Short-term effect of a new mouthrinse formulation on oral malodour after single use in vivo : a comparative, randomized, single-blind, parallel-group clinical study

ORGANOLEPTIC AND HALITOMETRIC ASSESSMENTS DO NOT CORRELATE WELL IN INTRA-ORAL HALITOSIS: A SYSTEMATIC REVIEW AND META-ANALYSIS

BACKGROUND

The gold standard method for diagnosing oral halitosis is the subjective organoleptic measurement. Device-supported methods are also widespread worldwide. The challenges and safety concerns around performing organoleptic measurements during pandemics and the diversity of measuring device alternatives raised our clinical question: which halitometer is the most suitable for diagnosing halitosis?

METHODS

This systematic review was registered in PROSPERO (ID CRD42022320024). The search was performed on March 23, 2022 in the following electronic databases: MEDLINE, Embase, Scopus, Web of Science, and CENTRAL. Adult populations with or without halitosis were included, and patients with systemic diseases were excluded. Organoleptic (subjective) measurement and the device-supported (objective) methods were compared; the primary outcome was the correlation coefficient, and the secondary was the specificity and sensitivity of the devices. QUADAS-2 and QUADAS-C were used to evaluate the risk of bias in the studies. Random-effects meta analyses were performed on the outcomes, and the secondary outcomes were plotted on a common ROC plot.

RESULTS

A total of 1231 records were found in the 5 databases. After the selection process, 76 articles were eligible for the systematic review, and 14,635 patients were involved in the qualitative analysis. The pooled Spearman's correlation coefficient (c.c.) for sulfide monitors was 0.65; 95% CIs: [0.53-0.74]; I2 = 95%, P < .01. The pooled Spearman's c.c. for portable gas chromatographs was 0.69; 95% CIs: [0.63-0.74]; I2 = 12%, P < .01. The pooled Spearman's c.c. for gas chromatographs was 0.76; 95% CIs: [0.67-0.83]; I2 = 0%, P < .01.

DISCUSSION

None of the most commonly used halitometers proved to be significantly superior to the others. Halimeter and OralChroma measurements did not correlate well with the organoleptic level of oral halitosis in adults. Therefore, better halitometers need to be developed as an alternative to organoleptic measurements.

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.

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.

A randomized cross-over short-term study on the short-term effects of a zinc-lactate containing mouthwash against oral malodour

AIM

This randomized controlled cross-over-design-study investigated short-term effects on oral malodour of a zinc-lactate-containing mouthwash.

MATERIALS AND METHODS

Sixteen subjects (18-65 years) with an organoleptic score (OLS) ≥2 were included. Following rinses were used: (A) a zinc-lactate-containing mouthwash (10 ml/30 s); (B) a zinc-lactate-containing mouthwash (15 ml/60 s); (C) a rinse without zinc-lactate (3 droplets/10 ml tap water/30 s) and (D) tap water (10 ml/30 s). Each formulation was evaluated by two blinded examiners comparing OLS and three volatile-sulphur-compounds (VSC; H₂S (hydrogen sulphide), CH₃SH (methyl mercaptan) and (CH₃)₂S (dimethyl sulphide)) before, 1 and 3 h after rinsing. Subject's perception was investigated with a visual-analogue-scale. Linear mixed models were used to compare all parameters simultaneously with respect to the four treatment groups with a significance level α < 0.05.

RESULTS

OLS was significantly reduced by A and B compared to C and D after 3 h (p < 0.006). The sum of the 3 VSCs as well as H₂S alone were significantly reduced by rinses A and B after 1 and 3 h compared to rinses C and D (p < 0.05). Significant differences were found between the four rinses for 'Taste' (p = 0.003), for 'Change of mouth feeling' (p = 0.001), for 'Feeling of freshness' (p = 0.002) and for 'Effectiveness' (p = 0.002) in favour of A & B.

CONCLUSION

A zinc-lactate-containing mouthwash reduced OLS and VSC over a period of 3 h with favourable patient reported outcomes.

Efficacy of different mouthrinse formulations in reducing oral malodour: a randomized clinical trial

AIMS

The aim of this study was to assess the efficacy of mouthrinses formulations in oral malodour.

MATERIAL & METHODS

This single-centre, double-blind, randomized, parallel group clinical trial compared the efficacy of Halita™ and meridol(®) with and without zinc lactate versus negative and positive control. Volunteers with confirmed oral malodour (18/group) rinsed with one mouthrinse during 7 days (15 ml, 2x/day for 1 min.). 15 min. after a first rinse (masking effect), and after 7 days (therapeutic effect) the change in organoleptic scores and level of sulphur compounds was recorded.

RESULTS

All rinses showed a masking effect (OLS 1 to 2 values reduced), only the rinses with antimicrobial ingredients showed a therapeutic effect (OLS 1 to 1.5 value less). The addition of zinc resulted in a more pronounced masking effect. Halita™ and meridol(®) with zinc showed the best therapeutic effect.

CONCLUSION

Although the masking effect of the rinses can be attributed partially to a dilution and the effect of aromas, the therapeutic effect should be linked to the anti-microbial action of active ingredients and counter action of zinc ions on VSC. A complete resolution of the unpleasant breath by additional mechanical intervention remains to be proven.

Halitology (breath odour: aetiopathogenesis and management)

This article reviews the aetiopathogenesis of halitosis (oral malodour) and management. Halitosis is any disagreeable breath odour. In most patients, the odour originates from the oral cavity. In some patients, it has an extra-oral aetiology and, in a few, metabolic anomalies are responsible. In other patients complaining of malodour, this is imagined rather than real. Volatile sulphur compounds (VSCs) and other elements appear largely responsible for the malodour. Predisposing factors include poor oral hygiene, hyposalivation, dental appliances, gingival and periodontal disease and mucosal disease. The first step in assessment is objective measurement to determine whether malodour is present. If present, the oral or extra-oral origin should be determined, because the latter requires medical investigation and support in therapy, as is also the case where the malodour is imagined rather than real. Oral malodour is managed largely by oral health improvement, plus use of one or more of the wide range of antimalodour therapies, and sometimes also with use of a malodour counteractive. Emergent treatments include probiotics and vaccines targeted against causal micro-organisms or their products.