Self-reported Knowledge and Practice of Saudi Dental Hygiene Students Towards the use of Chlorhexidine Mouthwash

Self-reported Knowledge and Practice of Saudi Dental Hygiene Students Towards the use of Chlorhexidine Mouthwash

Mushir Mulla1 , * Open Modal iD
Authors Info & Affiliations
The Open Dentistry Journal 31 Mar 2023 RESEARCH ARTICLE DOI: 10.2174/18742106-v17-230317-2022-160



To assess the knowledge and practice of Saudi dental hygiene students regarding the use of mouthwashes in clinical practice.


Mouthwashes are chemical plaque control agents which are widely used for the prevention of tooth decay, gaining fresh breath, reducing plaque and calculus formation, and reducing gingival inflammation. Chlorhexidine is considered a gold standard mouthwash because of its substantivity action. Thus, it is very important for dental practitioners to understand the knowledge and practices regarding the use of Chlorhexidine mouthwash


The primary objective of this study was to find dental hygiene students’ knowledge about chlorhexidine mouthwash and its side effects and also identify their practice toward the use of mouthwashes as plaque inhibiting agents.


An online version of a pre-tested and validated questionnaire was used to test the knowledge and practices towards the use of Chlorhexidine mouthwash. Thus, A Cross-sectional questionnaire survey was carried out in Saudi Arabia on dental hygiene students.


A total of 144 filled questionnaires were obtained out of which 88% were male and 12% were female. After converting the scores into percentages, any score <60% was categorized as a poor score, 60-80% as an average score, and >80% as a good score. Dental hygiene students showed an average knowledge about Chlorhexidine mouthwash with a score of 62.27% and also poor practice with a score of 57.98%.


The findings of this cross-sectional study demonstrate that most of the Dental hygiene students in Saudi Arabia have got average knowledge and poor practice about the usage of Chlorhexidine mouthwash.

Clinical Significance:

Being the oral health care providers, it is mandatory for dental hygiene students to have adequate knowledge regarding the usage of mouthwashes. With optimum knowledge, they will be able to deliver the right information to the patients thereby ensuring the proper practice of the same.

Keywords: Chlorhexidine, Mouthwash, Dental hygiene students, Knowledge and practice, Cross-sectional study, Plaque.


Although oral diseases such as dental caries, gingivitis, and periodontitis are considered multifactorial, dental plaque plays a major role in the establishment of these diseases. Past literature has confirmed a very strong relation between these [1-3]. Various procedures are carried out to eliminate the cause of these diseases. Likewise, periodontal therapy is carried out to eliminate the bacterial plaque thereby avoiding a further build-up of plaque bacteria which would lead to disease progression [4-6]. Non-surgical as well as surgical periodontal therapy are two mechanical methods used for the same [7, 8]. Along with mechanical methods, various chemical plaque-controlling agents have also been used as an adjunct. Chemical plaque-controlling agents have proven to be beneficial in patients with limited dexterity, associated systemic illness, post-surgical management, etc. [9-11].

Mouthwashes are one such chemical plaque control agent which has been used widely to obtain beneficial results in terms of gaining fresh breath, prevention of tooth decay, reducing plaque and calculus formation, and reducing gingival inflammation [12, 13]. Mouthwash contains active ingredients such as chlorhexidine gluconate, cetylpyridinium chloride, hydrogen peroxide, hexetidine, methyl salicylate, domiphen bromide, thymol, eucalyptol, menthol, benzalkonium chloride, methylparaben, and sometimes fluoride, enzymes and calcium [14]. It also contains water, and sweeteners namely sucralose, sorbitol, xylitol, and sodium saccharine. Chlorhexidine, triclosan, and listerine are the most commonly used mouthwashes [15]. Chlorhexidine is considered gold standard mouthwash because of its substantivity action which is, it has the ability to stay for a longer duration in the mouth by binding to hard and soft tissues [16, 17].

As dental practitioners have a greater role in educating patients regarding the beneficial use of mouthwashes. The hypothesis of this study is that adequate knowledge regarding mouthwashes will lead to optimum practice towards their uses by dental hygiene students. Thus, this study was conducted amongst Saudi dental hygiene students to assess their knowledge and practice towards the use of mouthwashes in clinical practice.


A cross-sectional study was conducted among the dental hygiene students of Saudi Arabia to assess their knowledge and practice regarding chlorhexidine mouthwash. The study period lasted from February 2021 to August 2021. At the beginning of the study, ethical clearance was taken from the Institutional review board of the College of Dentistry, Qassim University. The study questionnaire was validated and pre-tested amongst the Dental Hygiene students at Qassim University. For Validation, 4 subject experts were asked for their valuable recommendations after rating every question. The questions were thus modified and used on 40 Dental hygiene students from Qassim University. The students gave a report on how well they could understand the questions. And the final Questionnaire of 18 questions was prepared based on their feedback. Based on the results of the pilot study, a sample size of 140 was calculated using the formula: n = (S^2 [Z _(1-α/2) +Z _(1-α/2)]2)/([x-μ] ^2), a 95% confidence level (α = 0.05) and 5% confidence interval to attain a significant result. The questionnaire was forwarded to dental hygiene students studying in various colleges in Saudi Arabia, by employing a convenience snowball sampling technique. They were invited to participate in the study through various social media platforms. Personal messages and e-mails were also sent to achieve maximum participation. Google forms were used to prepare the questionnaire. Any questionnaire that was completely filled was included. Anonymity and confidentiality of the provided data were guaranteed to the study participants. The submitted questionnaire was regarded as consent to participation by the students.

The research questionnaire comprised three parts; the first part contained questions related to sociodemographic details, the second part contained seven questions related to knowledge, and the third part contained six questions related to practice regarding chlorhexidine mouthwash. All the data were then tabulated and subjected to statistical analysis using the Statistical Package of Social Science (SPSS) version 16.


A total of 144 filled questionnaires were obtained at the end of the timeline. Out of which 88% were male and 12% were female. The maximum number of students were from Qassim University. Table 1 shows demographic data.

Table 1.
Demographic data of the participants (N = 144).
Study Variable N (%)
• Male 127 (88%)
• Female 17 (12%)
• Qassim University 65 (45%)
• King Saud University 24 (17%)
• King Abdulaziz University 6 (4%)
• Al Baha University 13 (9%)
• Prince Sattam Bin Abdulaziz University 12 (8%)
• Inaya Medical College 16 (11%)
• Mustaqbal University 8 (6%)
Academic Year
• First-year 43 (30%)
• Second year 36 (25%)
• Third year 65 (45%)

When asked about the type of mouthwashes they knew, 67% of students were aware of Chlorhexidine mouthwash (Fig. 1).

The questionnaire consisted of seven questions regarding knowledge and six questions regarding the practice of chlorhexidine mouthwash. The participants had to choose from the options given for each question in the questionnaire. Every correct answer scored 1 whereas the wrong answer was 0. Based on Bloom’s cut-off point, the score was categorized as poor, average, or good score (Table 2).

Interpretation of the scores after converting into percentages was; Poor for less than 60%, Average for 60% - 80%, and Good for scores above 80%. Thus, the dental hygiene students had an average knowledge of Chlorhexidine mouthwash with a score of 62.27% and also poor practice with a score of 57.98%.

Fig. (1). Knowledge of dental hygiene students regarding type of mouthwashes.
Table 2.
Responses for each question.
Knowledge Related Questions Correct Wrong Total
What is the role of mouthwash N 105 39 144
% 72.91 27.09 100
What is the taste of mouthwash N 96 48 144
% 66.66 33.34 100
Where patients could get Chlorhexidine mouthwash N 79 65 144
% 54.86 45.14 100
Does Chlorhexidine cause Allergic reactions? N 97 47 144
% 67.36 32.64 100
What are other effects of mouthwash N 90 54 144
% 62.5 37.5 100
How long does the taste remain in the mouth after rinsing N 71 73 144
% 49.3 50.7 100
Practice Related Questions
How many times per day do you advise your patient to use the mouthwash N 98 46 144
% 68 32 100
When do you use mouthwash N 78 66 144
% 54.16 45.84 100
How long to keep the mouthwash in the mouth N 90 54 144
% 62.5 37.5 100
Do you dilute the mouthwash N 63 81 144
% 43.75 56.25 100
What is the time interval that you keep between mouthwash and eating/drinking N 55 89 144
% 38.2 61.8 100
Do you think there is a need for more awareness programs about in detailed usage of the mouthwash N 117 27 144
% 81.25 18.75 100


Poor oral hygiene causes the accumulation of dental plaque. This can lead to inflammation of the periodontal tissues causing gingivitis and periodontitis. Mechanical removal of plaque is considered important to remove plaque. There are conditions in which chemical agents are also used along with mechanical techniques to aid in the treatment [18-20]. Thus, mouthwashes are regularly prescribed by dentists to fasten the healing of periodontal inflammation. Mouthwashes are commonly prescribed by dental practitioners for obtaining improved oral health post-oral prophylaxis treatment. As mouthwashes are indicated for various conditions, they are now being used for daily oral hygiene. However, it has been documented that regular use of mouthwashes is connected with certain side effects [21]. Authors have reported that frequent use of mouthwashes can be a risk factor for developing diabetes. Various other effects such as the development of calculus and extrinsic staining have also been reported. In the 1940s, Chlorhexidine, a bisbiguanide was developed in the UK and was used and sold as a general disinfectant. It was after a while that its antiplaque activity was discovered. Chlorhexidine mouthwash was available as mouthwash only by 1976 [22].

It is necessary to have proper knowledge regarding the use of chlorhexidine mouthwashes. The findings of this Cross-sectional study demonstrate that most of the Dental hygiene students in Saudi Arabia have got average knowledge and poor practice about the usage of Chlorhexidine mouthwash. Thus, the results do not support the research hypothesis.

This study was carried out to assess the knowledge and practice of dental hygiene students of Saudi Arabia regarding the use of chlorhexidine mouthwash. Research has been carried out on dental students, but not on dental hygiene students in Saudi Arabia [23]. Out of the total seven colleges, 144 students participated. 12% were females and 88% were male students. The reason could be that more male students enrolled than females in the field of dental hygiene. In the present study, most of the students were aware of the chlorhexidine mouthwash as compared to the other mouthwashes. When compared to another study conducted by Benjamin et al., most of the participants in their study used Betadine mouthwash. This difference in the findings can be suggestive of the difference in the geographic setting [24].

In the present study, nearly half of the study participants reported that chlorhexidine mouthwash causes allergic reactions whereas 11% of students mentioned extrinsic stains. The lack of sufficient knowledge regarding the side effects of chlorhexidine mouthwash can be a reason for the over-prescription of mouthwashes even for unwanted cases. Chlorhexidine is used for various purposes which can be either a therapeutic reason or prophylactic. When used in the ideal dosage, side effects can be minimalized and efficacy can be maximized [25]. Previous studies have reported various commonly observed side effects such as a change in taste, feeling of numbness, pain, xerostomia and tooth discoloration, and calculus formation. Less frequently observed was parotid gland swelling. Paraesthesia and desquamation of the oral mucosa. But the main issue is the discoloration of the tooth which discourages the patients and results in discontinuing the use [26-28].

As regards to the role of Mouthwash, students responded that mouthwash can be used for Gingivitis, Periodontitis, Bad breath & Dental caries. Chlorhexidine can be used either for presurgical cases or post-surgical cases (short-term maintenance and long-term maintenance). Chlorhexidine rinse is done pre-operatively to reduce the bacterial load intraorally prior to the commencement of the treatment. For short-term post-operative care where toothbrushing is contraindicated, chlorhexidine rinse is advised. For other cases where long-term postoperative management is required to reduce the inflammation, local administration in the form of a chip is advised [29-31].

Also, regarding the taste of mouthwash, there were differences in the opinions of students. 67% of students described it as bitter in taste, 13% described it to be as tasteless, 11% as Sugary and 9% students described it as Salty. In this study, most of the students (55%) reported that Chlorhexidine mouthwash is available at the pharmacy. Chlorhexidine is an antimicrobial agent which is available in different formulations such as varnishes, mouthwashes, gels, and chips. All of these are available by prescription at hospitals & pharmacies [32-34].

According to the study by Nevada et al., almost 75% of dental practitioners prescribe and encourage patients to use mouthwash twice daily [34]. In our study too, the majority of Dental hygiene students (68%) prefer to advise the use of mouthwash twice a day. Also, most of the students in this study (54.16%) responded that they use mouthwash after brushing which is, as per, the studies conducted by Shahid Mitha et al. [35].

Around 56.25% of the students mentioned that they dilute the mouthwash and around 62.5% mentioned that they keep the mouthwash for more than 30 seconds. But for optimum effect Chlorhexidine mouthwash should be used undiluted. Chlorhexidine is a broad spectrum that affects Gram-positive, and Gram-negative bacteria and also fungi. It acts either by inactivating the microorganisms or by killing them. Its mode of action depends upon the concentration used. Within 30 seconds, chlorhexidine is found to kill all Gram-positive and Gram-negative bacteria. When used in low concentration, the integrity of the bacterial cell wall is affected. With respect to the time interval of use of mouthwash and eating/drinking, only 38.2% of students mentioned about 1 hour. It is always advised to keep an interval of more than 1 hr between the use of any agents and rinsing. Various agents tend to deactivate chlorhexidine thereby reducing its efficacy. Insoluble salts are formed when in contact with anionic compounds commonly found in detergents, carbomers, acrylates, etc. [36].

Similar studies were carried out to assess the knowledge and practice regarding mouthwash among dental students and practitioners. Although both study participants showed adequate knowledge but dental practitioners showed excellent practice as well [ 24, 37]. In the present study, the majority of the responses were from Qassim University, which could be a reason for bias in the results obtained. Also, the study was conducted through a questionnaire which could have also led to bias. These are the limitations observed by the author in this study. As this is the only study conducted on Saudi Arabian dental hygiene students, the insights obtained from this study may be of assistance for future research.


To the best of the author’s knowledge, this is the first study conducted to assess dental hygiene students of Saudi Arabia. Through our findings, it can be concluded that Dental hygiene students in Saudi Arabia have got average knowledge and poor practice about the usage of Chlorhexidine mouthwash.

Since dental hygiene students are going to be Dental health practitioners, it is important for them to have adequate knowledge, correct attitude, and motivation toward the proper use of mouthwashes. More knowledge should be imparted to them regarding mouthwashes through their curriculum and seminar & workshops. They must be aware about the various types of mouthwashes available in the market along with their indications and side effects. This will help them in the proper prescription of mouthwashes and improve the oral health of the community.


SPSS = Statistical Package of Social Science
STM = Short-term Maintenance
LTM = Long-term Maintenance


The author confirms sole responsibility for the following: study conception and design, data collection, analysis and interpretation of results, and manuscript preparation.


The study was approved by the Institutional Review Board of the College of Dentistry, Qassim University.


No animals were used in this study. All procedures performed in studies involving human subjects were in accordance with the ethical standards of the institutional and research committee and with the 1975 Declaration of Helsinki as revised in 2013.


Informed consent was obtained from all subjects involved in the study.


The data presented in this study are available on request from the corresponding author [M.M].


STROBE guidelines were followed in this study.


This research received no external funding.


The authors declare no conflict of interest, financial or otherwise.


Declared none.


Loesche WJ. Chemotherapy of dental plaque infections. Oral Sci Rev 1976; 9: 65-107.
Socransky SS. Microbiology of periodontal disease-present status and future considerations. J Periodontol 1977; 48(9): 497-504.
Loesche WJ. Clinical and microbiological aspects of chemotherapeutic agents used according to the specific plaque hypothesis. J Dent Res 1979; 58(12): 2404-12.
Axelsson P, Nyström B, Lindhe J. The long-term effect of a plaque control program on tooth mortality, caries and periodontal disease in adults. Results after 30 years of maintenance. J Clin Periodontol 2004; 31(9): 749-57.
Costerton JW, Lewandowski Z, DeBeer D, Caldwell D, Korber D, James G. Biofilms, the customized microniche. J Bacteriol 1994; 176(8): 2137-42.
Socransky SS, Haffajee AD. Dental biofilms: Difficult therapeutic targets. Periodontol 2000 2002; 28(1): 12-55.
Egelberg J, Claffey N. Role of mechanical dental plaque removal in prevention and therapy of caries and periodontal diseases. In a: Proceeding of the European workshop on mechanical plaque control. In: Berlin, Quintessence Books; 1998; pp. 121-37.`
Löe H. Mechanical and chemical control of dental plaque. J Clin Periodontol 1979; 6(7): 32-6.
Vyas T, Bhatt G, Gaur A, Sharma C, Sharma A, Nagi R. Chemical plaque control-a brief review. J Family Med Prim Care 2021; 10(4): 1562-8.
Mulla M, Mulla M, Hegde S, Koshy AV. In vitro assessment of the effect of probiotic lactobacillus reuteri on peri-implantitis microflora. BMC Oral Health 2021; 21(1): 408.
Mulla M, Mulla M, Kashyap R, Hegde S, Maiya A, Sarpangala MS. Evaluation of the efficacy of a dentifrice containing amine fluoride on gingival status—a clinical investigation. FR IJPR 2020; 12: 4799-805.
Grover V, Mahendra J, Gopalakrishnan D, Jain A. Effect of octenidine mouthwash on plaque, gingivitis, and oral microbial growth: A systematic review. Clin Exp Dent Res 2021; 7(4): 450-64.
Barnett ML. The rationale for the daily use of an antimicrobial mouthrinse. J Am Dent Assoc 2006; 137(Suppl.): S16-21.
Ciancio SG. Mouthwashes: Rationale for use. Am J Dent 2015; 28 Spec No A: 4A-8A.
Koburger T, Hübner NO, Braun M, Siebert J, Kramer A. Standardized comparison of antiseptic efficacy of triclosan, PVP-iodine, octenidine dihydrochloride, polyhexanide and chlorhexidine digluconate. J Antimicrob Chemother 2010; 65(8): 1712-9.
James P, Worthington HV, Parnell C, et al. Chlorhexidine mouthrinse as an adjunctive treatment for gingival health. Cochrane Database Syst Rev 2017; 3(3): CD008676.
K DRH, v DK, Gundala DR, G DA, S DN, M DMR. To evaluate the efficacy of sub gingival irrigation with octenidol and chlorhexidine on periodontal inflammation. Int J Adv Resissue 2017; 5(3): 1920-6.
Farah CS, McIntosh L, McCullough MJ. Mouthwashes, 32 Australian Prescriber. Australian Government Publishing Service 2009; pp. 162-4. Available from: https://www.oralhealthgroup. com/features/mouthwashes-and-their-use-in-dentistry-areview/
Chye RML, Perrotti V, Piattelli A, Iaculli F, Quaranta A. Effectiveness of different commercial chlorhexidine-based mouthwashes after periodontal and implant surgery. Implant Dent 2019; 28(1): 74-85.
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.
Ouanounou A, Ng K, Chaban P. Adverse drug reactions in dentistry. Int Dent J 2020; 70(2): 79-84.
Raszewski Z, Nowakowska-Toporowska A, Weżgowiec J, Nowakowska D. Design and characteristics of new experimental chlorhexidine dental gels with anti-staining properties. Adv Clin Exp Med 2019; 28(7): 885-90.
Doumani M, Alsulayhim SA, Alsaggaf KH, et al. Knowledge and attitude of dental students in Riyadh City toward the effect of mouthwashes on surface roughness and color stability of some esthetic restorations. J Family Med Prim Care 2021; 10(2): 953-60.
Benjamin SN, Gathece LW, Wagaiyu EG. Knowledge, attitude and use of mouthwash among dental and medical students of the University of Nairobi. Int J Dent Oral Health 2016; 2(4): 01-6.
Poppolo Deus F, Ouanounou A. Mouthwashes and their use in dentistry: A review. Oral Health 2021; 22-34.
Haydari M, Bardakci AG, Koldsland OC, Aass AM, Sandvik L, Preus HR. Comparing the effect of 0.06%, 0.12% and 0.2% chlorhexidine on plaque, bleeding and side effects in an experimental gingivitis model: a parallel group, double masked randomized clinical trial. BMC Oral Health 2017; 17(1): 1-8.
Brookes ZLS, Bescos R, Belfield LA, Ali K, Roberts A. Current uses of chlorhexidine for management of oral disease: A narrative review. J Dent 2020; 103: 103497.
Mulla M. Psychological impact of the COVID-19 pandemic on dental hygiene students in Saudi Arabia: A nation-wide study. J Contemp Dent Pract 2022; 22(12): 1426-33.
Periodontal Disease-Oral Health Conditions-Division of Oral Health-CDC. Center for Disease Control and Prevention Available from: conditions/periodontal-disease.html (Accessed on: 27 November 2021).
DynaMed-Chlorhexidine gluconate. 2020. Available from: (Accessed on: 5 August 2021).
Asadoorian J. Therapeutic oral rinsing with commercially available products: Particle-titleosition paper and statement from the Canadian Dental Hygienists Association. Can J Dent Hyg 2016; 50(3): 126-39.
Walsh T, Oliveira-Neto JM, Moore D. Chlorhexidine treatment for the prevention of dental caries in children and adolescents. Cochrane Libr 2015; CD008457(4): CD008457.
Mulla M. Knowledge, attitude and practices of Saudi dental hygiene students towards novel corona virus disease (COVID -19): A nation‐wide study. Int J Dent Hyg 2022; 00: idh.12632.
Niveda R, Jaiganesh R. Knowledge and attitude toward mouthwashes and their uses among dental undergraduate and postgraduate students. Drug Invention Today 2019; 12(6): 1-18.
Mitha S, Elnaem MH, Koh M, et al. Use and perceived benefits of mouthwash among Malaysian adults: an exploratory insight. J Adv Oral Res 2016; 7(3): 7-14.
Denton GW. Chlorhexidine In: Block, Seymour S Disinfection. 2000.
Shrestha E, Kafle S, Chaulagain R. Knowledge and practice towards use of mouthwash among dental practitioners in chitwan. J Karnali Acad Health Sci 2021; 4(10): 1-8.