choosing_a_mouthwash_or_rinse_thats_right_for_you_lgSlipping endlessly through the crack between oral and respiratory medicine, the humble mouthwash has slowly won more respect among savvy practitioners and patients as a solution for a range of indications. In Japan many millions of people gargle three times a day with povidone-iodine or other mouthwashes to ward off upper respiratory tract infections (URTIs), and Japanese clinical studies have confirmed the value of this approach. Worldwide, in a less-than-systematic and sometimes downright casual manner, medical practitioners recommend gargling to patients; and many people on their own have decided that gargling makes sense, while millions swish with mouthwash to protect teeth and gums as well as to combat halitosis.

Still, for curious reasons, this formidable method of suppressing infections remains in medical limbo. Not because there is no need. The average American suffers 2.5 episodes of URTI per year, with high costs for treatment, lost days of work, and morbidity. URTIs also exacerbate asthma, and they can enter the lungs and prove fatal.

Meanwhile, the financial costs of ineffective care of teeth and gums are very high, and oral infections cause considerable pain, loss of teeth, and in some cases systemic disease. Thus a truly effective mouthwash that can be gargled, then €”swished around the teeth and oral cavity €”would be of exceptional value, especially if its use could be expanded from the limited numbers of people who use it now to a majority of people everywhere.

Many companies have developed proprietary or generic mouthwashes, with the leader being Johnson & Johnson’s Listerine, acquired from Pfizer in 2006. Pfizer had funded and largely staffed a series of clinical trials that supported claims of efficacy for Listerine in the treatment of gingivitis and other dental and periodontal disorders. But it did not push aggressively to obtain FDA approval of Listerine for specific indications, nor did it market Listerine as a treatment of URTIs. Meanwhile, the findings and practices of the Japanese regarding URTIs have not had any discernible impact on the American health system or, it appears, on those of other countries.

What is going on here? One senses that the problems are less of science than of psychology and the preferences of interested parties. Let us first examine the swishing (oral care) side of mouthwash, then the gargling (anti-URTI) side. Our findings can point to a path forward toward a research agenda, optimization of use, and public education.

Swishing for Oral Care

First mentioned in ancient China, mouthwashes form a venerable component of oral care. Nonetheless, they generally stand third behind brushing and flossing in the recommendations of American dental groups, and they can be rated as optional whereas brushing and flossing are designated as mandatory.

But studies have repeatedly shown that adherence to flossing is poor. For instance, just 11% of Danes and 14% of Germans reported that they flossed daily (Zimmer S et al. Periodontol 2006;72(8):1380-5). Moreover, many people don’t floss correctly, and self-flossing of children has been shown not to have reduced caries risk (Hujoel PP et al. J Dent Res 2006;85(4):298-305). Flossing is inherently an exacting task, and most people evidently don’t want to be bothered or are not skillful enough to perform it correctly. So to tell them to floss is to give them a counsel of perfection, worthless in the great majority of cases. Yet for decades many dentists have insisted on this approach even though the very formidable alternative of mouthwash exists.

Aware that flossing was a privileged competitor of Listerine, Pfizer funded a clinical trial of flossing vs the use of “an essential oil antiseptic mouthrinse” (Listerine Antiseptic) in controlling gingivitis (gum inflammation) (Bauroth K et al. JADA 2003;134:359-65). Over 6 months, the Listerine group, which rinsed with 20 mL twice daily for 30 seconds, scored a gingival index reduction of 11.1 percent vs. 4.3 percent for flossing, and a plaque index reduction of 20 percent vs. 3.4 percent for flossing. Both differences were statistically significant. The authors concluded that the essential oil mouthrinse was “at least as good as” dental floss for controlling gingivitis; but in fact we can conclude that it was significantly superior to flossing, even without taking into consideration the problem of adherence to flossing.

Metaanalyses of comparative trials of flossing vs mouthwash have confirmed this (Berchier CE et al. Int J Dent Hygiene 2008;6:265-79). Other studies support the view that mouthwashes with various ingredients—€”essential oils such as thymol and eucalyptol, hypertonic saline (the low-cost solution), methyl salicylate, menthol, chlorhexidine gluconate, cetylpyridinium chloride, hydrogen peroxide, tea catechins, zinc, and so on—€”can prove effective in oral care, including against caries, gingivitis, periodontal disease, and halitosis. However, more comparative studies are needed.

Increasingly, companies have combined ingredients to achieve higher effectiveness without the side effects that might attend an excessive amount of a single antimicrobial ingredient. Many tests have shown chlorhexidine gluconate and cetylpyridinium chloride to be effective against dental plaque, but their taste represents a negative factor. They and other ingredients can stain teeth, but the addition of a whitener can counteract this tendency.

There is also the question of the safety of ethanol. Johnson & Johnson and the generic manufacturers that follow its formula for Listerine Antiseptic include as an “inactive ingredient” 21.6% ethanol. While various rationales are offered for this high ethanol content, we should not believe for a minute that ethanol is an inactive ingredient. Ethanol at this concentration, especially in combination with other active ingredients, can destroy microbes, though exactly how effective it is against which microbes remains a mystery. In its other antimicrobial applications, ethanol has been proven effective against viruses and bacteria at 50% concentration and is highly effective at 80% (Moorer WR Int J Dent Hyg 2003;1:138-42). Indeed, we might surmise that Listerine performs so well in clinical trials largely because it contains so much ethanol, which is why Pfizer and Johnson & Johnson have not been willing to reduce the ethanol content.

But in turn that creates a problem because studies implicate ethanol-containing mouthwashes in the etiology of oral cancer. Australian cancer researchers recently concluded that “alcohol-containing mouthwashes contribute to the increased risk of development of oral cancer” (McCullough MJ, Farah CS Aust Dent J 2008 Dec;53(4):302-5; see also Carretero-Pelaez MA et al. Med Oral 2004;9:116-23). While McCullough and Farah state that such mouthwashes may be safe in a specific short-term application, they strongly advise against long-term daily use of ethanol-containing mouthwashes, though presumably the percentage of ethanol makes a difference. What constitutes long-term use and what percentage of ethanol begins to pose a risk require careful investigation, in part because of the leading market position of Listerine and its generic equivalents, in part because it would be a pity to lose entirely the value of ethanol in mouthwashes. It appears, for instance, that a mouthwash with ethanol can prove very helpful in a short-term therapeutic mode, as will be discussed below.

Gargling vs Respiratory Infections

Physicians and lay persons alike have long recommended gargling as a adjuvant remedy of respiratory infections and other ailments. However, it appears that only the Japanese have elevated this simple practice to an important technique in healthcare. The Japanese have concentrated on the prophylactic effect of gargling. In particular, they have tested it in schools (millions of Japanese students regularly gargle), hospitals, and nursing homes. For instance, gargling with tea catechin extracts led to an incidence of influenza of only 1.3% in a nursing home in contrast to a rate of 10% among controls, even though the level of catechins was only half of that in green tea sold in Tokyo (all subjects had received an influenza vaccine) (Yamada H et al. J Alt Comp Med 2006;12(7):669-72).  Gargling with green tea led to a 4.9% rate of laboratory-confirmed influenza versus 6.9% in controls who gargled with tap water in a trial of Japanese high school students, though the results did not reach the level of significance (Ide K et al.  PLOSOne, May 2014, Vol. 9, Issue 5, e96373).

In a trial with 387 healthy subjects aged 18-65, researchers compared a povidone-iodine gargle with gargling tap water at least thrice daily and a no-gargling control group for 60 days (Satamura K et al. Am J Prev Med 2005;29(4):302-7). The incidence rate of the first URTI was 0.26 episodes per 30 person days in the controls; 0.17 in the water gargling; and 0.24 in the povidone-iodine group. The researchers explained the comparatively strong showing of tap water as an effect of washing out the pathogens and suggested that the relatively high level of chlorine in the cities studied (0.5-0.8 mg/L) might also have had an effect.

In contrast, povidone-iodine’s strong bactericidal effects destroy normal flora in the pharynx and oral cavity, leaving an opening to pathogenic viral invasion. Povidone-iodine also injures pharyngeal tissue; and its irritant effect might deter users from thoroughly gargling. Povidone-iodine also introduces the risk of hypothyroidism, though that has only occurred in a few cases. In general, therefore, one could conclude that the level of microbicidal activity of a mouthwash is less important than it might appear, and that other effects must be taken into consideration. However, povidone-iodine gargling might have a useful role in special indications such as reducing the transport of bacteria during oral intubation (Ogata J et al. Can J Anesth 2004;51(9):932-6).

While the Japanese clearly are leading the world in the area of prophylactic gargling, one senses that the rigor of some of their practices could impede the spread of gargling even among the broader Japanese population, let alone the rest of the world. For instance, many Japanese garglers prefer povidone-iodine because of its powerful in vitro microbicidal effect, even though it has been shown in vivo to be less effective than tap water, which contains chlorine, a proven microbicide. And the protocols of the Japanese trials call for a demanding gargling schedule €”e.g., 30 seconds at a time three times in a row, repeated three times a day. Ideally, one would like to devise a simple protocol of 15 seconds of gargling followed by 15 seconds of swishing, twice per day, to ensure better adherence.

Therapeutic Gargling

If gargling can prove so effective against URTIs in a prophylactic mode, one must ask how effective it might be in actually treating early-stage URTIs, in effect stopping them before they can spread. Such Therapeutic Gargling (TG) would be a precious added weapon in the struggle against respiratory infections.

Infections are most vulnerable in their initial stage before the microbes have had a chance to multiply and entrench themselves. In the case of a head cold, gargling 4-8 times a day may prevent the virus from entering and establishing itself in the rear of the oral cavity, from which it could spread further.

But many respiratory viral and bacterial infections commence with a sore throat.  In these cases, the invading microbe appears to establish a beachhead in the throat where it can safely multiply before the immune system can develop a response sufficient to wipe it out. Once the numbers of microbes reach a high enough level, they can break out and spread the infection throughout the respiratory tract or even system-wide. At the moment when an individual first becomes aware of having a sore throat, the invading microbes are most vulnerable because they tend to be concentrated in one place—€”a small tract in the throat.

After becoming aware of a soreness in the throat that is reminiscent of such soreness that heralded past infections, the individual should try to make sure that he/she actually has a sore throat and is not just imagining it (shining a flashlight on the back of the throat can show redness, which is diagnostic). Then, using, for instance, a saline- or ethanol-based mouthwash, one should gargle for 20-30 seconds, repeating this every 20 minutes for several hours, then at greater intervals. Gargling 10-12 times the first 24 hours and 5-6 times the second 24 hours might give the best assurance of full destruction of the microbes. It is possible that other protocols could be devised that would even more swiftly and surely prove effective.

Of utmost importance is to start gargling as soon as possible.   Once a sore throat makes its presence known, one must not put off treatment but rather stop whatever one is doing, find something to gargle with, and, after making sure that the throat is sore, start gargling.   In 15 years of this writer’s personal experience, TG is effective 80-90% of the time (this assumes that the infections are not self-limiting); and when it is not, the culprit is almost always delay in starting to gargle.

Even if TG is begun only after the microbes have started to spread from the throat, it may be able to reduce the severity and length of the respiratory disorder and keep it from spreading to the bronchi and lungs. Untreated microbes in the throat otherwise serve as reservoir fueling the spread of the disorder throughout the entire respiratory tract.

Therapeutic Gargling has only been used informally, but the anecdotal results are very encouraging. TG would be most useful for those with weakened immunity who are subject to frequent respiratory infections. It may not be necessary for people whose immune system is robust enough to fend off infections on its own.

If indeed TG were shown in clinical studies to be effective, it could significantly or perhaps even dramatically reduce the incidence of respiratory infections and the resulting morbidity and mortality. It could also save many billions of dollars in medical costs.

The Halitosis Dimension

Many people use mouthwash for a reason that is not strictly speaking a medical one but rather a social one: to combat halitosis. Bad breath results from many causes. For instance, users might wish simply to cover up temporary smells of smoke, alcohol, garlic, or an acid stomach after drinking coffee. Or they could suffer from permanently high level of volatile sulfur compounds generated by bacteria breaking down organic substrates in the oral cavity and throat. Recesses under the tongue, gums, or tonsils may hide the bacteria involved. Regardless, mouthwash can effectively treat such odors for several hours at a time.

This capability clearly lends mouthwash considerable social utility. In turn, the use of mouthwash against bad breath can convey other benefits in terms of oral health and prophylaxis against URTIs. So part of a strategy to deploy mouthwash more effectively would entail finding ways to take advantage of the social considerations that induce people to use mouthwash against halitosis to benefit their overall health.

Thinking in terms of defense against halitosis has the peculiar merit that the remedy of a mouthwash spans the otherwise fairly rigid boundary between oral care and gargling for protection against respiratory infections. It provides the dentist a reason to encourage gargling, and it opens the door to the consideration of oral care by the respiratory infection specialist. As a review of the management of halitosis (van den Broek AMWT et al. Oral Dis 2008;14:30-39) makes clear, there are many ways to treat halitosis. We need to explore these modalities for their potential medical benefits in addition to the social ones. And any effort to identify a single recommended category of mouthwash should take careful account of the powerful social need to cover up bad breath and treat perduring halitosis because that will win adherents and boost adherence.

Barriers to Full Implementation

There seems to be sufficient evidence regarding both oral care and anti-URTI effects that researchers, research funders, professional organizations, and public health authorities should put a high priority on optimizing the use of mouthwash and communicating its value to people around the world. The very modest cost of mouthwashes adds another rationale for such efforts. Indeed, this should all have been done decades ago if the medical system operated correctly.

However, deep-set attitudes and interests block the way. First, general research funders have been negligent in this area for many decades. Even though mouthwashes excel against oral and throat infections, funding overwhelmingly goes to more technical approaches in areas like molecular biology. Staffers concerned with oral care are not concerned about respiratory infections, and vice versa. Nobody is charged with ensuring that two-for-the-price-of-one solutions receive priority. These attitudes and institutional priorities are not going to change soon.

Second, even though some companies display interest in this lucrative market, it is not easy to assure proprietary rights over something as mundane as a mouthwash. So only a few companies have been willing to fund studies, while other pharmaceutical companies and individuals might actually lose money if the mouthwash approach became more popular.

Third, professional organizations such as the American Dental Association perhaps rightly refuse to move out of their field of oral care to investigate and communicate the virtues of mouthwash in the prophylaxis and treatment of respiratory infections. Dental and respiratory medicine organizations have little incentive to link up with each other across the boundaries of specialties. Also, some members of the ADA howled when the Pfizer-funded study suggested that mouthwash was as good as flossing, and Pfizer retreated. Nobody is going to oblige the ADA or other dental groups or individuals to stop promoting flossing instead of mouthwash €”unless the health and economic costs of failing to pursue the optimization of mouthwashes and their full implementation become a priority for government officials charged with public health and with curbing runaway health expenditures.

In poor countries, respiratory diseases exact a heavy toll, and oral diseases add to this. So the opportunity to deploy a low-cost intervention such as regular use of mouthwash as a public health measure could prove very attractive to conscientious practitioners and officials as well as non-government organizations. An effort in this direction could work better than one aimed at changing the status quo in rich countries with their entrenched interests oblivious to or even hostile to the notion of relying on such a mundane and low-cost intervention as the mouthwash.

A Research Agenda

Clearly, more research on mouthwashes could lead toward an optimal deployment of this promising modality. Here is a research agenda:

  1. Find out which mouthwash works best against which indication. Which conveys the best overall effect? We need to test Listerine (ethanol, eucalyptol, thymol, menthol, and methyl salicylate), other proprietary formulas, green tea catechins, hypertonic saline, hydrogen peroxide, and tap water (chlorine and minerals?), both for prophylaxis and, in the case of URTIs, for Therapeutic Gargling.
  2. Test ethanol vs ethanol + essential oils. Test the antimicrobial action of ethanol in oral care and against URTIs.
  3. Investigate the risk of oral cancer from ethanol and other ingredients. At what level of use does this risk become sufficiently significant to necessitate authoritative communication of it to the public?
  4. Investigate the value of flossing vs mouthwash. Flossing is hardly likely to be effective against URTIs.
  5. Determine how many lung infections start as throat infections and can in theory be stopped there with gargling before reaching the lungs. Specifically, investigate the use of prophylactic and therapeutic gargling vs influenza, TB, pneumonia, and biowarfare agents.
  6. Study the comparative epidemiology of oral and respiratory diseases in Japan and in other countries.
  7. Investigate the effects of mouthwash for swishing and gargling on halitosis, cough, smoking, asthma, damage from air pollution, and other oral and respiratory tract phenomena.
  8. Identify what features of mouthwashes lead to better adherence.
  9. Investigate the effects of swishing and gargling with tap water. What mechanisms and molecules contribute to the effects?
  10. Devote special attention to hypertonic saline and green tea mouthwashes. As the low-cost solution, hypertonic saline seems unusually attractive, and yet drug companies have no incentive to investigate or promote it.  In a Japanese clinical trial, gargling with saline came in second to gargling with green tea in preventing URTIs in children aged 2-6.(Noda T et al., J Epidemiol 2012;22(1):45-49)  But green tea can stain teeth and is not quite as widely available.  Nonetheless, green tea’s excellent action and natural ingredients make it equally deserving of special research attention.
  11. Determine the minimal effective regime for gargling and swishing. Would 15 seconds of each two times per day be enough?
  12. Identify ways to bridge the gap between the dental and respiratory disease professions. Find ways to communicate findings and recommendations to them and to the public.

Conclusion

Clinical trials have demonstrated that mouthwash can be effective against microbes in both oral care and respiratory infections. A concerted research and communication effort can further define its optimal uses and communicate the results to people worldwide. Allowing this low-cost, compelling solution to an array of health problems to languish as it has for decades would show a negligent disregard for the health of the public. Even just spreading the word about current findings would move us in the direction of better deploying the significant potential of this simple, practical approach to improving  oral and respiratory health worldwide.

*****

Kenneth J. Dillon is an historian who writes on science, medicine, and history.   See the biosketch at About Us.

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