexidine.
In this study, participants rinsed their mouths with a CHX-containing mouthwash for 1 minute, twice a day, for a week. Blood and saliva samples showed a “significant decrease in saliva pH and buffering capacity, accompanied by increased saliva lactate and glucose levels. Participants also showed higher systolic blood pressures and lower saliva and plasma nitrite concentrations.
2. Mouth Staining
When you think of staining in the mouth you probably think of smoking and coffee. It turns out that a benign-seeming mouthwash can cause mouth stains too.
One review wanted to find out what the adverse effects were of using mouthwash and, surprisingly, there's a lot of research out there on mouthwash. This 2019 systematic review looked at 85 studies, most of which lasted 3 weeks or less. They found that, of all of the adverse effects, tooth staining was the most common. They came to the conclusion that the most likely cause of this is the ingredient chlorhexidine (CHX).
3. Linked To Head & Neck Cancer
A 2017 study examined the link between mouthwash and cancer by comparing 8,981 people with head and neck cancer to a control group of 10,090 people. The researchers used an odds ratio to determine the strength of the correlation between cancer and mouthwash use.
They found that, compared to those who never used mouthwash, those who use mouthwash have a greater association of cancer of the head and neck by 1%, oral cavity by 11%, and oropharynx by 22%. For cancers of the hypopharynx and larynx, however, there was a lower association of 22% and 30% respectively.
The paper states that the connection may be due to the fact that most mouthwashes contain alcohol which is "a known cause of head and neck cancer." In mouthwash, this alcohol is in the form of acetaldehyde.
Another possible explanation is the known relationship between nitrate/nitrite and cancer. When nitrate and nitrite are ingested, they can be converted into nitrosamines, which are potent carcinogens. Nitrosamines have been shown to cause cancer in animals, and there is some evidence to suggest that they may also be linked to cancer in humans. The International Agency for Research on Cancer (IARC) has gone as far as to classify ingested nitrate and nitrite as "probably carcinogenic to humans."
It’s important to note that not all sources of nitrate and nitrite are the same. Processed meats, such as bacon and hot dogs, are a significant source of nitrite and are also associated with an increased risk of cancer. However, nitrate and nitrite in vegetables are generally considered safe and are even thought to have health benefits.
More on the relationship between the microbiome and nitrates and nitrites below.
4. Inhibits Exercise Benefits
If you do your shower/shave/oral care routine after your workout, you might want to hold off on the antimicrobial mouthwash.
A small study "Post-exercise hypotension and skeletal muscle oxygenation after nitrate/nitrite intake in healthy humans" aimed to investigate the relationship between exercise and antimicrobial mouthwash. They had 23 individuals do two treadmill tests at moderate intensity and then rinse their mouths with either an antibacterial mouthwash or a placebo mouthwash. In the placebo group, the typical beneficial effects of exercise were noticed, including lower systolic blood pressure, increased circulatory nitrite, and improved tissue oxygenation which indicates a healthy microvascular response.
When the antibacterial mouthwash users were tested, these hormetic effects of exercise were negatively impacted. The systolic blood pressure was 61% lower at 1 hour and nonexistent at the 2-hour recovery mark. Additionally, there was no change in circulatory nitrite and an "impaired microvascular response" after exercise.
Craig Cutler, the study co-author, said, "In effect, it’s like oral bacteria are the ‘key’ to opening up the blood vessels. If they are removed, nitrite can’t be produced and the vessels remain in their current state.”
The study surmised that the antibacterial ingredients in the mouthwash negatively impact the oral microbiome. As discussed above, the microbiome is essential for the formation of nitric oxide which may play a direct role in metabolic disorders such as diabetes. Other research points to the fact that nitrate intake is associated with improvement in the performance of endurance exercise, endothelial function, and lower blood pressure.
5. Associated With Systemic Disease
While we're still in the early days of understanding the microbiome, researchers tend to agree on the fact that it plays an important role in maintaining health and influencing disease. The microbiome is the community of microorganisms that live in and on the human body. The cells of the microbiome are in the gut, the digestive tract, the nose, and, yes, the mouth.
Promoting a healthy microbiome by doing things such as consuming probiotics and limiting processed foods is important, however, so is keeping the healthy bacteria alive and thriving. “Killing bacteria” has been all the rage in recent history, but now we’re learning that many of those microorganisms are important for our health (a fact we’re also learning the hard way with the effects of antibiotics—more on those here).
Research shows that the "imbalance of microbial flora contributes to oral diseases and systemic diseases." They’ve found that disrupting this sensitive and critical part of our body influences our bodies and is associated with diabetes, atherosclerosis, inflammatory bowel disease (IBS), rheumatoid arthritis (RA), colon cancer, obesity, and Alzheimer's disease, among others.
What To Do Instead
If mouthwash with alcohol is out, what do I do? The best options are to:
Use mouthwash less. Since there is a dose-dependent relationship (i.e. the more you use, the more negative effects), simply stop using mouthwash. If you’re using that mouthwash to cover up consistent bad breath (halitosis)—despite flossing and brushing your teeth—you may have an underlying health condition that you should talk to your doctor about.
One common source of bad breath is mouth breathing. Learn about the concerns with mouth breathing and how you can mouth tape at night to help address this issue here.
Switch to an alcohol-free mouthwash. Quitting mouthwash altogether might not be an option for everyone. I get it because I’m in the same boat. When I do need a swig of a minty mouth cleanse, I go with a natural kind. We use hello mouthwash which is made without alcohol, fluoride, sulfates, artificial sweeteners, or dyes (more on the harms of artificial dyes here).
Do oil pulling. Oil pulling is a traditional Ayurvedic practice that involves swishing oil in the mouth for around 20 minutes before spitting it out to reduce the harmful bacteria. I make my own coconut oil tablets and rinse with them periodically, an idea I got from Ben Greenfield.
How to make your own mouthwash tablets:
Melt organic coconut oil in a pan, put in some organic essential oil drops (peppermint is my go-to), put them in a silicone mold, and then put them in the refrigerator. Once they’re solid, I put them in a mason jar and keep them on the bottom shelf of the refrigerator door for easy access before I leave for work. Swish around for 20 minutes (good mouth workout too) and make sure to NOT spit it out in the sink. Coconut oil transitions from liquid to solid relatively quickly around the 75° mark.
Saltwater can be an occasional go-to as a mouth rinse, however, avoid doing this for long periods of time. Too much of this may result in the erosion of tooth enamel, rendering your teeth vulnerable to chipping and developing cavities.
Conclusion
Frequent mouthwash is a health concern that tends to fly under the radar, at least for now. There is emerging research that conventional mouthwash use is associated with diabetes, mouth staining, cancer, and even limiting the benefits you get from exercise. Furthermore, disrupting the oral microbiome is associated with health concerns such as IBS, arthritis, obesity, and Alzheimer's. The potential mechanisms for this include the alcohol and ingredients like CHX on the microbiome, including through the influence of nitrite/nitrates.
While more research is needed, I abide by the precautionary principle (taking measures to prevent harm in situations where scientific evidence is uncertain or insufficient) and limit my mouthwash use. If and when you use it, go for the natural kind which is free of alcohol, CHX, and dyes. Alternatively or additionally, consider going the oil pulling route.
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