Over-the-counter mouthwash use, nitric oxide and hypertension risk
Open accessAbstract
Purpose: Mouthwash is used by a large population. Short-term clinical trials have shown that antibacterial mouthwash deplete oral nitrate-reducing bacteria, and decrease systemic nitric oxide bioavailability. Our previous publication from the San Juan Overweight Adults Longitudinal Study (SOALS) was the first to show frequent over-the-counter mouthwash use was independently associated with increased risk of prediabetes/diabetes. This manuscript evaluates whether over-the-counter mouthwash was associated with increased risk of hypertension.Materials and methods: SOALS recruited 40-65 year old overweight/obese individuals; baseline evaluations started in 2011 and the 3-year follow-up exam was completed by 2016. From the 1028 participants (76%) who completed follow-up, we excluded people with reported physician diagnosis of hypertension or systolic or diastolic BP at or above the hypertension cut-offs (n = 481), missing smoking (n = 1), missing physical activity (n = 1) and missing alcohol intake (n = 5) at baseline; 540 participants were included. The primary exposure was mouthwash use twice daily or more. The primary outcome for this manuscript is self-reported physician-diagnosed hypertension over the follow-up. We used Poisson regression controlling for age, sex, smoking, physical activity, waist circumference, alcohol intake, systolic blood pressure, pre-diabetes/diabetes status and cardiac medication use. We additionally evaluated other mouthwash use categorizations.Results: Twelve percent (66/540) developed hypertension over follow-up. People who used mouthwash twice/day or more had higher incidence of hypertension compared to less frequent users (Incidence Rate Ratio = 1.85; 95% Confidence Interval: 1.17, 2.94), and compared to non-users (IRR = 2.17; 95% CI: 1.27, 3.71). Several additional potential confounders evaluated did not impact these associations. Associations persisted among never smokers. Additional outcomes including BP assessed at a single study visit did not show associations.Conclusion: In this study, frequent regular use of over-the-counter mouthwash was associated with increased risk of hypertension, independent of major risk factors for hypertension and several other potential confounders.
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The magnitude of the blood-pressure-lowering response to dietary nitrate depends on baseline blood pressure and the composition of the oral microbiota.
“The magnitude of the response depends on baseline blood pressure and the composition of the oral microbiota, which is essential for nitrate reduction.”
From Dietary Nitrate-Rich Vegetables as Natural Modulators of Health: Mechanisms and Benefits in Ageing Populations (2026) · cites this paper as [157]
The Introduction (page unavailable) says oral bacteria reduce nitrate to nitrite and that disrupting oral microbes can affect nitric-oxide availability and blood pressure. The Discussion (page unavailable) reports stronger associations between mouthwash use and hypertension among people with higher baseline blood pressure, but it does not establish that baseline pressure or oral-microbiota composition determines the magnitude of blood-pressure lowering from dietary nitrate. (LLM, conf=0.82)
Experimental — accuracy not yet measuredUsing antibacterial mouthwash can impair nitrate reduction and reduce the blood-pressure-lowering effects of dietary nitrate.
“Using antibacterial mouthwash can impair this process and reduce the blood-pressure-lowering effects of dietary nitrate [157,158].”
From Dietary Nitrate-Rich Vegetables as Natural Modulators of Health: Mechanisms and Benefits in Ageing Populations (2026) · cites this paper as [157]
The oral microbiota is essential for nitrate reduction.
“which is essential for nitrate reduction”
From Dietary Nitrate-Rich Vegetables as Natural Modulators of Health: Mechanisms and Benefits in Ageing Populations (2026) · cites this paper as [157]
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Does Mouthwash Use Increase Risk of Diabetes and Hypertension? A Systematic Review
Sindhusha, B. S. D., Ravoori, S., & Pachava, S. (2025) · Journal of Applied Dentistry and Oral Sciences · doi:10.1177/30497418251384004 · Cited by 1 · see citing works
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Self-citationThe effect of antibacterial mouthwash on blood pressure in humans: a scoping review
Singh, B., North, P., Rushetsky, Z. M., Brito, R. C., & Jenney, F. E. (2026) · BMC Cardiovascular Disorders · doi:10.1186/s12872-026-06572-4
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Bhowmick, D., Nayek, M., Aquil, A., Rudra, A., Mistry, S., Nair, V., & Das, I. (2026) · Oral Diseases · doi:10.1111/odi.70537
- Authors
- Joshipura, K., Muñoz-Torres, F., Fernández-Santiago, J., Patel, R. P., & Lopez-Candales, A.
- Affiliations
- Harvard University (US)
- Center for Clinical Research and Health Promotion, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico;
- University of Puerto Rico, Medical Sciences Campus (PR)
- University of Alabama at Birmingham (US)
- Cardiology Division, Department of Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
- Corresponding author
- Joshipura, Kaumudi
- Venue
- Blood Pressure
- Publisher
- Informa UK Limited
- Published
- 2019-11-11
- Volume
- 29
- Issue
- 2
- Pages
- 103-112
- ISSN
- 0803-7051 (ISSN-L)
- 1651-1999
- PMC
- PMC7125030
- OpenAlex
- W2982947735
- Cited by
- 58
- References
- 36
- Citations by year
- 2026: 11 · 2025: 9 · 2024: 11 · 2023: 8 · 2022: 10 · 2021: 3 · 2020: 6
- FWCI
- 5.49
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Blood Pressure (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
- Funders
- National Institutes of Health
- National Institute of Diabetes and Digestive and Kidney Diseases (P30DK079626)
- National Institute of Dental and Craniofacial Research (R01DE028195, R01DE020111)
- National Institute on Minority Health and Health Disparities (S21MD001830, U54MD007587, U54MD007600)
- Topics
- Health Sciences › Dentistry › Periodontics › Oral microbiology and periodontitis research
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Blood Pressure and Hypertension Studies
- Health Sciences › Medicine › Physiology › Nitric Oxide and Endothelin Effects
- Keywords
- mouthwash use, hypertension risk, nitric oxide, nitrate-reducing bacteria, antibacterial mouthwash, overweight adults, obesity, hypertension incidence
- MeSH terms
- Adult, Aged, Bacteria, Blood Pressure, Female, Humans, Hypertension, Longitudinal Studies, Male, Middle Aged, Mouth, Mouthwashes, Nitric Oxide, Puerto Rico, Risk Factors, Time Factors, Incidence, Risk Assessment
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