Recipe - Compounding Worksheet
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These recipes are intended for use by the pharmacy manufacturing departments only.
Chlorhexidine Gluconate Mouthwash (Alcohol Free)   0.12%
Lot No Expiry(mm/yyyy) Ingredients Master Formula
    chlorhexidine gluconate  20%  PO SOLN   
    glycerin  100%  PO SOLN   
    peppermint oil    OIL   
    Water, sterile       QS 
Recipe Total Quantity:
Final Quantity Desired: mL

Directions: 1. Combine the chlorhexidine, glycerin, and peppermint oil and shake well.
2. QS to final volume with sterile water.
3. Transfer to final container and label.

Notes Although a commercial product is available (Peridex®), it contains alcohol and is not recommended for pediatric use. Strength of compounded formulation is the same as the commercial product. Compounded product is to be prepared ONLY in the event that the commerical product is NOT available or unsuitable.

If Spirit of Peppermint is used, increase quantity to 0.2 mL for every 200 mL of prepared final product.

Assign expiry date using USP 795 guidelines, since no stability data available.
USP 795 guidelines - For Water-Containing Oral Formulations:
The BUD is not later than 14 days when stored at controlled cold temperatures.

THIS FORMULATION IS NOT BASED ON LITERATURE, but is from unpublished data, historical use, or physician/pharmacy experience.

Packaging:  Amber Plastic Bottle

Auxiliary Labels: Protect From Light
  Refrigerate

Storage/Expiry:Refrigerator: 14 days

Last Date Revised: 25-Jun-19

References:Alberta Children's Hospital -anectodal

USP 34 – NF 29, 2nd Volume 1. Chapter 795: Pharmaceutical compounding – Nonsterile preparations. Rockville, MD, USA: United States Pharmacopeial Convention; 2010

Completed Compound Check
Lot NoDate Prepared Expiry DateTechnicianPharmacist
   6-Dec-2021         


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