Antiseptic Mouthwash, Mouth Bacteria and Blood Pressure

Table of Contents

1. How Mouth Bacteria Feed the Nitric Oxide Pathway
2. Rinses Reliably Cut Nitrite in the Mouth
3. Trials That Found a Blood Pressure Rise
4. Trials That Found No Blood Pressure Rise
5. Two 2026 Reviews of the Mixed Results
6. Chlorhexidine Compared With Other Ingredients
7. The San Juan Cohort: Hypertension and Prediabetes
8. Exercise and Blood Pressure After Rinsing
9. Dietary Nitrate Studies
10. The Tongue, the Gums and Oral Bacteria
11. Studies in Rats
12. Plaque, Gums and Known Side Effects
13. The Limits of This Evidence
14. Key Research Papers
15. Connections
16. Featured Videos

How Mouth Bacteria Feed the Nitric Oxide Pathway

The body makes nitric oxide in two ways. The better-known route builds it from the amino acid arginine using an enzyme. The second route runs through nitrate and nitrite, which were once thought to be inert end products. A 2008 review described how these two compounds can be recycled in the body to form nitric oxide, as an alternative to the arginine route, in particular when oxygen is low (Lundberg 2008).

The second route has a path through the mouth, known as the enterosalivary circulation of nitrate. It runs in these steps:

1. Nitrate enters the blood from food, and also from the body's own nitric oxide as it breaks down.
2. The salivary glands pull nitrate out of the blood and concentrate it in saliva.
3. Bacteria in the mouth, many of them on the tongue, reduce that nitrate to nitrite.
4. Saliva is swallowed, nitrite reaches the blood, and part of it is converted to nitric oxide, which widens blood vessels.

The mouth stage matters because humans lack the enzyme activity that performs the third step (Hyde 2014). A study of tongue scrapings from six healthy volunteers identified 14 candidate nitrate-reducing species, seven of which had not previously been thought to do this work (Hyde 2014). Later work followed two of the genera, Rothia and Neisseria. After ten days of nitrate supplements in 18 people, the relative abundance of Rothia rose 127% and Neisseria 351%, and high amounts of these bacteria were correlated with greater rises in plasma nitrite (Vanhatalo 2018).

Nitrite has a complicated reputation. The Kapil 2013 paper notes that this mouth process was historically viewed as harmful, because nitrite can promote the formation of potentially cancer-causing N-nitrosamines. That side of the subject is covered on the Nitrates and Nitrites page.

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Rinses Reliably Cut Nitrite in the Mouth

The part of the chain with the most consistent support is the effect on nitrite itself.

• A cross-over study in seven healthy volunteers tested a chlorhexidine rinse before an oral dose of sodium nitrate (10 mg per kg of body weight). The rinse left nitrate in saliva and plasma unchanged, abolished its conversion to nitrite in saliva, and markedly reduced the rise in plasma nitrite (Govoni 2008).
• A week of chlorhexidine rinsing in 19 healthy volunteers reduced oral nitrite production by 90% and plasma nitrite by 25% compared with a control week (Kapil 2013).
• Three days of antibacterial mouthwash in 15 people treated for hypertension decreased oral nitrate-to-nitrite reduction and salivary nitrite. The fall in plasma nitrite was only a trend (Bondonno 2015).
• A week of antibacterial mouthwash in vegetarians and omnivores cut the mouth's nitrate-reducing capacity by 78% and 85% respectively (Ashworth 2019).
• Seven days of chlorhexidine in 36 healthy people was followed by lower nitrite in saliva and plasma, along with a shift in the salivary bacteria and more acidic saliva (Bescos 2020).

Plasma nitrite did not always follow the mouth. In one double-blind trial, chlorhexidine cut oral nitrate conversion but had no effect on plasma nitrate or nitrite (Sundqvist 2016). That gap is one place where the simple chain weakens. A rinse that disrupts the mouth step does not always change what reaches the blood.

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Trials That Found a Blood Pressure Rise

Blood pressure is reported as two numbers: systolic, the upper number, and diastolic, the lower number.

Kapil 2013: 19 healthy volunteers, seven days. Participants had a seven-day control period, then seven days of a chlorhexidine-based antiseptic mouthwash, with clinic, home and 24-hour ambulatory readings. Systolic and diastolic blood pressure rose by 2 to 3.5 mmHg. The rises correlated with the fall in circulating nitrite (r² = 0.56). The effect appeared within one day and lasted through the seven days. The order was fixed, with control always first, rather than randomly assigned.

Bondonno 2015: 15 people treated for hypertension, three days. In this randomized cross-over trial, mean age 65, antibacterial mouthwash was compared with water. Systolic pressure was 2.3 mmHg higher with the mouthwash (95% confidence interval 0.5 to 4.0). Diastolic pressure and plasma cyclic guanosine monophosphate, a marker of nitric oxide signaling, did not change significantly. The authors described this as a small elevation. Among the studies on this page, it is the trial that tested a rinse in people already treated for high blood pressure.

Tribble 2019: healthy people with no mouth disease, one week. Twice-daily chlorhexidine was associated with a significant rise in systolic pressure after a week. How often a person cleaned the tongue predicted how much systolic pressure and the tongue bacteria changed. Recovery from the rinse was followed by an enrichment of nitrate-reducing bacteria on the tongue.

Bescos 2020: 36 healthy people, seven days. Chlorhexidine was followed by a trend toward higher systolic pressure, not a clear rise. The design was single-blind and not randomized, with the placebo week always first.

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Trials That Found No Blood Pressure Rise

Sundqvist 2016: 17 young women, three days. This randomized, double-blind, cross-over trial enrolled healthy women with normal blood pressure, mean age 23. They ate a low-nitrate diet and rinsed three times a day with chlorhexidine or a look-alike placebo rinse with similar taste. Oral nitrate conversion fell, but plasma nitrite, 24-hour ambulatory blood pressure and resting metabolic rate were unaffected.

Ashworth 2019: 41 young adults, one week. Healthy young vegetarians (22) and omnivores (19) used a placebo and an antibacterial mouthwash for a week each, in a non-randomized, single-blind design. The mouth's nitrate-reducing capacity fell steeply, yet blood pressure and resting metabolic rate did not rise significantly in either group. Dietary nitrate intake was also not statistically different between the groups: 97 mg per day in vegetarians and 78 mg per day in omnivores.

Bhowmick 2026: 90 people, 21 days. In this parallel randomized trial, published as a preliminary report, participants rinsed with 2% saline, 0.2% chlorhexidine or 0.1% octenidine for 21 days and were followed to day 42. Systolic pressure rose slightly in all three groups, including saline, and the authors called the changes clinically insignificant. Pulse pressure, the gap between the two blood pressure numbers, rose in the antimicrobial groups and returned to baseline by day 42. The authors concluded that short-term antimicrobial mouthwash had no clinically significant effect on blood pressure.

Two Studies That Fit Neither List

Woessner 2016: 12 men, a single session. Twelve men with normal blood pressure drank 140 mL of beetroot juice (8.4 mmol of nitrate), then gargled hourly for four hours with one of three commercial mouthwashes of different strengths, one of them chlorhexidine, or with water. Plasma and salivary nitrite fell in steps with stronger rinses. The abstract reports a treatment effect on systolic pressure, words it as a reduction from the stronger rinses, and gives no size in mmHg. This was a short test during a large nitrate load, not a test of everyday use.

Vanhatalo 2025: 75 younger and older adults, two weeks. This placebo-controlled, double-blind cross-over study gave 39 young and 36 older adults three separate two-week conditions, one of them antiseptic mouthwash. The oral bacteria of both age groups were reported as unaffected by the mouthwash condition, unlike the shift seen in the seven-day Bescos 2020 study. The abstract gives its blood pressure figures for beetroot juice and states no blood pressure figure for mouthwash, so it is not counted here either way.

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Two 2026 Reviews of the Mixed Results

Two reviews published in 2026 tried to make sense of these findings.

The pooled analysis. A systematic review and meta-analysis searched for studies of chlorhexidine mouthwash and human blood pressure through December 2024 and found 100 unique studies, of which five met the criteria. Two of the five reported significant rises. Combined, the difference from controls was 1.56 mmHg systolic (95% confidence interval −0.67 to 3.80) and −0.10 mmHg diastolic (−1.99 to 1.78). Neither was significant. The authors stated a moderate level of confidence that, for patients to whom chlorhexidine has been recommended, any change is insignificant or very small, and estimated its clinical importance as negligible (Toonen 2026). A commentary on the same review rated certainty as low, citing methodological limitations and indirect study populations (Mutahar 2026).

The scoping review. A second review covered antibacterial mouthwash more broadly and included nine studies from 2014 onward. Five found significant rises and four found no significant relationship. The authors pointed to differences in length of use, mouthwash ingredients, participants and measurement schedules, and to weak spots such as short washout periods and lack of randomization. They concluded that no firm conclusions can be drawn at this time (Singh 2026).

The two reviews fit together better than their headlines suggest. The pooled confidence interval still includes a rise of up to 3.80 mmHg, which covers the size of the rises seen in the Kapil and Bondonno trials, and it also includes no change at all. A 2023 review came to a similar reading of the wider field, describing the proposed links between mouthwash and systemic disease as having limited levels of evidence (Alrashdan 2023).

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Chlorhexidine Compared With Other Ingredients

"Mouthwash" is not one product. Chlorhexidine is by far the most studied ingredient, and a 2023 review described the data on other over-the-counter types as generally scarce (Alrashdan 2023). Much of the trial evidence concerns chlorhexidine, while the cohort data concern over-the-counter use.

• Chlorhexidine. The strongest and most consistent effect on nitrite. Blood pressure results range from a 2 to 3.5 mmHg rise (Kapil 2013) to no change (Sundqvist 2016), with a pooled result that is not significant (Toonen 2026).
• Non-chlorhexidine "weak" rinses. In a six-day trial with beetroot juice, both chlorhexidine and a non-chlorhexidine rinse held back the rise in plasma nitrite, the chlorhexidine rinse more so. Blood pressure during treadmill walking rose more with chlorhexidine than with water, but not more than with the weaker rinse (McDonagh 2015). Woessner 2016 also found that the effect on nitrite grew in steps with the strength of the rinse.
• Cetylpyridinium chloride. In a blinded trial, 30 healthy young adults rinsed with cetylpyridinium or sodium chloride for seven days. Salivary nitrate, nitrite, cyclic guanosine monophosphate and breath nitric oxide did not change with either rinse. The share of nitrite in saliva was lower with cetylpyridinium (17% against 25%). Blood pressure was not an outcome listed in the abstract (Gallardo 2025).
• Octenidine. In the 21-day Bhowmick trial, 0.1% octenidine worked about as well as 0.2% chlorhexidine on gum and bacterial measures, with fewer adverse events and no clinically significant blood pressure effect (Bhowmick 2026).

The abstracts of the Bondonno, Ashworth and Clarke trials say "antibacterial mouthwash" without naming the ingredient, and the San Juan abstracts say "over-the-counter mouthwash." Neither San Juan abstract separates results by ingredient, which leaves open which ingredients, if any, are behind the association. No abstract read for this page tested a fluoride-only rinse for blood pressure.

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The San Juan Cohort: Hypertension and Prediabetes

The trials above last days or weeks. The longest human mouthwash data on this page come from the San Juan Overweight Adults Longitudinal Study, which enrolled overweight and obese adults aged 40 to 65 in Puerto Rico and followed them for about three years.

Prediabetes and diabetes (Joshipura 2017). Of 1,206 people recruited, free of diabetes and major cardiovascular disease, 945 had complete follow-up. Mouthwash was common: 43% used it at least once a day and 22% at least twice. Using it twice a day or more was linked to a higher rate of prediabetes or diabetes than less frequent use (rate ratio 1.55, 95% confidence interval 1.21 to 1.99) or no use (1.49, 1.13 to 1.95). The figures stayed similar after adjusting for income, education, oral hygiene, oral conditions, sleep breathing disorders, diet, medications and several blood markers. Use less than twice a day showed no association, which the authors read as a possible threshold.

Hypertension (Joshipura 2020). After excluding people who already had hypertension and those with missing data, 540 participants were analyzed, and 66 of them (12%) developed hypertension. Using mouthwash twice a day or more was linked to a higher rate than less frequent use (rate ratio 1.85, 95% confidence interval 1.17 to 2.94) and than no use (2.17, 1.27 to 3.71). The associations held among people who had never smoked. The main outcome was self-reported, doctor-diagnosed hypertension. Other outcomes, including blood pressure measured at a single study visit, showed no association.

Nitrite and blood markers (Guo 2025). A cross-sectional analysis of the same cohort's baseline found that twice-daily use or more went with lower serum nitrite. It was not associated with the other markers of inflammation and blood vessel function that were tested, although the relationship between nitrite or nitrate and some of those markers differed between frequent and less frequent users.

These results are associations in one cohort. The authors adjusted for many factors, but people who rinse twice a day may differ from others in ways the analysis did not capture, and a study of this design cannot establish cause. A 2024 systematic review of oral hygiene and cardiometabolic risk reports increases of 85% and 55% for hypertension and diabetes with mouthwash, the same sizes as the San Juan rate ratios above (Church 2024). The same review found toothbrushing and cleaning between the teeth associated with a lower risk of developing type 2 diabetes or hypertension.

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Exercise and Blood Pressure After Rinsing

Blood pressure normally dips for a while after exercise, an effect called post-exercise hypotension. A randomized, double-blind, cross-over trial tested whether mouth bacteria help cause it. Twenty-three healthy people did treadmill exercise at moderate intensity, then rinsed with antibacterial mouthwash or a placebo rinse.

• With placebo, systolic pressure was 5.2 mmHg lower at one hour and 3.8 mmHg lower at two hours than before exercise, and circulating nitrite rose from 59 to 100 nanomolar at two hours.
• With mouthwash, the fall in systolic pressure was 61% smaller at one hour and gone at two hours. Circulating nitrite did not change, and the blood vessel response in muscle was impaired (Clarke 2019).

A second trial looked at blood pressure during exercise. Twelve healthy volunteers took beetroot juice (70 mL, 6.2 mmol of nitrate, twice a day) for six days, while rinsing three times a day with chlorhexidine, a weaker non-chlorhexidine rinse or water. Resting blood pressure changes did not differ. During treadmill walking, four hours after the last dose, the rise in systolic and mean arterial pressure was greater with chlorhexidine than with water, but not compared with the weaker rinse (McDonagh 2015).

Muscle strength appeared unaffected in a separate pilot trial. Seven days of cetylpyridinium mouthwash did not change peak torque, speed or power of the knee muscles in 30 healthy young adults (Gallardo 2025).

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Dietary Nitrate Studies

The mouthwash question grew out of research on vegetables high in nitrate, such as green leafy vegetables and beetroot. Those trials are themselves mixed.

• Webb 2008. In healthy volunteers, 500 mL of beetroot juice lowered blood pressure by a peak of 10.4/8 mmHg at about three hours, in step with plasma nitrite. Interrupting the conversion of nitrate to nitrite in the mouth prevented the plasma nitrite rise and blocked the fall in pressure.
• Kapil 2015. In 68 people with hypertension, half on medication and half not, a trial gave 250 mL of beetroot juice daily for four weeks, against a nitrate-free beetroot juice. Clinic pressure fell by 7.7/2.4 mmHg, 24-hour ambulatory pressure by 7.7/5.2 and home pressure by 8.1/3.8, relative to placebo.
• Bondonno 2015, the second paper. In 27 people treated for hypertension, one week of nitrate-rich beetroot juice raised plasma nitrite threefold and salivary nitrite sevenfold, but home and 24-hour blood pressure did not differ from placebo.
• Ashor 2017. Thirteen trials with 325 participants, lasting one to six weeks, gave pooled falls of 4.1 mmHg systolic and 2.0 mmHg diastolic. These were significant only in resting clinic readings, not in 24-hour or home monitoring.
• Zhang 2023. Across 19 articles, nitrate lowered systolic pressure by 2.42 mmHg in healthy people, while no significant reduction was found in people with hypertension.
• Norouzzadeh 2025. Across 75 randomized trials and 1,823 participants, each extra millimole of nitrate went with 0.28 mmHg lower systolic pressure in acute studies and 0.48 mmHg lower in medium-term studies.

People respond differently, and age appears to matter. In a replicate cross-over trial of 15 healthy men, 140 mL of nitrate-rich beetroot juice reduced pressure by 7/6 mmHg against placebo, but with response differences of about ±7 mmHg systolic from one man to the next (Hayes 2025). Older adults (67 to 79 years) saw mean arterial pressure fall by 4 mmHg after two weeks of beetroot juice, an effect absent in young adults (Vanhatalo 2025). The earlier Vanhatalo 2018 study reported a similar age pattern. The food itself may also act differently from a pill: in people with high blood pressure, five weeks of 300 mg per day of nitrate from green leafy vegetables or from potassium nitrate pills produced overlapping changes in mouth bacteria, and only the vegetables raised salivary buffering capacity and lowered lactate (du Toit 2024).

The overall picture for nutrition is on the Beets for Nitrates and Blood Pressure and Celery, Dietary Nitrate, and Blood Pressure pages.

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The Tongue, the Gums and Oral Bacteria

Antiseptic rinses are not the only thing that may affect the mouth's nitrate step. The health of the gums and the mix of bacteria appear to matter on their own.

• Gum disease. In a study of 15 people with periodontitis and 15 healthy controls, beetroot juice lowered systolic and diastolic pressure in the healthy group at 90 minutes, but not in the periodontitis group. After periodontal treatment, including removal of plaque, the effect returned (Sanchez-Orozco 2025). The authors asked for confirmation in randomized trials.
• Women with hypertension. Among 55 pregnant and non-pregnant women, those with hypertension had lower salivary nitrite and less of the nitrate-reducing genus Veillonella. Nitrate-reducing activity in the mouth was associated with both baseline diastolic pressure and its change after a beetroot dose (Willmott 2023).
• Older women, long follow-up. In a cohort of 1,215 postmenopausal women at baseline, 15 species in plaque below the gum line were associated with later hypertension over a mean of 10.4 years, 10 with higher risk and 5 with lower (LaMonte 2022). This study did not test mouthwash.
• Tongue cleaning. In the Tribble 2019 trial, tongue cleaning frequency predicted how much chlorhexidine changed systolic pressure. Tongue care itself is covered on the Tongue Scraping page.

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Studies in Rats

Animal work supplied some of the earliest evidence, and its results do not transfer directly to people. In rats given nitrate in their drinking water, a twice-daily antiseptic mouthwash greatly reduced nitrate-reducing bacteria and removed the fall in blood pressure that nitrate otherwise produced (Petersson 2009). In hypertensive rats, oral nitrite lowered pressure even with antiseptic mouthwash, while oral nitrate did not, which suggests the rinse affects the nitrate step rather than nitrite itself (Pinheiro 2016). In a one-week study in rats, a rinse containing inorganic nitrate and antioxidants produced more favorable blood pressure changes than a chlorhexidine rinse (Senkus 2025). No abstract read for this page reports a human trial of that kind of rinse.

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Plaque, Gums and Known Side Effects

Rinses are used for practical reasons, and the blood pressure question sits next to measured effects on the teeth and gums.

Chlorhexidine. A Cochrane review of 51 studies and 5,345 participants, with rinsing for at least four weeks alongside brushing, found a large reduction in plaque at 4 to 6 weeks and at 6 months, rated high-quality evidence. Gingivitis fell by 0.21 points on a 0 to 3 scale in people with mild inflammation, a reduction the reviewers judged not clinically relevant. There were insufficient data for moderate or severe gum inflammation. The review states that rinsing for four weeks or longer causes tooth staining. Taste changes were reported in 11 studies, mouth soreness, irritation, peeling and ulcers in 13, and burning sensations in 9 (James 2017).

Everyday over-the-counter rinses. An umbrella review of nine systematic reviews covered low-concentration chlorhexidine, cetylpyridinium chloride, essential oils, fluoride and oxygen-releasing rinses. In all nine reviews, prolonged daily use helped reduce plaque and gum inflammation scores, though not always significantly. The essential-oil rinses gave the best results among the types tested (Koromantzos 2026).

Hospitals. A separate debate concerns chlorhexidine mouth care in hospital patients. A single-center observational study of 82,274 patients found low-level exposure associated with more deaths (odds ratio 2.61, 95% confidence interval 2.32 to 2.92), most strongly in patients with a lower risk of death. No harmful effect was seen in intensive care patients. The authors argued against indiscriminate widespread use in hospitals in the absence of proven benefit in specific groups (Deschepper 2018). A later review proposed disturbed nitric oxide balance as a possible explanation and described itself as hypothesis-generating (Blot 2021). Patients who receive such care may differ from those who do not, and this kind of study cannot fully separate that from an effect of the rinse. These findings concern hospitalized patients and not the use of a rinse at home.

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The Limits of This Evidence

• The trials are small and short. The human mouthwash trials of nitrite and blood pressure on this page ran from 7 to 90 people. None lasted more than 21 days of rinsing, so they cannot show what years of use do.
• The trials measure pressure, not disease. None of their abstracts reports heart attacks or strokes as outcomes. A rise of 2 to 3.5 mmHg over a week says nothing direct about those events.
• The long-term data come from one cohort of one kind of person. The San Juan participants were overweight or obese adults aged 40 to 65. The hypertension result rests on 66 cases and a self-reported diagnosis, and single-visit blood pressure readings in the same study showed no association.
• Trial designs differ. Some compared rinses with water, some with placebo rinses, and some used a fixed order. The Singh 2026 review named short washouts and lack of randomization as weaknesses. Diets also differ, and the one trial here that combined double-blinding with a low-nitrate diet found no change.
• Few people with hypertension have been tested. The direct mouthwash trial in treated hypertension on this page enrolled 15 people. Most other participants were healthy.
• The chain has a broken link in some studies. Lower nitrite in the mouth was not always followed by lower plasma nitrite or higher blood pressure (Sundqvist 2016, Ashworth 2019).
• Financial interests appear on more than one side. Some Toonen 2026 authors disclose past fees or grants from manufacturers of dental care products. Authors of some nitrate papers disclose patents on therapeutic nitrate, or a financial interest in a business that sells nitric oxide products (Willmott 2023, Hyde 2014).

Taken together, the mouth nitrite effect is well documented, a small short-term blood pressure effect has been seen in some trials and not others, and the longer-term link rests on association. Whether regular rinsing changes heart or metabolic outcomes remains unknown.

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Key Research Papers

1. Bondonno CP, Liu AH, Croft KD, Considine MJ, Puddey IB, Woodman RJ, Hodgson JM. Antibacterial mouthwash blunts oral nitrate reduction and increases blood pressure in treated hypertensive men and women. Am J Hypertens. 2015;28(5):572-5. PubMed PMID: 25359409
2. Kapil V, Haydar SM, Pearl V, Lundberg JO, Weitzberg E, Ahluwalia A. Physiological role for nitrate-reducing oral bacteria in blood pressure control. Free Radic Biol Med. 2013;55:93-100. PubMed PMID: 23183324
3. Govoni M, Jansson EA, Weitzberg E, Lundberg JO. The increase in plasma nitrite after a dietary nitrate load is markedly attenuated by an antibacterial mouthwash. Nitric Oxide. 2008;19(4):333-7. PubMed PMID: 18793740
4. Sundqvist ML, Lundberg JO, Weitzberg E. Effects of antiseptic mouthwash on resting metabolic rate: A randomized, double-blind, crossover study. Nitric Oxide. 2016;61:38-44. PubMed PMID: 27769826
5. Ashworth A, Clarke C, Farnham G, Liddle L, Burleigh M, Rodiles A, Sillitti C, Kiernan M, Moore M, Hickson M, Easton C, Bescos R. Dietary intake of inorganic nitrate in vegetarians and omnivores and its impact on blood pressure, resting metabolic rate and the oral microbiome. Free Radic Biol Med. 2019;138:63-72. PubMed PMID: 31082507
6. Bescos R, Ashworth A, Clarke C, Brookes ZL, Belfield L, Rodiles A, Casas-Agustench P, Farnham G, Liddle L, Burleigh M, White D, Easton C, Hickson M. Effects of Chlorhexidine mouthwash on the oral microbiome. Sci Rep. 2020;10(1):5254. PubMed PMID: 32210245
7. Tribble GD, Angelov N, Weltman R, Wang BY, Eswaran SV, Gay IC, Parthasarathy K, Dao DV, Richardson KN, Ismail NM, Sharina IG, Hyde ER, Ajami NJ, Petrosino JF, Bryan NS. Frequency of Tongue Cleaning Impacts the Human Tongue Microbiome Composition and Enterosalivary Circulation of Nitrate. Front Cell Infect Microbiol. 2019;9:39. PubMed PMID: 30881924
8. Woessner M, Smoliga JM, Tarzia B, Stabler T, Van Bruggen M, Allen JD. A stepwise reduction in plasma and salivary nitrite with increasing strengths of mouthwash following a dietary nitrate load. Nitric Oxide. 2016;54:1-7. PubMed PMID: 26778277
9. Bhowmick D, Nayek M, Aquil A, Rudra A, Mistry S, Nair V, Das I. Effects of Antimicrobial Mouthwashes on Oral Health and Blood Pressure: A Preliminary Parallel Randomized Controlled Trial. Oral Dis. 2026. doi:10.1111/odi.70537. Online ahead of print. PubMed PMID: 42861455
10. Toonen LSJ, Van Swaaij BWM, Vagevuur ML, Van der Weijden FGA, Timmerman MF, Slot DE. The Effect of Chlorhexidine Mouthwash on Blood Pressure: A Systematic Review and Meta-Analysis. Int J Dent Hyg. 2026;24(3):390-403. PubMed PMID: 41820203
11. Mutahar M, Alshirah A, Al-Moraissi EA. Should chlorhexidine mouthwash be a concern for blood pressure in dental patients? Evid Based Dent. 2026;27(3):65-66. PubMed PMID: 42420435
12. Singh B, North P, Rushetsky ZM, Brito RC, Jenney FE Jr. The effect of antibacterial mouthwash on blood pressure in humans: a scoping review. BMC Cardiovasc Disord. 2026;26(1):807. PubMed PMID: 42754848
13. Alrashdan MS, Leao JC, Doble A, McCullough M, Porter S. The Effects of Antimicrobial Mouthwashes on Systemic Disease: What Is the Evidence? Int Dent J. 2023;73 Suppl 2:S82-S88. PubMed PMID: 37867067
14. Joshipura K, Muñoz-Torres F, Fernández-Santiago J, Patel RP, Lopez-Candales A. Over-the-counter mouthwash use, nitric oxide and hypertension risk. Blood Press. 2020;29(2):103-112. PubMed PMID: 31709856
15. Joshipura KJ, Muñoz-Torres FJ, Morou-Bermudez E, Patel RP. Over-the-counter mouthwash use and risk of pre-diabetes/diabetes. Nitric Oxide. 2017;71:14-20. PubMed PMID: 28939409
16. Guo K, Joshipura K, Ricart K, Patel RP, Gower BA, Andriankaja OM, Morou-Bermudez E. Association of over-the-counter mouthwash use with markers of nitric oxide metabolism, inflammation, and endothelial function-a cross-sectional study. Front Oral Health. 2025;6:1488286. PubMed PMID: 39981124
17. Church L, Franks K, Medara N, Curkovic K, Singh B, Mehta J, Bhatti R, King S. Impact of Oral Hygiene Practices in Reducing Cardiometabolic Risk, Incidence, and Mortality: A Systematic Review. Int J Environ Res Public Health. 2024;21(10):1319. PubMed PMID: 39457293
18. Clarke C, Kiernan M, Willis JR, Gallardo-Alfaro L, Casas-Agustench P, White D, Hickson M, Gabaldon T, Bescos R. Post-exercise hypotension and skeletal muscle oxygenation is regulated by nitrate-reducing activity of oral bacteria. Free Radic Biol Med. 2019;143:252-259. PubMed PMID: 31369841
19. McDonagh ST, Wylie LJ, Winyard PG, Vanhatalo A, Jones AM. The Effects of Chronic Nitrate Supplementation and the Use of Strong and Weak Antibacterial Agents on Plasma Nitrite Concentration and Exercise Blood Pressure. Int J Sports Med. 2015;36(14):1177-85. PubMed PMID: 26332900
20. Gallardo EJ, Zoughaib WS, Singhal A, Hoffman RL, Coggan AR. Pilot randomized trial of the effect of antibacterial mouthwash on muscle contractile function in healthy young adults. PLoS One. 2025;20(2):e0312961. PubMed PMID: 39937800
21. Lundberg JO, Weitzberg E, Gladwin MT. The nitrate-nitrite-nitric oxide pathway in physiology and therapeutics. Nat Rev Drug Discov. 2008;7(2):156-67. PubMed PMID: 18167491
22. Hyde ER, Andrade F, Vaksman Z, Parthasarathy K, Jiang H, Parthasarathy DK, Torregrossa AC, Tribble G, Kaplan HB, Petrosino JF, Bryan NS. Metagenomic analysis of nitrate-reducing bacteria in the oral cavity: implications for nitric oxide homeostasis. PLoS One. 2014;9(3):e88645. PubMed PMID: 24670812
23. Webb AJ, Patel N, Loukogeorgakis S, Okorie M, Aboud Z, Misra S, Rashid R, Miall P, Deanfield J, Benjamin N, MacAllister R, Hobbs AJ, Ahluwalia A. Acute blood pressure lowering, vasoprotective, and antiplatelet properties of dietary nitrate via bioconversion to nitrite. Hypertension. 2008;51(3):784-90. PubMed PMID: 18250365
24. Kapil V, Khambata RS, Robertson A, Caulfield MJ, Ahluwalia A. Dietary nitrate provides sustained blood pressure lowering in hypertensive patients: a randomized, phase 2, double-blind, placebo-controlled study. Hypertension. 2015;65(2):320-7. PubMed PMID: 25421976
25. Bondonno CP, Liu AH, Croft KD, Ward NC, Shinde S, Moodley Y, Lundberg JO, Puddey IB, Woodman RJ, Hodgson JM. Absence of an effect of high nitrate intake from beetroot juice on blood pressure in treated hypertensive individuals: a randomized controlled trial. Am J Clin Nutr. 2015;102(2):368-75. PubMed PMID: 26135348
26. Ashor AW, Lara J, Siervo M. Medium-term effects of dietary nitrate supplementation on systolic and diastolic blood pressure in adults: a systematic review and meta-analysis. J Hypertens. 2017;35(7):1353-1359. PubMed PMID: 28319596
27. Zhang Y, Zhang H, An W, Li D, Qin L. Regulatory effect of dietary nitrate on blood pressure: a meta-analysis of randomized controlled trials. Food Funct. 2023;14(4):1839-1850. PubMed PMID: 36740972
28. Norouzzadeh M, Hasan Rashedi M, Ghaemi S, Saber N, Mirdar Harijani A, Habibi H, Mostafavi S, Sarv F, Farhadnejad H, Teymoori F, Khaleghian M, Mirmiran P. Plasma nitrate, dietary nitrate, blood pressure, and vascular health biomarkers: a GRADE-Assessed systematic review and dose-response meta-analysis of randomized controlled trials. Nutr J. 2025;24(1):47. PubMed PMID: 40128734
29. Hayes E, Alhulaefi S, Siervo M, Whyte E, Kimble R, Matu J, Griffiths A, Sim M, Burleigh M, Easton C, Lolli L, Atkinson G, Mathers JC, Shannon OM. Inter-individual differences in the blood pressure lowering effects of dietary nitrate: a randomised double-blind placebo-controlled replicate crossover trial. Eur J Nutr. 2025;64(2):101. PubMed PMID: 39992469
30. Vanhatalo A, Blackwell JR, L'Heureux JE, Williams DW, Smith A, van der Giezen M, Winyard PG, Kelly J, Jones AM. Nitrate-responsive oral microbiome modulates nitric oxide homeostasis and blood pressure in humans. Free Radic Biol Med. 2018;124:21-30. PubMed PMID: 29807159
31. Vanhatalo A, L'Heureux JE, Black MI, Blackwell JR, Aizawa K, Thompson C, Williams DW, van der Giezen M, Winyard PG, Jones AM. Ageing modifies the oral microbiome, nitric oxide bioavailability and vascular responses to dietary nitrate supplementation. Free Radic Biol Med. 2025;238:682-696. PubMed PMID: 40615058
32. du Toit L, Sundqvist ML, Redondo-Rio A, Brookes Z, Casas-Agustench P, Hickson M, Benavente A, Montagut G, Weitzberg E, Gabaldón T, Lundberg JO, Bescos R. The Effect of Dietary Nitrate on the Oral Microbiome and Salivary Biomarkers in Individuals with High Blood Pressure. J Nutr. 2024;154(9):2696-2706. PubMed PMID: 39019159
33. Sanchez-Orozco NY, Rosier BT, Ruiz-Gutierrez A, Marquez-Sandoval F, Artacho A, Carrera-Quintanar L, Mira A. The blood pressure lowering effect of beetroot juice is impaired in periodontitis and recovered after periodontal treatment. NPJ Biofilms Microbiomes. 2025;11(1):10. PubMed PMID: 39788958
34. Willmott T, Ormesher L, McBain AJ, Humphreys GJ, Myers JE, Singh G, Lundberg JO, Weitzberg E, Nihlen C, Cottrell EC. Altered Oral Nitrate Reduction and Bacterial Profiles in Hypertensive Women Predict Blood Pressure Lowering Following Acute Dietary Nitrate Supplementation. Hypertension. 2023;80(11):2397-2406. PubMed PMID: 37702047
35. LaMonte MJ, Gordon JH, Diaz-Moreno P, Andrews CA, Shimbo D, Hovey KM, Buck MJ, Wactawski-Wende J. Oral Microbiome Is Associated With Incident Hypertension Among Postmenopausal Women. J Am Heart Assoc. 2022;11(6):e021930. PubMed PMID: 35234044
36. Petersson J, Carlström M, Schreiber O, Phillipson M, Christoffersson G, Jägare A, Roos S, Jansson EA, Persson AE, Lundberg JO, Holm L. Gastroprotective and blood pressure lowering effects of dietary nitrate are abolished by an antiseptic mouthwash. Free Radic Biol Med. 2009;46(8):1068-75. PubMed PMID: 19439233
37. Pinheiro LC, Ferreira GC, Amaral JH, Portella RL, Tella SOC, Passos MA, Tanus-Santos JE. Oral nitrite circumvents antiseptic mouthwash-induced disruption of enterosalivary circuit of nitrate and promotes nitrosation and blood pressure lowering effect. Free Radic Biol Med. 2016;101:226-235. PubMed PMID: 27769921
38. Senkus KE, Azrad M, Bolland A, Park HA, Tice JR, Zhang M, Liu T, Blood AB, Van Der Pol W, Morrow C, Crowe-White KM. Functional mouth rinse containing inorganic nitrate and antioxidants bolsters the enterosalivary pathway and lowers blood pressure in Wistar rats. Sci Rep. 2025;15(1):26827. PubMed PMID: 40702063
39. James P, Worthington HV, Parnell C, Harding M, Lamont T, Cheung A, Whelton H, Riley P. Chlorhexidine mouthrinse as an adjunctive treatment for gingival health. Cochrane Database Syst Rev. 2017;3(3):CD008676. PubMed PMID: 28362061
40. Koromantzos PA, Bobetsis YA, Giota C, Gizani S, Apatzidou DA, Rahiotis C, Kalfas S, Seremidi K, Papadimitriou K, Karakostas P, Davidopoulou S, Kaklamanos E, Papaioannou W. Effect of Adjunctive Use of Commercial Daily Mouthwashes on Periodontal Health: An Umbrella Review. J Clin Periodontol. 2026;53(3):407-423. PubMed PMID: 41265469
41. Deschepper M, Waegeman W, Eeckloo K, Vogelaers D, Blot S. Effects of chlorhexidine gluconate oral care on hospital mortality: a hospital-wide, observational cohort study. Intensive Care Med. 2018;44(7):1017-1026. PubMed PMID: 29744564
42. Blot S. Antiseptic mouthwash, the nitrate-nitrite-nitric oxide pathway, and hospital mortality: a hypothesis generating review. Intensive Care Med. 2021;47(1):28-38. PubMed PMID: 33067640

PubMed Topic Searches

1. PubMed: antiseptic mouthwash, blood pressure and nitrite
2. PubMed: chlorhexidine mouthwash and blood pressure
3. PubMed: oral nitrate-reducing bacteria and nitric oxide
4. PubMed: over-the-counter mouthwash, hypertension and diabetes
5. PubMed: dietary nitrate and blood pressure meta-analyses

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Connections

• Dentistry & Oral Health — the section this page belongs to
• Oral Microbiome — the wider community of mouth bacteria
• Tongue Scraping — the tongue, where many nitrate-reducing bacteria live
• Gingivitis — the gum condition these rinses are used for
• Gum Disease — how gum health relates to the nitrate step
• Hypertension — high blood pressure in full
• Prediabetes — the other outcome in the San Juan cohort
• Beets for Nitrates and Blood Pressure — the food side of the same pathway
• Nitrates and Nitrites — the safety and food-supply side of these compounds

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