Alcohol use in mouthwash and possible oral health concerns

Abstract

To establish the presence and quantify Ethanol in commercially available mouthwashes.
Samples from twelve commercially available mouthwashes were tested for the presence of Ethanol followed by the estimation of percentage of Ethanol in five brands in Pakistan Council of Scientific and Industrial Research (P.C.S.I.R) and Husein Ebrahim Jamal (H.E.J.) labs, Karachi.
Ten out of twelve brands of mouthwashes were found to be Ethanol positive.
Alcohol (Ethanol) in the mouthwashes does not contribute to any therapeutic action. It is alarming to find the presence of alcohol in the mouthwashes which claim to contain no alcohol.

Full text

practitioner's own sexual orientation can enter into conflict
while dealing with such patients. Whether the patient wants to
maintain the orientation or request for treatment is another
question. Seeking treatment because of discrimination cannot
be successful and could only aggravate the distress for the
patient. Even when the patients presenting with psychiatric
problems are treated, the core issue remains unresolved that
could lead to multiple relapses over a time period.
There is little evidence about success in treatment for
homosexuality especially for those who are exclusively
homosexual. Empirical studies are not done on homosexuals in
Pakistan though some literature is available about
homosexuality and AIDS. How much are we trained to tackle
this issue in clinical practice? Do we need special training? Are
the psychiatrists aware of problem-specific psychotherapeutic
approaches? These questions need to be answered.
References
1- HIV Second Generation Surveillance in Pakistan, National Report Round2, in
National AIDS Control program Ministry of Health, Government of Pakistan
HIV?AIDS Surveillance Project; 2006-7.
2- No authours listed. Pakistan combats hidden AIDS menace. AIDS Wkly Plus
1996; 20: 16-7.
3- UNAIDS and WHO. AIDS epidemic update, UNAIDS, Geneva. [Online]
2006 (Cited 2008 Jan 28). Available from URL:
http://data.unaids.org/pub/EpiReport/2006/2006_EpiUpdate_en.pdf.
4- Facts about Homosexuality and Mental Health in 'Homosexuality and Mental
Health.' [Online] 2008. (Cited 2008 Sept 10). Available from URL:
http://psychology.ucdavis.edu/rainbow/HTML/facts_mental_health.HTML.
5- Cameron P. "The psychology of Homosexuality" [Online] 2006 (Cited 2008
Aug 27). Available from URL: http://www.familyresearchinst.org?FRI
_EduPamphlet6.html.
6. Fergusson DM, Horwood LJ, Beautrais AL. Is sexual orientation related to
mental health problems and suicidality in young people? Arch Gen Psychiatry,
1999; 56: 876-80.
7. Cochran SD, Mays MV, Sullivan JG. Prevalence of mental disorders,
psychological distress, and mental health services use among lesbian, gay, and
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8. Hogg RS, Strathdee SA, O'Shaughnessy MV, Montaner JS, Schechter MT.
Modelling the impact of HIV disease on mortality in gay and bisexual men.
Internat J Epidemiol. 1997; 26: 657-61.
9. Huebner DM, Rebchook GM, Kegeles SM. Experiences of harassment,
discrimination, and physical violence among young gay and bisexual men.
Am J Public Health 2004; 94: 1200-3.
10. Paul JP, Catania J, Pollack L, Moskowitz J, Canchola J et al. Suicide attempts
among gay and bisexual men: lifetime prevalence and antecedents. Am J
Public Health 2002; 92: 1338-45.
11. Skegg K, Nada-Raja S, Dickson N, Paul C, Williams S. Sexual orientation and
self-harm in men and women. Am J Psychiatry 2003; 160: 541-6.
12. Remafedi G. Sexual orientation and youth suicide. JAMA; 1999; 282:1291-2.
13. Gilman SE, Cochran SD, Mays VM, Hughes M, Ostrow D, Kessler R. Risk
of psychiatric disorders among individuals reporting same-sex sexual partners
in the National Comorbidity Survey. Am J Public Health, 2001; 91: 933-9.
14. King M. Discrimination against homosexual people and their health. Student
BMJ 2007; 15: 257-92.
186 J Pak Med Assoc
Introduction
Mouthwashes are considered beneficial in the
prevention and treatment of variety of oral or orophryngeal
diseases such as gingivitis, periodontitis and other
inflammatory conditions. Apart from the various
therapeutically active ingredients in the mouthwashes such
as essential oils, Chlorhexidine, Fluoride, Potassium Nitrate
and Benzydamine, one ingredient that is present generally
in every mouthwash is "alcohol" (Ethanol, the term alcohol
and Ethanol are used interchangeably in this article) that is
in a concentration of 0-27% as compared to the alcohol
content in beer (4%) and wine (12%). Ethanol by virtue of
its structural configuration is bipolar that helps it dissolve
hydrophobic as well as hydrophilic components.
The concentration of alcohol used in the mouthwash
lags behind the optimum concentration of 50% to 70% at
which alcohol is able to exert its antiseptic effect, hence
except for its use as a solvent, alcohol in the mouthwash
does not contribute to any other therapeutic effect. Due to
this reason, alcohol free mouthwashes in the clinical trials
Students’ Corner
“Alcohol use in mouthwash and possible oral health concerns”
Muhammad Wasif Haq,1Mehwish Batool,2Syed Hammad Ahsan,3Navid Rashid Qureshi4
4th Prof B.D.S Students,1,2 Liaquat College of Medicine and Dentistry, Karachi.3,4
Abstract
Objective: To establish the presence and quantify Ethanol in commercially available mouthwashes.
Methods: Samples from twelve commercially available mouthwashes were tested for the presence of Ethanol
followed by the estimation of percentage of Ethanol in five brands in Pakistan Council of Scientific and Industrial
Research (P.C.S.I.R) and Husein Ebrahim Jamal (H.E.J.) labs, Karachi.
Results: Ten out of twelve brands of mouthwashes were found to be Ethanol positive.
Conclusion: Alcohol (Ethanol) in the mouthwashes does not contribute to any therapeutic action. It is alarming
to find the presence of alcohol in the mouthwashes which claim to contain no alcohol (JPMA 59:186; 2009).

have proven to be as effective as alcohol based
mouthwashes, with the former having lesser side effects.1
It has been postulated that alcohol in the mouthwash
in reference to its local effects and metabolism, acts
similarly to alcohol in the beverages.2As mouthwashes are
kept in contact with oral mucosa, there is absorption of
various ingredients including alcohol because of rich blood
supply and relatively high permeability of oral mucosa. This
has been measured by estimation of urinary excretion of
Ethyl glucoronide (product of Ethanol metabolism) in
concentration of as minimum as 50 ng/ml and as maximum
as 300ng/ml after rinsing with 12% Ethanol based
mouthwash.3Similarly alcohol has average oral fluid to
blood concentration ratio of 1.07 when compared with few
other drugs such as Barbiturates (0.3) and Diazepam (0.01-
0.02).4The breath analyzers (used for detection of alcohol
consumption) show positive readings after rinsing with
alcohol based mouthwashes implicating that effect of
alcohol in mouth is greater on rinsing than on swallowing.5
The metabolism of alcohol starts intra-orally by the
normal oral flora that results in the production of well
known toxic metabolite acetaldehyde.6Oral mucosa unlike
most tissues of body, lacks alcohol dehydrogenase due to
which acetaldehyde may be accumulated for a long duration
of time in the mouth before being cleared.
Research has shown the permeability of oral mucosa
to be directly proportional to the increase in concentration
of Ethanol such that the mucosal permeability being greater
at 15% Ethanol than at 5% Ethanol and sharply rises from
25% Ethanol to 50% Ethanol, beyond which no increase in
the permeability was observed (Figure).7Such an increase
in mucosal permeability has been evidenced to enhance the
penetration of carcinogens such as Nitrosnornicotine.8
Considering the above mentioned scientific data that
emphasizes on risks of high alcohol content in mouthwash,
we planned a study to determine the qualitative and
quantitative presence of Ethanol in commercially available
mouthwashes in Pakistan; products labeling alcohol and
those not labeling alcohol.
Material and Methods
Four samples each from twelve commercially
available mouthwashes were collected from three super
stores in Karachi. The batch number, manufacturing date
and expiry date of the samples were noted.
Atotal of four tests were performed. The tests were
divided into the qualitative tests used for the detection of
alcohol in the samples and the quantitative tests.
The qualitative/preliminary tests employed three
tests namely Iodoform test, Chromic Acid test and Nuclear
Magnetic Resonance (N.M.R.) spectroscopy.
In the Iodoform test , a standard volume of 5 ml of
the sample was taken and reacted with 2 ml of Iodine and
5% NaOH. Samples of twelve brands of mouthwashes were
tested using this reaction. The presence of Ethanol is
indicated by the formation of yellow precipitates of
Iodoform (Triiodomethane).9
The second test employed was Chromic Acid test in
which Potassium Dichromate oxidizes alcohol that was
indicated by the color change of Potassium Dichromate
from orange to green, this is the same reaction used in the
Breath Analyzers to measure concentration of alcohol. A
standard volume of 3 ml of every sample was taken and
reacted with few drops of concentrated Sulfuric acid.
Twelve samples were tested using this reaction.
After the two qualitative tests, two alcohol negative
samples were excluded while from remaining ten samples;
five mouthwashes were selected randomly (non-probability
sampling) for further confirmatory tests for the presence of
Ethanol followed by estimation of percentage of Ethanol in
the selected five samples.
In the third qualitative test, N.M.R. spectroscopy
was utilized. This technique detects radio frequency
absorbed by protons at applied magnetic fields denoting
chemical shifts on the recording paper. 3 ml of the sample
was taken. Five samples were submitted for this test.
In the fourth test, quantitative assessment of Ethanol
by Gas Chromatography (G.C.) was performed. To rule out
the element of bias and variability, two samples were
submitted in the lab of P.C.S.I.R and three samples were
submitted in H.E.J. labs.
Results
In the preliminary tests Iodoform and Chromic acid
test, twelve samples of mouthwashes namely Listerine,
Enziclor, Signal, Prodent, Niflam, Protect (Alcohol free),
Vol. 59, No. 3, March 2009 187
Figure: Increase in the permeability of oral mucosa in a stepwise pattern in relation
to increasing concentrations of Ethanol. Ethanol concentrations above 50% cause
no change in the permeability of oral mucosa.

Oral B (Alcohol free), Clinica, Neo-nexus, Hi-Paradent,
Pepsodent (Alcohol free) and Enliven (Alcohol free) were
tested. Except for two products; Oral B (Alcohol free) and
Enliven (Alcohol free), all the ten remaining samples gave
positive Ethanol reaction (Table-1). The samples that did
not contain alcohol were not subjected for further
confirmatory tests. In N.M.R. test, five samples namely
Listerine, Enziclor, Signal, Protect (Alcohol free) and
Pepsodent (Alcohol free) were selected and confirmed to be
Ethanol positive .In the quantitative assessment of Ethanol
in mouthwashes by G.C., the percentage of Ethanol was
determined in the selected five samples that were confirmed
to contain Ethanol by N.M.R., the percentage of alcohol
observed in these samples by P.C.S.I.R. and H.E.J. labs is
listed in Table 2.
Discussion
It is a matter of serious concern that alcohol is
present in many mouthwashes labeled as without alcohol
and in brands that do not mention any information regarding
presence of alcohol on the display panel of their products.
Such products are being sold over the counter without the
consumer knowing about it. The Drug Act, 1976 states that
in Pakistan companies require to mention their active
ingredients. Since alcohol is not an active ingredient
therapeutically, many companies defer from listing alcohol
in their list of ingredients.10 Only few brands such as
Listerine, Macleans, Colgate, Smokers and Signals are
currently mentioning alcohol in the ingredients with even
fewer brands mentioning the percentage of alcohol in the
product.
Although not therapeutically active, Ethanol in the
mouthwash has been proven to produce multiple other
effects many of which are not beneficial and un-necessary
for the user. These range from a characteristic burning
sensation upon contact with the oral mucosa by activation of
vanilloid receptor-1; a heat gated ion channel to a
dehydrating effect on the oral mucosa.11,12 Due to the
astringent action of ethanol, the use of high alcohol
mouthwashes in patients with radiation mucositis is not
recommended.13 Patients with Sjögren's syndrome should
avoid alcohol based mouthwash as it may aggravate
xerostomia, and with decreased salivary flow locally,
atrophic changes of oral epithelium may occur. Similarly
people on Alcohol Withdrawal therapy or patients on
Disulfiram therapy should also avoid using such
formulations. American Dental Association (ADA) advices
patients of burning mouth syndrome to avoid irritating
substances such as mouthwashes.14 Similarly alcohol is a
known cause of halitosis and mouthwashes only
temporarily relief the problem.15
Alcohol is an irritant to epithelium and in animal
studies; the topically applied alcohol was linked with
increased occurrence of tumours.16 Inflammatory changes
may also develop that may induce hyperkeratosis and
atrophy of mucosa. In a study that involved 40 hamsters,
two hamsters showed areas of hyper-parakeratinazation,
loss of cellular cohesion in basal cell layers with
mononuclear inflammatory cells when treated with 23%
Alcohol based mouthwash.17
Studies and case reports link such a high percentage
of alcohol in certain mouthwashes with development of
leukoplakia, the lesion was reversible when the mouthwash
was stopped.18 There has also been concern about the
correlation of high level of alcohol in the mouthwash with
increased susceptibility towards oral cancer.19 Although to
date, no scientific data establishes it as an etiological factor
but few cases have been documented in literature in which
alcohol containing mouthwashes are suspected, especially
of a patient who suffered from multiple recurrent oral
cancers, the patient gave a long history of using 14%
alcohol based mouthwash.18 However, it must be stated that
other local and systemic factors can aggravate the
susceptibility towards oral cancer.
The production of acetaldehyde intra-orally is also a
matter of grave concern. Acetaldehyde is a known
carcinogen and has been shown to cause hyperplastic and
188 J Pak Med Assoc
Table 1: Presence of Ethanol in samples by Iodoform,
Chromic Acid and N.M.R test.
Brand Name of Mouthwash Ethanol
Iodoform/Chronic Acid/NMR
1.Listerine* Positive
2.Enziclor* Positive
3.Signal* Positive
4.Prodent Positive
5.Niflam Positive
6.Protect (Alcohol free)* Positive
7.Oral B (Alcohol free) Negative
8.Clinica Positive
9.Neo-nexus Positive
10.Hi-Paradent Positive
11.Pepsodent (Alcohol free)* Positive
12.Enliven (Alcohol free) Negative
The marked (*) samples were tested by N.M.R. also and found to be Ethanol
positive.
Table 2: Results of percentage of Ethanol determined by G.C.
Brand Name of mouthwash Percentage of Ethanol
1.Listerine 24.5%
2.Protect (Alcohol free) 3.5%
3.Signal 13.8%
4.Enziclor 3.58%
5.Pepsodent (Alcohol free) 2.89%
The samples 1 and 2 were tested in P.C.S.I.R. labs while 3,4 and 5 in H.E.J. labs.

hyperproliferative changes in epithelium as well as it binds
to D.N.A. and proteins and destroys folate.20 This may lead
to decreased folic acid resulting in keratinzation
abnormalities leading to atrophy. Alcohol acts against
hepatic neo-antigens due to which tumour proliferation may
go unchecked and it also influences stem cell in the basal
cell layer by intracellular and intercellular pathway, a step
suggested to be of importance in development of oral
cancer.21
Stromyelysin 3; a gene involved in cancer metastasis
has been shown to be activated by acetaldehyde.22 In an
vitro study, acetaldehyde production from mouthwash was
proven to be cytotoxic for gingival fibroblasts.23 With
regards to cancer susceptibility from alcohol, Asian
population is more susceptible because of genetic
polymorphisms in Alcohol Dehydrogenase (ADH)
genotype that contributes to slower metabolism and
prolonged effects of ethanol metabolites.24
In relation to alcohol effect on composite
restorations, mouthwashes having high level of alcohol
have been studied to affect color and hardness of composite
restorations.25
FDA recommendations:
With raising concerns over safety of high alcohol
based mouthwashes, the Food and Drug Administration
(FDA) recommended following alcohol concentrations to
be used according to different age levels (Table 3).26
Currently most Chlorhexidine mouthwashes in
United States are formulated with maximum of 12% alcohol
while few others are entirely alcohol free. The U.S.
Consumer Product Safety Commission (CPSC) has
proposed child resistant packaging for mouthwashes having
3 grams or more Ethanol because of over eighteen thousand
cases of accidental ingestion by children over a period of
nine years resulting in coma, seizures and hypoglycemia
and two deaths reported so far.27,28 In case of hypoglycemia;
secondary to mouthwash ingestion, I/V glucose should be
given. Although FDA does not establish a causal relation
between alcohol in mouthwash and oral cancer, it suggests
further research to be carried out in this area. Furthermore,
American Cancer Society, National Cancer Institute (United
States) and Cancer Research Center UK discourage the use
of high alcohol based mouthwashes and categorize it as
possible risk factor.
Conclusion
In the present study, alcohol was present in all the
mouthwashes except for two products that were tested in
this study. It is a matter of serious concern to find the
presence of alcohol in the brands that claim to contain no
amount of alcohol, hence it is suggested that the regulatory
authorities of Pakistan and Pakistan Dental Association
(P.D.A.) in particular should play an active role and address
this issue. It is also recommended that the levels of alcohol
in the mouthwash need to be monitored and only the limit
necessary to dissolve active ingredients should be permitted
as well as making sure that all the brands should be obliged
to mention the exact percentage of alcohol as suggested by
F.D.A. thereby helping the consumer to choose any brand
depending upon the preferences. There is need for
development of child resistant packaging for mouthwashes
having high level of alcohol with instruction to keep out of
reach of children clearly written on the display panel to
avoid any accidental ingestion. We recommend that
depending on the different ingredients and their role in the
mouthwashes, these should be only prescribed when a
patient requires it in certain conditions. With regards to
susceptibility to increased risk towards oral cancer from
high alcohol based mouthwashes, definitive and conclusive
data is lacking and certainly there is a need for further
studies to be carried out to have a clear picture of any
association if at all from mouthwashes.
Acknowledgments
We would like to thank Liaquat College of Medicine
and Dentistry, Karachi for providing the funds and technical
support for the research project. We are also thankful to the
following people for their unlimited support and help;
Dr.Ali Farhan Razi, Prof.Naseer-ud-Din, Prof. Siraj-ud-
Daula, Prof.H.S.A. Athar, Dr.Bilal Abid, Dr. Mehwash
Kashif, Dr.Bahadur Ali, Dr.Ahmed Ali, Mr.Munawar,
Dr.Naheed Najmi, Col(R) Dr.Haq Nawaz, Dr.Imtiaz Ahmed
Lone, Prof Dr.Col (R) Sajjad Akbar, Dr.Iffat Khan, Rabia
Shafique and Miss.Humera Asif.
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Age limit % of Alcohol
1.Chilren under 6 Years Alcohol free, Otherwise 0.5% or less
2.Children between 6 to 12 Years 5% Alcohol
3.People over 12 Years Not more than 10% Alcohol

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190 J Pak Med Assoc
Madam, Communication and Interpersonal Skills
(CIPS) comprise an integral component of medical
professionalism.1-4 Effective CIPS augment quality health care
delivery, patient satisfaction, outcomes and physician's
confidence.1-3,5 Quite understandably, regulatory bodies such
as Accreditation Council for Graduate Medical Education
(USA), General Medical Council (UK) and College of
Physicians and Surgeons (Pakistan) have mandated their
incorporation into every residency programme.
Typically, the need for CIPS is considered equivalent to
the volume of direct patient interaction. Perhaps this is why
CIPS are not deemed priority training areas for radiologists.3
The neglect is reflected by the fact that radiology residents
perceive themselves inadequately skilled for communicating
with the patients and deem such situations stressful.1,2,6
Aradiologist carries the unique responsibility of
communicating with the patients, families, referring physicians
and other members of the health care team; there is potential
for loss of information at each interface.2,4,5 The routine
scenarios include discussing appropriateness of the requested
procedure, taking informed consent for it and sharing its
findings.4,6 At times, the situation may be more complex e.g.
when a patient inquires about the foetal well-being at the end
of a routine ultrasound exam during which foetal
anomaly/demise has been detected.4Aconsiderable proportion
of this communication is verbal, especially in acute care
setting. An accurate diagnosis may be rendered futile, with
possible ethical implications, if not communicated effectively,
in time, to the appropriate person.4,5 Added to it is the limited
duration of radiologist-patient interaction plus a lack of pre-
existing rapport2and the need for training "consultants of
consultants" in CIPS could not be any more obvious.4,6
This can be achieved through CIPS curricula
comprising of clearly defined objectives, effective learning
strategies such as role modeling or high fidelity simulations
and reliable techniques to gauge adequacy of these
attributes.1,2,5,6 The curriculum should emphasize long term
inculcation of basic principles of CIPS more than the amount
of knowledge attained.5,6
Currently, CIPS training for radiology residents in
Pakistan is limited to workshops organized by College of
Letter to the Editor
Communication & inter-personal skills? But I'm a radiologist…