Mouthrinses for the treatment of halitosis

In vitro comparison of zinc-based, chlorhexidine, and essential oil mouth rinses

BACKGROUND

Chlorhexidine (CHX)-based mouth rinses are frequently prescribed following periodontal surgeries. A more recently available brand of zinc-based mouth rinses advertises one of its mouth rinses as a substitute for chlorhexidine. The purpose of this study was to evaluate, in vitro, the effects of this brand of zinc-based mouth rinses on cell survival, cell motility, and gene expression of human gingival fibroblasts (HGFs).

METHODS

HGFs were exposed to essential oil (EO), CHX, and three types of one brand of zinc-based mouth rinses designed to treat breath malodor (ZnA), dry mouth (ZnB), and gingivitis (ZnC). Each mouth rinse was tested over a range of concentrations for its effects on HGF survival and motility. Gene expression of cytokines, interleukins, and growth factors were evaluated via reverse transcriptase-polymerase chain reaction (RT-PCR), as a means to assess potential influences on inflammation and wound healing.

RESULTS

Cell survival was significantly decreased for CHX and ZnC at 10% dilutions (p < 0.05). For all time points, cells exposed to ZnC displayed the greatest reduction in cell motility (p < 0.05). The various mouth rinses examined differentially altered the expression of growth factor transcripts. ZnC particularly enhanced the expression of BMP-2 and FGF-2.

CONCLUSION

ZnC was more cytotoxic and inhibited cell motility to a greater extent than any of the other mouth rinses. Therefore, using ZnC as an alternative to CHX could potentially have negative effects on wound healing after periodontal surgery. However, further investigation is required to confirm the clinical relevance of these in vitro findings.

PLAIN LANGUAGE SUMMARY

One type of zinc-based mouth rinse designed to replace chlorhexidine (often prescribed after oral surgeries) demonstrated the greatest oral cell death and reduction in cell movement when compared to other zinc-based mouth rinses. These zinc-based mouth rinses also reduced the amounts of proteins involved in regulating inflammation, potentially reducing the destruction of bone holding the teeth in place. They also changed the amounts of several molecules involved in tissue healing. It is unknown if this will speed or slow the healing of the soft tissues of the mouth.

Comparison between ozone and CHX gel application for reduction of pain and incidence of dry socket after lower third molar removal

OBJECTIVES

The aim of this study is to evaluate the efficacy between ozone gas and 1% chlorhexidine (CHX) gel in the incidence of dry socket after surgical extraction of impacted lower third molars.

MATERIAL AND METHODS

Overall, 30 patients of both genders were included in the study, with indication of surgical extraction of lower third molar, positioned similarly after being clinically and radiographically checked by X-ray and orthopantomography. Each patient was subjected to both groups in separate sessions: treated with ozone gas and with CHX gel 1%. Data on pain intensity, number of taken analgesics-painkillers, and dry socket were recorded for 48 h and at Day 7.

RESULTS

Ozone gas and CHX gel effectively reduced pain intensity and prevented dry socket. The number of taken analgesics 48 h and 7 days after surgery showed no statistical significance. The same was observed for the distribution of pain. Only one patient reported the occurrence of dry socket 7 days after the surgical extraction.

CONCLUSIONS

Ozone gas and CHX 1% gel are both efficient in decreasing postoperative symptoms and incidence rates of dry socket, but in comparison to each other, the use of ozone gas is showing a bit better prevention capability.

Revisiting Standard and Novel Therapeutic Approaches in Halitosis: A Review

Halitosis, or bad breath, is an oral health problem characterized by an unpleasant malodor emanating from the oral cavity. This condition can have different origins and causes a negative burden in social interactions, communication and quality of life, and can in uncommon cases be indicative of underlying non-oral non-communicable diseases. Most cases of halitosis are due to inadequate oral hygiene, periodontitis and tongue coating, yet the remaining proportion of cases are due to ear-nose-throat-associated (10%) or gastrointestinal/endocrine (5%) disorders. For this reason, the diagnosis, treatment and clinical management of halitosis often require a multidisciplinary team approach. This comprehensive review revisits the etiology of halitosis as well as standard and novel treatment that may contribute to higher clinical success.

A Fresh Look at Mouthwashes-What Is Inside and What Is It For?

Mouthwashes are a very popular additional oral hygiene element and there are plenty of individual products, whose compositions are in a state of flux. The aim of our study was to investigate the compositions of mouthwashes and their functions, as well as to discuss their effectiveness in preventing and curing oral diseases and side effects. We searched for mouthwashes available on the market in Poland. We identified 241 individual mouthwash products. The extraction of compositions was performed and functions of the ingredients were assessed. Then, analysis was performed. The evaluation revealed that there are plenty of ingredients, but a typical mouthwash is a water-glycerine mixture and consists of additional sweetener, surfactant, preservative, and some colourant and flavouring agent, as well as usually having two oral health substances, anticaries sodium fluoride and antimicrobial essential oils. The effectiveness or side effects of several substances of mouthwashes were thoroughly discussed. We recommend not multiplying individual mouthwash products and their ingredients beyond medical or pharmaceutical necessity, especially without scientific proof.

Evaluation of antimicrobial activity of chlorhexidine-containing oral gels against aspiration pneumonia-inducing bacteria: An In Vitro study

Aim

Hospitalised patients have a high risk of developing aspiration pneumonia because of poor oral care and oral microbial flora changes. Chlorhexidine (CHX) solution has been used to reduce inflammation and prevent infections in oral cavity, but it is difficult to use in inpatients. Gel-type antimicrobial agents rather than the liquid form may be effective for the oral management of hospitalised patients. Therefore, we evaluated the in vitro antimicrobial effects of CHX-containing oral gels on aspiration pneumonia-inducing bacteria compared to the CHX solution.

Materials and Methods

The experimental products of two oral gel types containing 1% and 0.1% CHX, respectively, were selected. Hexamedine, a 0.12% CHX solution, was used as a positive control. The antimicrobial activity of CHX agents against six pneumonia-causing bacteria and Streptococcus mutans, one of the most common oral bacteria, was comparatively analysed using the agar disk diffusion method.

Results

In the disk diffusion assay, the 1% CHX gels showed the highest inhibitory effect on all bacteria. All CHX agents including gels and solution had the highest antibacterial activity against Staphylococcus aureus compared with other bacteria.

Conclusions

We confirmed the significant antimicrobial effects of the 1% CHX oral gels on aspiration pneumonia-inducing bacteria. These results suggest that CHX gels may be an effective oral care method for preventing infection in inpatients who have difficulty using the solution.

Virucidal efficacy of chlorhexidine: a systematic review

This study aimed to systematically review the literature about the virucidal efficacy of CHX in comparison to other substances used in the oral cavity. Electronic searches were performed in four databases (PubMed, Scopus, Embase, and Web of Science). Only studies that presented the following characteristics were included: (1) verified virucidal efficacy of CHX against Herpes Simplex Type-1 (HSV-1), any Influenza, or any human coronavirus (HcoV); and (2) compared the virucidal efficacy of CHX with essential oils (Listerine^®), quaternary ammonium compounds, povidone-iodine, hydrogen peroxide, negative control substance, and absence of therapy. Two researchers independently selected the studies, extracted data and evaluated the risk of bias. A narrative data synthesis was used. Twenty-five studies were included, of which 21 were in vitro and four were randomized clinical trials (RCT). Studies assessed the virucidal efficacy of CHX against Herpes Simplex Type-1 (HSV-1) (10 studies), Influenza A (InfluA) (4 studies), human coronavirus (HCoV) (4 studies) and Severe Acute Respiratory Syndrome-Related Coronavirus (SARS-CoV-2) (11 studies). Most studies demonstrated that CHX has a positive virucidal efficacy against HSV-1 and InfluA strains. However, lower efficacy was shown to InfluA strain in comparison to povidone-iodine. Lower to none virucidal efficacy of CHX is expected for HCoV and SARS-CoV-2 strains for in vitro studies. Three RCT demonstrated that CHX was able to significantly reduce the viral load of SARS-CoV-2 for a short period. CHX may present an interesting virucidal efficacy against HSV-1 and InfluA viruses. CHX also presents transient efficacy against SARS-CoV-2 when used as a mouthwash.

Evaluation of the Efficacy of Lacer HaliTM Treatment on the Management of Halitosis: A Randomized Double-Blind Clinical Trial

Background: Halitosis of oral origin is very common in the general population. Due to their antimicrobial properties, chlorhexidine-based products are widely used in the management of this condition, but these are associated with reversible side effects. In this study we evaluated the efficacy of Lacer Hali^TM mouthrinse and toothpaste in subjects with intraoral halitosis after several applications under normal conditions of use. Methods: In this randomized clinical trial with mouth rinse and toothpaste, single-center, double-blinded, parallel participants were assigned to an experimental group (Lacer Hali^TM,, n = 20), a positive control group (Halita^TM, n = 20), and a placebo group (n = 20). The active duration of the study was 18 days. The clinical follow-up evaluations were performed at five time points (T0, T1, T2, T3, and T4). The intensity of halitosis was evaluated by organoleptic measurement and the portable gas chromatograph OralChroma^TM. The data were analyzed using generalized mixed linear models. Results: Sixty patients completed the study. Lacer Hali^TM, in comparison with Halita^TM, did not show statistically significant differences at any time during the study except for the levels of hydrogen sulfide and total volatile sulfur compounds at 15 days, where Halita^TM was better. Compared to the placebo treatment, Lacer Hali^TM, was significantly more efficient, in terms of both the organoleptic evaluations at 8 days and the levels of hydrogen sulfide. Conclusions: Lacer Hali^TM is an alternative to chlorhexidine-based toothpaste and mouthwashes in the management of halitosis.

Alternative therapies in controlling oral malodour: a systematic review

Is there a role for alternative therapies in controlling intra-oral halitosis? Treatments other than tongue cleaning and anti-halitosis products containing zinc, chlorhexidine and cetylpyridinium chloride were considered as alternative therapies. Four databases were searched (PubMed, EMBASE, Web of Science and The Cochrane Library). Inclusion criteria were: examination of alternative halitosis therapies, study population with oral malodour, a (negative or positive) control group and evaluation of breath odour via organoleptic and/or instrumental assessment. Data were extracted for descriptive analysis. The screening of 7656 titles led to the inclusion of 26 articles. Analysis showed heterogeneity concerning the population of interest (from cysteine-induced to genuine halitosis), the examined treatment and the reported outcomes. This made a meta-analysis impossible. Essential oils, fluoride-containing products and herbal substances were the most studied. Results varied enormously and none of the active ingredients had an unambiguously positive effect on the malodour. The risk of bias was assessed as high in all articles. Given the fact that little evidence was found for each of the investigated treatments, it could be concluded that there is currently insufficient evidence that alternative therapies are of added value in the treatment of halitosis.Clinical relevanceScientific rationale:Halitosis is a common problem causing social isolation. Out of embarrassment, patients search the internet, leading to many questions about alternative solutions (e.g. oil pulling, herbs). This is the first systematic review on these alternative therapies.Principal findings: Results varied among studies. Some promising results were found for fluoride-containing toothpastes and probiotics. For other products (such as herbal and antibacterial products and essential oils) results were inconsistent. Long-term follow-up studies on these products are scarce. Moreover, the quality of the studies was poor.Practical implications:No clear evidence was found to support a certain alternative anti-halitosis therapy.

Effects of Chlorine Dioxide on Oral Hygiene - A Systematic Review and Meta-analysis

Background

Effective and selective oral rinses are required in the daily medical and dental practice. Currently mouthwashes used have substantial side effects.

Objectives

Our aim was to evaluate the efficacy of chlorine dioxide-containing mouthwashes in comparison with other previously established mouth rinses in healthy adults using oral hygiene indices.

Methods

This work was registered in PROSPERO (CRD42018099059) and carried out using multiple databases and reported according to the PRISMA statement. The search terms used were “chlorine dioxide” AND “oral”, and only randomised controlled trials (RCTs) were included. The primary outcome was the alteration of the plaque index (PI), while the secondary outcomes were the gingival index (GI) and bacterial counts. For the risk of bias assessment, the Cochrane Risk of Bias Tool was used. Statistical analysis for data heterogeneity was performed by Q-value and I²-tests.

Results

364 articles were found in the databases. After the selection process, only five RCTs were eligible for meta-analysis. Data heterogeneity was low. There were no statistical differences in effectiveness between chlorine dioxide and other effective mouth rinses in PI (0.720±0.119 vs 0.745±0.131; 95%; confidence intervals (CIs): 0.487-0.952 vs 0.489-1.001, respectively) and GI (0.712±0.130 vs 0.745±0.131; 95% CIs: 0.457–0.967 vs 0.489–1.001, respectively) and also in bacterial counts.

Conclusion

Chlorine dioxide reduces both plaque and gingival indices and bacterial counts in the oral cavity similar to other routinely used oral rinses, however, the evidence supporting this outcome is very limited. Therefore, further large scale RCTs are needed to decrease the risk of bias.

Oral hygiene associated with antimicrobial photodynamic therapy or lingual scraper in the reduction of halitosis after 90 days follow up: A randomized, controlled, single-blinded trial

BACKGROUND

Although antimicrobial photodynamic therapy (aPDT) can reduce halitosis immediately after application, it returns after a week. This probably occurs because bacteria residing in the oral cavity may recolonize the dorsum of the tongue.

OBJECTIVE

Verify if modification of oral hygiene behavior associated with aPDT or lingual scraper can reduce halitosis after a 90-day follow-up.

METHODS

Forty adults with positive halitosis were randomized in G1 (n = 20) -aPDT + oral hygiene behavior (OHB) or G2 (n = 20)- lingual scraper + OHB. G1 group were submitted to 0.005 % methylene blue in the middle and posterior third of the tongue, with pre-irradiation of 1 min. Irradiations were performed with red laser diode (λ =660 nm), 100 mW, 318 J/cm², 3537 mW/cm², 9 J per point at 6 points. In the G2 group, the tongue was scraped 10 times on the right side and on the left side with a tongue scraper. All patients were instructed on OHB at baseline, 7 and 90 days (guidance on the use of dental floss and the Bass technique for brushing). Halitosis was evaluated by gas chromatography (OralChroma®). Values ​​> 112 ppb for Hydrogen sulfide (H₂S) gas was considered positive halitosis. Methylmercaptanes and dimethylsulfide were also measured. The gas measures were assessed at baseline, immediately, and at 7 and 90 days. Paired t-test was used for the statistical analysis. For comparison between groups, the t-test was used. Values of p < 0.05 were considered statistically significant.

RESULTS

There was no difference between groups immediately after treatment (p = .1532) after 7 days (p = 0.9312) and 90 days (p = 0.6642). For the aPDT group, there was a decrease in hydrogen sulfide ​​immediately after treatment (p = 0.0001), after 7 days, values remained 3-fold smaller (p = 0.0088) and 2-fold smaller after 90 days (p = 0.0270). For the scraper group, there was a decrease immediately after treatment (p = 0.0001), the values remains 2-fold smaller ​​(p = 0.0003) after 7 days and 3 months (p = 0.0001).

CONCLUSION

The oral hygiene behavior associated with aPDT or tongue scraper was not able to reduce halitosis after 90-day follow-up. Despite halitosis remaining ​​ higher than 112 ppb in all follow-up periods, the mean values remain 2 or 3 fold smaller than baseline values. Future studies should include other oral hygiene behavior to achieve better results in the treatment of halitosis.

Efficacy of antioxidant mouthwash in the reduction of halitosis: A randomized, double blind, controlled crossover clinical trial

Background/purpose

Halitosis is the unpleasant and offensive odour in exhaled air, which is linked to the presence of volatile sulphur compounds (VSC). Different mouthwashes have been used to treat halitosis. The objective of this study was to test the effect of an antioxidant (AO) mouthwash, and mouthwash containing [0.05% chlorhexidine, 0.05% cetylpyridinium chloride, and 0.14% zinc lactate (CHX-CPC-Zn)] on VSC.

Material and methods

Thirty-five subjects with halitosis participated in this clinical trial. At the baseline visit, a breath sample was taken and analyzed for the level of hydrogen sulphide (H₂S), methyl mercaptan (CH₃SH), and dimethyl sulphide (CH₃SCH₃) using portable gas chromatography (OralChroma™). Two mouthwashes were randomly provided to each subject in addition to saline solution (NaCl 0.9%) as control. Subjects were instructed to rinse with 20 ml of the mouthwash for 1 min twice daily for 2 weeks. At second visit, post-treatment breath sample was taken. Afterward, the patient was asked to refrain from using mouthwash for a washout period of 1 week. A similar procedure was repeated for each mouthwash interval.

Results

No significant differences in VSC level between all three groups were detected at baseline. A significant reduction in VSC level was obtained after using CHX-CPC-Zn mouthwash. On other hand, both AO mouthwash and saline had no significant impact on the level of VSC.

Conclusion

CHX-CPC-Zn mouthwash has a significant effect on VSC level reduction in subjects with confirmed halitosis. Besides, using AO mouthwash regularly for 2 weeks did not have any impact on improving the level of halitosis.

Small, but smelly: the importance of Solobacterium moorei in halitosis and other human infections

Solobacterium moorei (S. moorei) has been described as Gram-positive, non spore forming, obligate anaerobic bacillus from human feces. The traditional culture and identification of these strains is very difficult (as the strains are often not cultivable or they grow only relatively slowly, in addition to producing only a very few positive biochemical reactions in commercially available identification kits); thus, reliable identification may only be carried out using methods, such as matrix-assisted laser desorption/ionization time-of-flight mass spectrometry and DNA sequencing. Regarding its pathogenic role, the relevance of S. moorei in halitosis (oral malodor) has a good standing, as it has been suggested by multiple studies, while the isolation of these bacteria from invasive infections is very rare; there are only a few reports available in the literature, regarding infections outside the oral cavity. Based on these reports, affected patients are predominantly characterized compromised immunity and are frequently associated with a dental focus of infection. The aim of our present review is to summarize the currently available knowledge on the pathogenic role of S. moorei in halitosis and other infections and to emphasize the relevance of this neglected anaerobic pathogen.

Effects of Chlorhexidine mouthwash on the oral microbiome

Following a single blind, cross-over and non-randomized design we investigated the effect of 7-day use of chlorhexidine (CHX) mouthwash on the salivary microbiome as well as several saliva and plasma biomarkers in 36 healthy individuals. They rinsed their mouth (for 1 min) twice a day for seven days with a placebo mouthwash and then repeated this protocol with CHX mouthwash for a further seven days. Saliva and blood samples were taken at the end of each treatment to analyse the abundance and diversity of oral bacteria, and pH, lactate, glucose, nitrate and nitrite concentrations. CHX significantly increased the abundance of Firmicutes and Proteobacteria, and reduced the content of Bacteroidetes, TM7, SR1 and Fusobacteria. This shift was associated with a significant decrease in saliva pH and buffering capacity, accompanied by an increase in saliva lactate and glucose levels. Lower saliva and plasma nitrite concentrations were found after using CHX, followed by a trend of increased systolic blood pressure. Overall, this study demonstrates that mouthwash containing CHX is associated with a major shift in the salivary microbiome, leading to more acidic conditions and lower nitrite availability in healthy individuals.

Interventions for managing halitosis

BACKGROUND

Halitosis or bad breath is a symptom in which a noticeably unpleasant breath odour is present due to an underlying oral or systemic disease. 50% to 60% of the world population has experienced this problem which can lead to social stigma and loss of self-confidence. Multiple interventions have been tried to control halitosis ranging from mouthwashes and toothpastes to lasers. This new Cochrane Review incorporates Cochrane Reviews previously published on tongue scraping and mouthrinses for halitosis.

OBJECTIVES

The objectives of this review were to assess the effects of various interventions used to control halitosis due to oral diseases only. We excluded studies including patients with halitosis secondary to systemic disease and halitosis-masking interventions.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 8 April 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 3) in the Cochrane Library (searched 8 April 2019), MEDLINE Ovid (1946 to 8 April 2019), and Embase Ovid (1980 to 8 April 2019). We also searched LILACS BIREME (1982 to 19 April 2019), the National Database of Indian Medical Journals (1985 to 19 April 2019), OpenGrey (1992 to 19 April 2019), and CINAHL EBSCO (1937 to 19 April 2019). The US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (8 April 2019), the World Health Organization International Clinical Trials Registry Platform (8 April 2019), the ISRCTN Registry (19 April 2019), the Clinical Trials Registry - India (19 April 2019), were searched for ongoing trials. We also searched the cross-references of included studies and systematic reviews published on the topic. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) which involved adults over the age of 16, and any intervention for managing halitosis compared to another or placebo, or no intervention. The active interventions or controls were administered over a minimum of one week and with no upper time limit. We excluded quasi-randomised trials, trials comparing the results for less than one week follow-up, and studies including advanced periodontitis.

DATA COLLECTION AND ANALYSIS

Two pairs of review authors independently selected trials, extracted data, and assessed risk of bias. We estimated mean differences (MDs) for continuous data, with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 44 trials in the review with 1809 participants comparing an intervention with a placebo or a control. The age of participants ranged from 17 to 77 years. Most of the trials reported on short-term follow-up (ranging from one week to four weeks). Only one trial reported long-term follow-up (three months). Three studies were at low overall risk of bias, 16 at high overall risk of bias, and the remaining 25 at unclear overall risk of bias. We compared different types of interventions which were categorised as mechanical debridement, chewing gums, systemic deodorising agents, topical agents, toothpastes, mouthrinse/mouthwash, tablets, and combination methods. Mechanical debridement: for mechanical tongue cleaning versus no tongue cleaning, the evidence was very uncertain for the outcome dentist-reported organoleptic test (OLT) scores (MD -0.20, 95% CI -0.34 to -0.07; 2 trials, 46 participants; very low-certainty evidence). No data were reported for patient-reported OLT score or adverse events. Chewing gums: for 0.6% eucalyptus chewing gum versus placebo chewing gum, the evidence was very uncertain for the outcome dentist-reported OLT scores (MD -0.10, 95% CI -0.31 to 0.11; 1 trial, 65 participants; very low-certainty evidence). No data were reported for patient-reported OLT score or adverse events. Systemic deodorising agents: for 1000 mg champignon versus placebo, the evidence was very uncertain for the outcome patient-reported visual analogue scale (VAS) scores (MD -1.07, 95% CI -14.51 to 12.37; 1 trial, 40 participants; very low-certainty evidence). No data were reported for dentist-reported OLT score or adverse events. Topical agents: for hinokitiol gel versus placebo gel, the evidence was very uncertain for the outcome dentist-reported OLT scores (MD -0.27, 95% CI -1.26 to 0.72; 1 trial, 18 participants; very low-certainty evidence). No data were reported for patient-reported OLT score or adverse events. Toothpastes: for 0.3% triclosan toothpaste versus control toothpaste, the evidence was very uncertain for the outcome dentist-reported OLT scores (MD -3.48, 95% CI -3.77 to -3.19; 1 trial, 81 participants; very low-certainty evidence). No data were reported for patient-reported OLT score or adverse events. Mouthrinse/mouthwash: for mouthwash containing chlorhexidine and zinc acetate versus placebo mouthwash, the evidence was very uncertain for the outcome dentist-reported OLT scores (MD -0.20, 95% CI -0.58 to 0.18; 1 trial, 44 participants; very low-certainty evidence). No data were reported for patient-reported OLT score or adverse events. Tablets: no data were reported on key outcomes for this comparison. Combination methods: for brushing plus cetylpyridium mouthwash versus brushing, the evidence was uncertain for the outcome dentist-reported OLT scores (MD -0.48, 95% CI -0.72 to -0.24; 1 trial, 70 participants; low-certainty evidence). No data were reported for patient-reported OLT score or adverse events.

AUTHORS' CONCLUSIONS

We found low- to very low-certainty evidence to support the effectiveness of interventions for managing halitosis compared to placebo or control for the OLT and patient-reported outcomes tested. We were unable to draw any conclusions regarding the superiority of any intervention or concentration. Well-planned RCTs need to be conducted by standardising the interventions and concentrations.

Clinical effect of toothpaste and mouth rinse containing zinc lactate on oral malodor reduction

Background

This study aimed to investigate the effect of toothpaste and mouth rinse containing 0.14% zinc lactate on the reduction of three volatile oral malodor gases.

Material and Methods

Ten subjects with good health were recruited to take part in a crossover design study with a 7-day washout period. They were randomly assigned to use the test (toothpaste and rinse containing 0.14% zinc lactate) or placebo (negative control) treatment regimens within the two-week period. All subjects were asked to refrain from tooth brushing and eating in the morning prior to the gas collection periods. The assessment of malodor measured the quantity of three volatile sulphur compounds (VSCs) using an OralChromaTM device. Oral gas collecting was divided into four time periods; before breakfast and the morning oral hygiene practice (baseline); after oral hygiene at 30 minutes, 1 hour and 2 hours. After the baseline assessment, each subject used the test or placebo treatment regimen for 7 days. After 7 and 14 days, subjects returned to the study site to repeat the same procedures with different products. Kruskal-Wallis was used to analyze the mean differences of malodor gases between the two test regimens.

Results

The baseline mean of total VSCs in test and control groups was 6.5±3.7 and 1.7±9.3 ng/10 ml, respectively. The percent reduction of H2S at 30 minutes, 1 hour and 2 hours was statistically significant (p<0.005) in both treatments. The percent reduction of (CH3)2S and total VSCs in both treatments after 1 hour was statistically significant (p<0.005).

Conclusions

The test treatment regimen was more effective than the placebo treatment regimen. Key words:Zinc lactate, molodor, volatile sulphur compound, mouth rinse, toothpaste.

A Current Approach to Halitosis and Oral Malodor- A Mini Review

BACKGROUND

Halitosis, in other words, oral malodor is an important multifactorial health problem affecting the psychological and social life of individuals and is the most common reason for referral to dentists after dental caries and periodontal diseases.

OBJECTIVE

The objective of this review was to present and discuss conventional and recently introduced information about the types, causes, detection and treatment methods of halitosis.

METHODS

An expanded literature review was conducted which targeted all articles published in peer-reviewed journals relating to the topic of halitosis. Only articles written in Turkish and English languages were considered. The review itself began with a search of relevant subject headings such as 'halitosis, oral malodor, volatile sulfur compounds in PubMed/Medline, Scopus, Google Scholar and Tubitak Ulakbim databases. A hand search of references was also performed.

RESULTS

When search results are combined, the total number of relevant literature was found to be 4646 abstracts and 978 full-text articles. Abstracts, editorial letters were not included and about half of full-text articles were not related to dental practice. Among the remaining 124 full-text articles, duplicated articles and articles written other than Turkish and English languages were removed and 54 full-text articles were used for this review.

DISCUSSION

According to the reviewed articles, both conventional and new methods were introduced in the management of halitosis. However, conventional methods seem to be more effective and widely used in the diagnosis and treatment of halitosis.

CONCLUSION

As being first line professionals, dentists must analyze and treat oral problems which may be responsible for the patient's malodor, and should inform the patient about halitosis causes and oral hygiene procedures (tooth flossing, tongue cleaning, appropriate mouthwash and toothpaste selection and use) and if the problem persists, they should consult to a medical specialist.

A timeline of hydrogen sulfide (H2S) research: From environmental toxin to biological mediator

The history of H2S - as an environmental toxin - dates back to 1700, to the observations of the Italian physician Bernardino Ramazzini, whose book "De Morbis Artificum Diatriba" described the painful eye irritation and inflammation of "sewer gas" in sewer workers. The gas has subsequently been identified as hydrogen sulfide (H2S), and opened three centuries of research into the biological roles of H2S. The current article highlights the key discoveries in the field of H2S research, including (a) the toxicological studies, which characterized H2S as an environmental toxin, and identified some of its modes of action, including the inhibition of mitochondrial respiration; (b) work in the field of bacteriology, which, starting in the early 1900s, identified H2S as a bacterial product - with subsequently defined roles in the regulation of periodontal disease (oral bacterial flora), intestinal epithelial cell function (enteral bacterial flora) as well as in the regulation of bacterial resistance to antibiotics; and (c), work in diverse fields of mammalian biology, which, starting in the 1940s, identified H2S as an endogenous mammalian enzymatic product, the functions of which - among others, in the cardiovascular and nervous system - have become subjects of intensive investigation for the last decade. The current review not only enumerates the key discoveries related to H2S made over the last three centuries, but also compiles the most frequently cited papers in the field which have been published over the last decade and highlights some of the current 'hot topics' in the field of H2S biology.

Evaluation of the Efficacy of G32 (Commercially Available Ayurvedic Preparation) in Reducing Halitosis - A Randomized Controlled Trial

INTRODUCTION

Oral malodour is a social malady affecting people of all the age groups. Effective management of oral malodour is the key to improve the quality of life of such people.

AIM

To evaluate the effectiveness of ayurvedic medication, G32 in controlling oral malodour and comparing the effects with Chlorhexidine (CHX).

MATERIALS AND METHODS

This was a single blind randomized controlled trial with parallel study design conducted at a hospital in the city of Udupi in Southern India. A total of 40 patients suffering with oral malodour, aged 17-35 years, were included in this trial. After inclusion into the study, the subjects were examined twice, with a one-week interval between both examinations. Volatile Sulphur Compounds (VSCs), gingival, plaque and tongue coating scores were assessed at both examinations. Subjects were randomly allocated to G32 group - ayurvedic formulation (intervention group) and CHX group (control group), and were provided with the respective formulations enough to be used twice daily for a period of one week. The difference between the mean scores of VSCs, plaque, and gingivitis and tongue coating were compared within the intervention and control groups, respectively, using paired t-test.

RESULTS

Both test and control groups showed a significant reduction in VSCs, plaque and gingivitis levels. The percentage reductions in VSCs, plaque and gingivitis were found to be similar among the two groups. There was no significant difference between the preintervention and postintervention scores in both the groups.

CONCLUSION

G32, an ayurvedic medication, can be an effective tool to deal with oral malodour.

Microbiological and clinical effects of an oral hygiene regimen

Objective

This study compared the additional effect of rinsing with a fluoride-free and alcohol-free 0.075% cetylpyridinium chloride (CPC) mouthwash to brushing alone on dental plaque, gingival inflammation, and supragingival plaque bacteria.

Methods

Adult subjects [n = 68] completed a washout period prior to baseline evaluations that evaluated gingival inflammation, gingival bleeding, dental plaque, and pocket probing depths along with microbiological analysis of supragingival plaque for bacteria. Subjects were randomized to two treatment groups: brush with fluoride toothpaste and rinse with the CPC mouthwash (test) or brush with fluoride toothpaste only (control), twice daily for the next four weeks. Subjects abstained from oral hygiene for twelve-hours prior to two-week and four-week post-treatment microbiological analysis of supragingival plaque for bacteria. Clinical assessments for gingival inflammation, gingival bleeding, dental plaque, and pocket probing depths were conducted at the four-week post-treatment visit.

Results

Compared to baseline, bacteria of dental plaque in the test group were reduced by 61.1% and 83.0% at the two-week and four-week evaluations, respectively (p < 0.05). Compared to baseline, bacteria of supragingival plaque in the control group were reduced by 2.3% at either post-treatment evaluations (p < 0.05). Additionally, dental plaque bacteria in the test was 69.8% and 86.8% lower than the control at the two-week and four-week evaluations (p < 0.05), respectively. After four-weeks, the test group showed 14.3% less gingivitis, 11.2% less dental plaque, 7.5% less gingival bleeding compared to the control group (p < 0.05).

Conclusions

Oral hygiene comprising toothbrushing and rinsing with a mouthwash containing 0.075% cetylpyridinium chloride demonstrated greater reductions of dental plaque bacteria, improving gingival health, and eliminating supragingival plaque than toothbrushing alone.

The impact of chewing gum on halitosis parameters: a systematic review

This study aimed to analyze the impact of chewing gum on halitosis parameters. Three databases were searched with the following focused question: 'Can chewing gum additionally reduce halitosis parameters, such as organoleptic scores and volatile sulfur compounds (VSC), when compared to a control treatment'? Controlled clinical trials presenting at least two halitosis measurements (organoleptic scores and/or VSC) were included. Ten studies were included, and different active ingredients were used. One study was performed using a chewing gum without any active ingredient. Chewing gum containing probiotic bacterium was shown to significantly reduce the organoleptic scores. Chewing gums containing zinc acetate and magnolia bark extract as well as allylisothiocyanate (AITC) with zinc lactate significantly reduced the levels of VSC in comparison to a placebo chewing gum. Furthermore, a sodium bicarbonate-containing chewing gum significantly reduced the VSC levels in comparison to rinsing with water. Furthermore, eucalyptus-extract chewing gum showed significant reductions in both organoleptic scores and VSC when compared with a control chewing gum. Chewing gum containing sucrose was able to reduce the VSC levels, in comparison to xylitol and zinc citrate chewing gum, but only for 5 min. It was concluded that chewing gums containing probiotics Lactobaccilus, zinc acetate and magnolia bark extract, eucalyptus-extract, and AITC with zinc lactate may be suitable for halitosis management. However, the low number of included studies and the high heterogeneity among the selected studies may limit the clinical applications of these findings.

Comparative evaluation of antimicrobial efficacy of three different formulations of mouth rinses with multi-herbal mouth rinse

CONTEXT

In response to the propagation of various anti-Streptococcus preventive agents, the discovery of newer and more efficient agents which are more economical, efficacious, and safe are gaining popularity in today's era.

AIMS

The purpose was to compare the antimicrobial efficacy of multi-herbal mouth rinse with essential oil-based, fluoride containing, and 0.2% chlorhexidine digluconate mouth rinses, well-evidenced chemical formulations, against Streptococcus mutans.

SETTINGS AND DESIGN

It is triple-blinded randomized controlled trial.

METHODOLOGY

One hundred and twenty adolescents aged between 15 and 17 years were randomized into four groups: (a) multi-herbal mouth rinse, 15 ml twice a day; (b) 0.2% chlorhexidine mouth rinse, 15 ml twice a day; (c) essential oil mouth rinse, 15 ml twice a day (d) 0.2% sodium fluoride mouth rinse, twice a day. Salivary and plaque samples were collected from subjects and oral streptococci colony forming units (CFUs)/mL was assessed using TYCSB agar.

STATISTICAL ANALYSIS USED

Repeated measures of ANOVA were used to compare the various mouthrinses followed by post hoc Bonferroni test for comparing multi-herbal mouthrinse with other mouthrinses. Significance was set at P < 0.05.

RESULTS

At baseline, there was no statistically significant difference in the distribution of baseline data groups, but reduction of S. mutans colony count of multi-herbal mouth rinse in comparison with the other mouthrinses had statistically significant values except Fluoride mouth rinse till 1 week postrinsing.

CONCLUSION

Chlorhexidine and multi-herbal mouth rinses showed statistically significant reduction in the S. mutans CFU count, in terms of efficacy and substantivity both.

Comparison of a commercially available herbal and 0.2% chlorhexidine mouthrinse for prevention of oral malodor: A clinical trial

Objectives:

Despite the adverse effects of chlorhexidine (CHX) in the oral cavity, it is still the most commonly prescribed mouthrinse for halitosis control due to its excellent results. The purpose of this study was to compare the efficacy of a mouthrinse with herbal formulation for halitosis control with 0.2% CHX gluconate containing rinse and to simultaneously assess adverse effects caused by the herbal mouthrinse if any.

Materials and Methods:

Ninety-six systemically healthy subjects with chronic generalized gingivitis were recruited in the study and divided into three groups receiving 0.2% CHX gluconate mouthrinse, herbal mouthrinse, or negative control, respectively as Group A, B, and C. The halimeter scores and organoleptic scores were recorded for each subject at baseline and after scaling. Others parameters recorded were plaque index and gingival index. All scores were reassessed on the 7^th and 14^th day, respectively. Statistical analysis was performed using Kruskal–Wallis ANOVA, Mann–Whitney U-test, and Wilcoxon matched pairs test.

Results:

There was an overall reduction in the halimeter scores both in Group A and B subjects which were not statistically significant within the groups; this was in accordance with the decrease in the mean organoleptic scores. Reduction in Group C scores was the least and differed statistically from both Group A and B scores.

Conclusions:

The results indicate an equivalent reduction in breath odor by both the herbal mouthrinse and CHX. Furthermore, side effects were less, and patient compliance was more with the herbal mouthrinse, which can thus be prescribed more safely and with predictable outcomes for oral malodor.

Halitosis: Current concepts on etiology, diagnosis and management

Halitosis or oral malodor is an offensive odor originating from the oral cavity, leading to anxiety and psychosocial embarrassment. A patient with halitosis is most likely to contact primary care practitioner for the diagnosis and management. With proper diagnosis, identification of the etiology and timely referrals certain steps are taken to create a successful individualized therapeutic approach for each patient seeking assistance. It is significant to highlight the necessity of an interdisciplinary method for the treatment of halitosis to prevent misdiagnosis or unnecessary treatment. The literature on halitosis, especially with randomized clinical trials, is scarce and additional studies are required. This article succinctly focuses on the development of a systematic flow of events to come to the best management of the halitosis from the primary care practitioner's point of view.

Halitosis - An overview: Part-I - Classification, etiology, and pathophysiology of halitosis

Halitosis is a condition where the breath is altered in an unpleasant manner for the affected individuals and impairs them socially as well as psychologically. Halitosis can be clinically classified as real halitosis, pseudohalitosis, and halitophobia. Real halitosis has oral and extra-oral etiologies and the pathophysiology involves interaction of anaerobic microbes (mainly) with the proteins present in the oral cavity fluids and contents, resulting in production of volatile sulfur compounds (VSCs). These VSCs, beyond responsible for halitosis, can also initiate and accelerate periodontal disease progression. Thus, this review is about the pathophysiology and various etiologies of halitosis, the knowledge of which can help in the betterment of treatment options.

Halitosis: a review of the etiologic factors and association with systemic conditions and its management

Halitosis is a general term defined as an unpleasant or offensive odor emanating from the breath, arising from either oral or nonoral sources. Extraoral factors, such as ear-nose-throat conditions or gastrointestinal, respiratory, and systemic diseases, may also contribute to oral malodor. Although, halitosis has a multifactorial etiology, local factors play an important role in the majority of cases. Halitosis may lead to significant personal discomfort and social embarrassment. Assessment of halitosis can be performed using organoleptic measurements, sulfide monitoring, gas chromatography, microbial testing and chemical test strips. Management approaches are based on masking oral malodor, reducing the levels of volatile organic compounds (VOCs) and volatile sulfur compounds (VSCs), and mechanical and/or chemical treatment. This review aims to identify the etiology of oral halitosis, describe the methods available for assessment and differential diagnosis and introduce a variety of management strategies. The importance of a multidisciplinary approach for the improvement of overall health and for the management and prevention of halitosis is highlighted.

Physical chemical effects of zinc on in vitro enamel demineralization

OBJECTIVES

Zinc salts are formulated into oral health products as antibacterial agents, yet their interaction with enamel is not clearly understood. The aim was to investigate the effect of zinc concentration [Zn(2+)] on the in vitro demineralization of enamel during exposure to caries-simulating conditions. Furthermore, the possible mechanism of zinc's action for reducing demineralization was determined.

METHODS

Enamel blocks and synthetic hydroxyapatite (HAp) were demineralized in a range of zinc-containing acidic solutions (0-3565ppm [Zn(2+)]) at pH 4.0 and 37°C. Inductively coupled-plasma optical emission spectroscopy (ICP-OES) was used to measure ion release into solution. Enamel blocks were analysed by Attenuated Total Reflectance-Fourier Transform Infrared Spectroscopy (ATR-FTIR), and HAp by X-ray diffraction (XRD) and neutron diffraction (ND).

RESULTS

ICP-OES analysis of the acidic solutions showed a decrease in [Ca(2+)] and [PO4(3-)] release with increasing [Zn(2+)]. FTIR revealed a α-hopeite (α-Zn3(PO4)2.4H2O)-like phase on the enamel surfaces at >107ppm [Zn(2+)]. XRD and ND analysis confirmed a zinc-phosphate phase present alongside the HAp.

CONCLUSIONS

This study confirms that zinc reduces enamel demineralization. Under the conditions studied, zinc acts predominantly on enamel surfaces at PO4(3-) sites in the HAp lattice to possibly form an α-hopeite-like phase.

CLINICAL SIGNIFICANCE

These results have a significant implication on the understanding of the fundamental chemistry of zinc in toothpastes and demonstrate its therapeutic potential in preventing tooth mineral loss.

Clinical evidence demonstrating the utility of inorganic nitrate in cardiovascular health

The discovery of nitric oxide and its role in almost every facet of human biology opened a new avenue for treatment through manipulation of its canonical signaling and by attempts to augment endogenous nitric oxide generation through provision of substrate and co-factors to the endothelial nitric oxide synthase complex. This has been particularly so in the cardiovascular system and it is well recognized that there is reduced bioavailable nitric oxide in patients with both cardiovascular risk factors and manifest vascular disease. However, these attempts have failed to deliver the expected benefits of such an approach. Recently, an alternative pathway for nitric oxide synthesis has been elucidated that can produce authentic nitric oxide from the 1 electron reduction of inorganic nitrite. Furthermore, it has long been known that symbiotic, facultative, oral microflora can facilitate the reduction of inorganic nitrate, that is ingested in the average diet in millimolar amounts, to inorganic nitrite itself. Thus, there exists an alternative reductive pathway from nitrate, via nitrite as an intermediate, to nitric oxide that provides a novel pathway that may be amenable to therapeutic manipulation. As such, various research groups have explored the utility of manipulation of this nitrate-nitrite-nitric oxide pathway in situations in which nitric oxide is known to have a prominent role. Animal and early-phase human studies of both inorganic nitrite and nitrate supplementation have shown beneficial effects in blood pressure control, platelet function, vascular health and exercise capacity. This review considers in detail the pathways of inorganic nitrate bioactivation and the evidence of clinical utility to date on the cardiovascular system.

How to deal with morning bad breath: A randomized, crossover clinical trial

Context:

The absence of a protocol for the treatment of halitosis has led us to compare mouthrinses with mechanical oral hygiene procedures for treating morning breath by employing a hand-held sulfide monitor.

Aims:

To compare the efficacy of five modalities of treatment for controlling morning halitosis in subjects with no dental or periodontal disease.

Settings and Design:

This is a five-period, randomized, crossover clinical trial.

Materials and Methods:

Twenty volunteers were randomly assigned to the trial. Testing involved the use of a conventional tongue scraper, a tongue scraper joined to the back of a toothbrush's head, two mouthrinses (0.05% cetylpyridinium chloride and 0.12% chlorhexidine digluconate) and a soft-bristled toothbrush and fluoride toothpaste for practicing oral hygiene.

Statistical Analysis Used:

Data analysis was performed using SPSS version 17 for Windows and NCSS 2007 software (P < 0.05). The products and the periods were compared with each other using the Friedman's test. When significant differences (P < 0.05) were determined, the products and periods were compared in pairs by using the Wilcoxon's test and by adjusting the original significance level (0.05) for multiple comparisons by using the Bonferroni's method.

Results:

The toothbrush's tongue scraper was able to significantly reduce bad breath for up to 2 h. Chlorhexidine reduced bad breath only at the end of the second hour, an effect that lasted for 3 h.

Conclusions:

Mechanical tongue cleaning was able to immediately reduce bad breath for a short period, whereas chlorhexidine and mechanical oral hygiene reduced bad breath for longer periods, achieving the best results against morning breath.

Halitosis: From diagnosis to management

Halitosis is formed by volatile molecules which are caused because of pathological or nonpathological reasons and it originates from an oral or a non-oral source. It is very common in general population and nearly more than 50% of the general population have halitosis. Although halitosis has multifactorial origins, the source of 90% cases is oral cavity such as poor oral hygiene, periodontal disease, tongue coat, food impaction, unclean dentures, faulty restorations, oral carcinomas, and throat infections. Halitosis affects a person's daily life negatively, most of people who complain about halitosis refer to the clinic for treatment but in some of the people who can suffer from halitosis, there is no measurable halitosis. There are several methods to determine halitosis. Halitosis can be treated if its etiology can be detected rightly. The most important issue for treatment of halitosis is detection etiology or determination its source by detailed clinical examination. Management may include simple measures such as scaling and root planning, instructions for oral hygiene, tongue cleaning, and mouth rinsing. The aim of this review was to describe the etiological factors, prevalence data, diagnosis, and the therapeutic mechanical and chemical approaches related to halitosis.

Physiological role for nitrate-reducing oral bacteria in blood pressure control

Circulating nitrate (NO(3)(-)), derived from dietary sources or endogenous nitric oxide production, is extracted from blood by the salivary glands, accumulates in saliva, and is then reduced to nitrite (NO(2)(-)) by the oral microflora. This process has historically been viewed as harmful, because nitrite can promote formation of potentially carcinogenic N-nitrosamines. More recent research, however, suggests that nitrite can also serve as a precursor for systemic generation of vasodilatory nitric oxide, and exogenous administration of nitrate reduces blood pressure in humans. However, whether oral nitrate-reducing bacteria participate in "setting" blood pressure is unknown. We investigated whether suppression of the oral microflora affects systemic nitrite levels and hence blood pressure in healthy individuals. We measured blood pressure (clinic, home, and 24-h ambulatory) in 19 healthy volunteers during an initial 7-day control period followed by a 7-day treatment period with a chlorhexidine-based antiseptic mouthwash. Oral nitrate-reducing capacity and nitrite levels were measured after each study period. Antiseptic mouthwash treatment reduced oral nitrite production by 90% (p < 0.001) and plasma nitrite levels by 25% (p = 0.001) compared to the control period. Systolic and diastolic blood pressure increased by 2-3 .5mmHg, increases correlated to a decrease in circulating nitrite concentrations (r(2) = 0.56, p = 0.002). The blood pressure effect appeared within 1 day of disruption of the oral microflora and was sustained during the 7-day mouthwash intervention. These results suggest that the recycling of endogenous nitrate by oral bacteria plays an important role in determination of plasma nitrite levels and thereby in the physiological control of blood pressure.

Limited evidence suggests that mouthrinses may be effective in reducing oral malodour

DATA SOURCES

Medline, The Cochrane Central Register of Controlled Trials (CENTRAL) and Embase databases were searched.

STUDY SELECTION

Screening and selection of studies was conducted independently by two authors, with randomised controlled trials (RCTs) or controlled clinical trials (CCTs) conducted in adults 18 years or older being included. Studies used the outcome measures of volatile sulphur compounds (VSCs), organoleptic measurement (OM) and tongue coating (TC). Studies with a duration of greater than one day were included. Selection was restricted to English language papers.

DATA EXTRACTION AND SYNTHESIS

Study quality was assessed by two authors with studies being separated into short- term (< 3 weeks) and longer-term study period groups (≥3 weeks). Meta-analysis was not conducted because of heterogeneity in the study designs, products used, outcome measures and data presentation.

RESULTS

Twelve RCTs were included (six cross-over studies and six parallel design). The short-term studies ranged from four days to two weeks and the long-term studies from three to four weeks. The risk of bias was assessed as high for two studies, moderate for three and low for seven. Nearly all mouthwashes with active ingredients had beneficial effects in reducing oral malodour in both short- and longer-term studies.

CONCLUSIONS

The most compelling evidence was provided for chlorhexidine mouthwashes, and those that contained a combination of cetyl pyridinum chloride and zinc provided the best evidence profile on oral malodour. Little data with respect to tongue coating were available, and none of the studies showed a beneficial effect for this parameter.

Halitosis: the multidisciplinary approach

Halitosis, bad breath or oral malodour are all synonyms for the same pathology. Halitosis has a large social and economic impact. For the majority of patients suffering from bad breath, it causes embarrassment and affects their social communication and life. Moreover,halitosis can be indicative of underlying diseases. Only a limited number of scientific publications were presented in this field until 1995. Ever since, a large amount of research is published, often with lack of evidence. In general, intraoral conditions, like insufficient dental hygiene, periodontitis or tongue coating are considered to be the most important cause (85%) for halitosis. Therefore, dentists and periodontologists are the first-line professionals to be confronted with this problem. They should be well aware of the origin, the detection and especially of the treatment of this pathology. In addition, ear-nose-throat-associated (10%) or gastrointestinal/endocrinological (5%) disorders may contribute to the problem. In the case of halitophobia, psychiatrical or psychological problems may be present. Bad breath needs a multidisciplinary team approach: dentists, periodontologists, specialists in family medicine, ear-nose-throat surgeons, internal medicine and psychiatry need to be updated in this field, which still is surrounded by a large taboo.Multidisciplinary bad breath clinics offer the best environment to examine and treat this pathology that affects around 25% of the whole population. This article describes the origin, detection and treatment of halitosis, regarded from the different etiological origins.

Mouthwash use in general population: results from adult dental health survey in grampian, Scotland

OBJECTIVES

The purpose of this study was to determine the pattern of mouthwash use and to investigate the associated factors in general population.

MATERIAL AND METHODS

An Adult Dental Health Survey was conducted on 3,022 residents of Grampian region of Scotland (adjusted participation rate 58.2%). Participants received a questionnaire consisting of questions on oral health and behavioural factors.

RESULTS

The majority of participants (38.1%) have never used mouthwash, 17.5% used mouthwash less than once a month, 19.4% used mouthwash once every few days and 25.1% used mouthwash daily. Prevalence of use decreased with age (P < 0.001). Woman were more likely to use mouthwash than men (P = 0.004). Mouthwash use decreased with decrease in the level of deprivation (P < 0.001). Never-smokers were less likely to use mouthwash (40.3%) compared to smokers (53.1%) or those who stopped smoking (46.5%) (P < 0.001). Mouthwash was used by smaller proportion of people drinking alcohol on daily basis (36.6%), than by abstainers (42.2%) (P = 0.012). There was a positive relationship between flossing or brushing pattern and mouthwash use (P < 0.001). There was statistically significant relationship between mouthwash use and reasons for the last dental visit (P = 0.009). When compared to healthy individuals, mouthwash was used by higher proportion of people reporting that they had gum disease (P = 0.001), ulcers (P = 0.001), oral infections or swelling (P = 0.002) or other problems (P = 0.025).

CONCLUSIONS

Mouthwash use in general population is associated with socio-demographic, health and behavioural factors.