---
title: The Truth About Mouthwash and Heart Health
description: Antibacterial mouthwash may harm oral bacteria needed for nitric oxide production, and frequent use is linked to higher blood pressure and diabetes risk.
image: https://www.casi.org/hubfs/casi/featured/4-9-mouthwash-cardiovascular.jpeg
---

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Research & Education

# The Truth About Mouthwash and Heart Health

DM Danielle C. Male, MS, CNS, LDN Apr 09, 2024

![The Truth About Mouthwash and Heart Health](https://www.casi.org/hs-fs/hubfs/casi/featured/4-9-mouthwash-cardiovascular.jpeg?width=960)

Research suggests that there may be an association between an [unhealthy oral microbiome and adverse effects on the cardiovascular system](https://www.casi.org/articles/growing-connection-oral-microbiome-cardiovascular-health). Specifically, poor dental hygiene practices, periodontal disease, dental caries, or tooth loss may be associated with an increased risk of cardiovascular disease. [Daily brushing, flossing, and annual dental examinations](https://academic.oup.com/eurheartj/article/40/14/1138/5251907?login=false) support optimal oral health and may potentially promote heart health. However, could twice-daily mouthwash also play a role?

## Unmasking the potential hidden risks of mouthwash

Over-the-counter (OTC) [mouthwashes](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6628144/) are commonly used to freshen breath or leave a pleasant taste. Most contain [antibacterial ingredients](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6628144/), such as chlorhexidine, triclosan, cetylpyridinium chloride, alcohol, essential oils, fluoride, and peroxide. Depending on the concentration, these ingredients may be either [bacteriostatic or bactericidal](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6628144/). They target a [broad spectrum of bacteria](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6628144/) rather than specific pathogens. [Cosmetic mouthwashes](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6628144/) offer only temporary benefits with no known chemical or biological applications beyond freshness. While [antibacterial mouthwashes](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6628144/) may support those with dental plaque or gingivitis, their effectiveness against severe forms of periodontal disease and dental caries is unclear. 

The oral microbiome comprises over [700 bacterial species](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6628144/). In addition to targeting pathogenic bacteria, mouthwashes may harm [beneficial commensal bacteria](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6628144/) vital for local and systemic health. One of the major roles of commensal oral bacteria for systemic health is supporting [healthy nitric oxide (NO) production and bioavailability.](https://www.casi.org/articles/oral-microbiome-nitric-oxide-production-healthy-blood-pressure) 

Nitric oxide is needed for [normal blood pressure and circulation](https://www.casi.org/articles/oral-microbiome-nitric-oxide-production-healthy-blood-pressure). During what is known as the “[enterosalivary pathway](https://www.casi.org/articles/dual-pathways-nutrients-enhanced-nitric-oxide-production),” the body is able to convert dietary intake of nitrates from food or supplements into NO. However, a crucial step in the enterosalivary pathway requires a healthy oral microbiome, allowing the [reduction](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10578647/) of salivary nitrate to nitrite by [nitrate reductases](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10578647/) found in certain [commensal oral bacteria](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10578647/)*.* Even with ample dietary nitrate intake, this pathway can only proceed with the presence of these commensal oral bacteria. Although the body has an alternative NO production pathway ([endogenously in the endothelium](https://www.casi.org/articles/dual-pathways-nutrients-enhanced-nitric-oxide-production)), this pathway may be insufficient in certain individuals due to [increased age, cardiovascular health conditions, or endothelial dysfunction](https://www.casi.org/articles/dual-pathways-nutrients-enhanced-nitric-oxide-production).

## The silent microbiome destroyer

An [in vitro study](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10690546/) shows that mouthwashes containing 0.12% chlorhexidine may destroy over 90% of the oral-nitrate-reducing bacteria, leading to an 85% reduction in reduced nitrate. Several [small clinical studies](https://www.casi.org/articles/oral-microbiome-nitric-oxide-production-healthy-blood-pressure) have observed an association between frequent mouthwash use (containing chlorhexidine or [alcohol-free mouthwash](https://pubmed.ncbi.nlm.nih.gov/22403975/)) with increased blood pressure and decreased nitrite levels. 

A [longitudinal 3-year study](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6628144/) (n = 1,206) observed that participants who used OTC mouthwash more than twice daily at baseline had a 55% significantly elevated risk of prediabetes and diabetes compared to less frequent users and non-mouthwash users. Interestingly, mouthwash use less than twice daily had no association, suggesting a potential threshold effect. However, the study lacked details on mouthwash types or antibacterial agents, necessitating further investigation.

## Conclusion and other related articles

Current research suggests that indiscriminate use of antibacterial mouthwashes may cause [more harm than good regarding heart health](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6628144/), as it may disrupt the oral microbiome and healthy NO production and bioavailability. However, further research is needed to draw definitive conclusions.   

**[Learn more about the growing connection between the oral microbiome and cardiovascular health](https://www.casi.org/articles/growing-connection-oral-microbiome-cardiovascular-health)**

[**Find out how the oral microbiome is necessary for healthy NO status and blood pressure**](https://www.casi.org/articles/oral-microbiome-nitric-oxide-production-healthy-blood-pressure)

[**Explore the dual pathways and nutrients needed for enhanced NO production**](https://www.casi.org/articles/dual-pathways-nutrients-enhanced-nitric-oxide-production)

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DM

### Danielle C. Male, MS, CNS, LDN

Clinical Application

## Clinical Considerations in Practice

 In clinical practice, practitioners considering the topics discussed above may also weigh nutrient form, delivery and formulation, alongside individual patient variability.

### Practitioner Formulation Example

![NOx Oral Microbiome Gum™](https://cdn.sanity.io/images/lemtscrs/production-www/93727261a49fdcf073b43a684ce845902e97aba0-800x800.png?w=128&h=128&fit=max&auto=format)

NOx Oral Microbiome Gum™

Prebiotic blend

[Explore Formulations →](https://www.designsforhealth.com/products/nox-oral-microbiome-gum)

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#### [Science Update Bifidobacterium Postbiotic Promotes Healthy Body Composition and Akkermansia Genus: A Randomized Controlled Trial Apr 14, 2026](https://www.casi.org/articles/bifidobacterium-postbiotic-promotes-healthy-body-composition-and-akkermansia-genus-a-randomized-controlled-trial)

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