Periodontitis is associated with impaired olfactory function: A clinical study

AIM

To explore the association between periodontitis and olfactory disorders.

METHODS

Clinical data were collected from 198 individuals between the ages of 18 and 60 years living in Denmark. The exposure was periodontitis, and the outcome was olfactory function (Threshold, Discrimination, Identification - TDI score), both measured clinically. Covariates included sex, age, education level, income, usage of nasal spray, tongue coating, halitosis, xerostomia, smoking, and history of COVID-19. Structural equation modeling was used to estimate the association between periodontitis and olfactory function. Periodontitis was defined using the AAP/EFP classification and dichotomized into "no" (healthy subjects) and "yes" (Stages I, II, and III). Olfactory function was treated as a one-factor latent variable, including the different olfactory scores. In addition, extra models were performed considering each olfactory component as a separate outcome and the TDI Global Score.

RESULTS

The results showed that periodontitis was associated with a lower olfactory function [standardized coefficient (SC) -0.264, 95% CI -0.401, -0.118]. Additionally, periodontitis was also associated with a lower olfactory Threshold (odorant concentration required for detection) (SC -0.207, 95% CI -0.325, -0.089), Discrimination (ability to discriminate between odorants) (SC -0.149, 95% CI -0.270, -0.027), Identification (ability to identify odorants) scores (SC -0.161, 95% CI -0.277, -0.045), and TDI Global Score (SC -0.234, 95% CI -0.370, -0.099).

CONCLUSIONS

This study suggests that periodontitis is associated with olfactory impairment.

Effect of sleeve gastrectomy on the levels of oral volatile sulfur compounds and halitosis-related bacteria

Background

The association between sleeve gastrectomy and halitosis remains relatively unknown. Therefore, this study aimed to evaluate the effect of sleeve gastrectomy on halitosis and the oral bacterial species associated with halitosis in patients with obesity.

Methods

This was a prospective longitudinal cohort study that examined patients before and after sleeve gastrectomy and followed the patients at three time intervals (1, 3, and 6 months) after sleeve gastrectomy. Clinical periodontal measurements (plaque index [PI], gingival index [GI], and probing depth [PD]) were obtained. In addition, plaque samples were collected for quantification of the periodontopathogenic bacteria: Porphyromonas gingivalis, Tannerella forsythia, Treponema denticola, and Fusobacterium nucleatum using real-time quantitative polymerase chain reaction (qPCR). In addition, breath samples were collected to analyze the concentration of volatile sulfur compounds (VSCs), namely hydrogen sulfide (H2S), methyl mercaptan (CH3SH), and dimethyl sulfide (CH3SCH3), via portable gas chromatography (Oral Chroma™).

Results

Of the 43 patients initially included, 39 completed the study, with a mean age of 32.2 ± 10.4 years. For PI and GI repeated measurements one way analysis of variance showed a significant increase (p-value < 0.001 for both) one month after surgery, with mean values of 1.3 and 1.59, respectively, compared to the baseline. During the same period, the number of P. gingivalis increased, with a p-value = 0.04. Similarly, the levels of hydrogen sulfide (H2S) and methyl mercaptan (CH3SH) increased significantly in the first month after surgery (p-value = 0.02 and 0.01, respectively).

Conclusion

This study demonstrated that sleeve gastrectomy may lead to increased halitosis one month post-surgery, attributed to elevated and P. gingivalis counts, contributing to the development of gingivitis in obese patients who underwent sleeve gastrectomy. This emphasizes the importance of including oral health professionals in the multidisciplinary team for the management of patients undergoing bariatric surgery.

Effectiveness of a Daily Honeycomb-Shaped Dental Chew in Reducing Calculus, Plaque, Gingivitis and Malodor in Dogs

Periodontal disease in dogs is common. Client compliance with oral hygiene and oral care for pets is low. The gold standard is annual dental prophylaxis under general anesthesia with imaging followed by home care including daily brushing. Clients should be offered methods to reduce calculus, plaque, gingivitis, and resulting halitosis that are time efficient, cost-effective, and easy to administer between annual preventative dental prophylaxis with the goal to move into maintenance phase of managing periodontal disease. This study aimed to evaluate the efficacy of a honeycomb-shaped dental chew in reducing hardened calculus, plaque, gingivitis, and malodor in client-owned dogs in their normal home environment including various breeds, skull types, ages, and weights. Calculus, plaque, and gingival scores with volatile sulfur compounds readings were performed under sedation and evaluated under general anesthesia after 60 consecutive days of receiving a daily honeycomb-shaped dental chew treat. There was an overall statistically significant percentage reduction of calculus (26.6%), plaque (14.2%), and malodor (46.71%). Gingival scores did not demonstrate statistically significant reduction (0.99%). Use of this honeycomb-shaped daily dental chew significantly reduced calculus, plaque, and associated malodor in dogs when fed consecutively for 60 days.

Narrative review on artificially intelligent olfaction in halitosis

Halitosis, commonly known as oral malodor, is a multifactorial health concern that significantly impacts the psychological and social well-being of individuals. It is the third most frequent reason for individuals to seek dental treatment, after dental caries and periodontal diseases. For an in-depth exploration of the topic of halitosis, an extensive literature review was conducted. The review focused on articles published in peer-reviewed journals and only those written in the English language were considered. The search for relevant literature began by employing subject headings such as 'halitosis, oral malodor, volatile sulfur compounds, artificial intelligence, and olfaction' in databases such as PubMed/Medline, Scopus, Google Scholar, Web of Science, and EMBASE. Additionally, a thorough hand search of references was conducted to ensure the comprehensiveness of the review. After amalgamating the search outcomes, a comprehensive analysis revealed the existence of precisely 134 full-text articles that bore relevance to the study. Abstracts and editorial letters were excluded from this study, and almost 50% of the full-text articles were deemed immaterial to dental practice. Out of the remaining articles, precisely 54 full-text articles were employed in this review. As primary healthcare providers, dentists are responsible for diagnosing and treating oral issues that may contribute to the development of halitosis. To effectively manage this condition, dentists must educate their patients about the underlying causes of halitosis, as well as proper oral hygiene practices such as tongue cleaning, flossing, and selecting appropriate mouthwash and toothpaste. This narrative review summarises all possible AI olfaction in halitosis.

Association between periodontitis and depression severity - A cross-sectional study of the older population in Hamburg

The aim of the current study is to investigate the association between periodontitis (exposure variable) and depression severity (outcome variable) in an older German population. We evaluated data from 6,209 participants (median age 62 years) of the Hamburg City Health Study (HCHS). The HCHS is a prospective cohort study and is registered at ClinicalTrial.gov (NCT03934957). Depression severity were assessed with the 9-item Patient Health Questionnaire (PHQ-9). Periodontal examination included probing depth, gingival recession, plaque index, and bleeding on probing. Descriptive analyses were stratified by periodontitis severity. Multiple linear regression models were adjusted for age, sex, diabetes, education, smoking, and antidepressant medication. Linear regression analyses revealed a significant association between log-transformed depression severity and periodontitis when including the interaction term for periodontitis * age, even after adjusting for age, sex, diabetes, education, smoking and antidepressant medication. We identified a significant association between severe periodontitis and elevated depression severity, which interacts with age. Additionally, we performed a linear regression model for biomarker analyses, which revealed significant associations between depression severity and severe periodontitis with log-transformed inflammatory biomarkers interleukin 6 (IL-6) and high-sensitivity C-reactive protein (hsCRP). In order to identify new therapeutic strategies for patients with depression and periodontal disease, future prospective studies are needed to assess the physiological and psychosocial mechanisms behind this relationship and the causal directionality.

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.

Effect of Photodynamic Therapy on Halitosis: A Systematic Review of Randomized Controlled Trials

BACKGROUND

This systematic review aimed to assess the effectiveness and safety of aPDT for the treatment of halitosis.

METHODS

Search strategies were conducted in October 2021 without language or data restrictions, on the following databases: MEDLINE, EMBASE, CENTRAL, LILACS and BBO, as well as a manual search. Randomized clinical trials (RCTs) with parallel design were considered for inclusion, assessing individuals (adolescents and adults) with a clinical diagnosis of halitosis treated with photodynamic therapy (aPDT). Primary outcomes assessed were halitosis measurements, adverse events and quality of life. The risk of bias for each included study was evaluated with the Cochrane Risk of Bias tool and the certainty of the body of the evidence was assessed with the GRADe approach.

RESULTS

Six RCTs (total of 225 participants) were included and due to clinical diversities it was not possible to group the outcome data in meta-analyses. Based on very low-certainty evidence (GRADE) the results showed that, when compared to tongue scraper, aPDT seems to promote a little to no difference in reducing halitosis and in the microbiological analysis. No adverse events were reported. Considering aPDT combined with tongue scraper, better outcome results were observed when compared to tongue scraper alone.

CONCLUSIONS

Based on very low-certainty evidence, the findings of this review are uncertain about the effects of aPDT for halitosis control. Further RCTs with higher number of participants and long term assessments need to be conducted to support the use of this intervention. The protocol was registered in the PROSPERO database (number: CRD42020215319) on 19 November 2020-retrospectively registered.

The effect of Brazilian propolis type-3 against oral microbiota and volatile sulfur compounds in subjects with morning breath malodor

OBJECTIVES

To evaluate propolis type-3 mouthrinse effects on the concentration of volatile sulfur compounds (VSCs) and on tongue dorsum microbial profile.

MATERIALS AND METHODS

A three-step double-blind, crossover, randomized study with 10 individuals divided into three groups: I-placebo (P); II-ethanolic extract of propolis type-3 3% (EEP); and III-chlorhexidine 0.12% (CHX) and instructed to rinse twice daily for 5 days. Each experimental period was followed by a 21-day washout interval. Morning mouth breath was assessed by VSC concentrations and microbiological samples were obtained from tongue dorsum at baseline and the end of period of rinses and analyzed using checkerboard DNA-DNA hybridization technique for 39 bacterial species.

RESULTS

CHX and EEP presented the lowest VSC concentration when compared with placebo (p < 0.05). Even in the absence of mechanical plaque control, CHX and EEP treatments reduced VSC levels and there were no statistical differences for VSC measurement between CHX and EEP. There was a significant reduction in mean counts of 10 species including some VSC producers (Prevotella intermedia, Porphyromonas gingivalis, Treponema denticola, and Tannerella forsythia) by EEP. Total counts of organisms, gram-negative and gram-positive bacterial species showed a decrease for EEP and CHX (p < 0.05). In addition, no statistical difference was observed between EEP and CHX (p > 0.05). A positive correlation was observed between decrease of bacterial counts and decrease of VCSs concentration for the EEP and CHX.

CONCLUSIONS

The use of a 3% propolis type-3 mouthrinse is an effective way to prevent morning bad breath. Thus, propolis may be a promising agent for the treatment of halitosis.

CLINICAL RELEVANCE

Propolis type-3 may be used as adjuvant treatment for morning breath malodor.

Salivary β-galactosidase, halitosis parameters in periodontal health and disease, and their changes after periodontal treatment

BACKGROUND

In this study, we aimed to evaluate the salivary β-galactosidase and Halimeter values (HMV), organoleptic scores (OLS) and Winkel tongue coating index (WTCI) in periodontal health and periodontitis (P), and also their changes after phase I periodontal therapy and tongue cleaning.

METHODS

The participants were separated as follows: 25 P with halitosis (Group 1), 25 P without halitosis (Group 2) and 25 healthy controls (Group 3). Periodontal recordings, HMV, OLS and WTCI scores were recorded, and whole saliva β-galactosidase levels were measured colorimetrically in the samples at baseline and 1 month after the therapy.

RESULTS

The baseline values of HMV, OLS, WTCI and salivary β-galactosidase levels were significantly higher in Group 1 than in Group 2 (P < 0.05). There was a statistically significant decrease in periodontal recordings, HMV, OLS, WTCI and salivary β-galactosidase levels in all P patients by the therapy (P < 0.05). However, major reductions in halitosis measurements and saliva enzyme levels were observed in Group 1 after the treatment.

CONCLUSION

Our results showed that salivary β-galactosidase was associated with halitosis parameters and phase I periodontal therapy played an important role to reduce this enzyme level and halitosis parameters in P.

The Chairside Periodontal Diagnostic Toolkit: Past, Present, and Future

Periodontal diseases comprise a group of globally prevalent, chronic oral inflammatory conditions caused by microbial dysbiosis and the host immune response. These diseases specifically affect the tooth-supporting tissues (i.e., the periodontium) but are also known to contribute to systemic inflammation. If left untreated, periodontal diseases can ultimately progress to tooth loss, lead to compromised oral function, and negatively impact the overall quality of life. Therefore, it is important for the clinician to accurately diagnose these diseases both early and accurately chairside. Currently, the staging and grading of periodontal diseases are based on recording medical and dental histories, thorough oral examination, and multiple clinical and radiographic analyses of the periodontium. There have been numerous attempts to improve, automate, and digitize the collection of this information with varied success. Recent studies focused on the subgingival microbiome and the host immune response suggest there is an untapped potential for non-invasive oral sampling to assist clinicians in the chairside diagnosis and, potentially, prognosis. Here, we review the available toolkit available for diagnosing periodontal diseases, discuss commercially available options, and highlight the need for collaborative research initiatives and state-of-the-art technology development across disciplines to overcome the challenges of rapid periodontal disease diagnosis.

General Health, Systemic Diseases and Oral Status in Adult Patients with Coeliac Disease

The prevalence of coeliac disease in the general population is 0.5–1%; however, most patients remain undiagnosed until adult age. In some cases, the onset is represented by sub-clinical signs, some of which can be found in the mouth. The aim of this research was to identify any associations between the clinical characteristics of coeliac disease and oral manifestations. A structured questionnaire was administered to a group of 237 individuals with coeliac disease. 100% of the subjects fully completed the questionnaire. Among them, 182 (76.7%) were female, 64 patients (27%) were aged 15 to 24 years, 159 (67%) were aged 25 to 55 and 14 (6%) were aged 56 and over. Significant associations were observed in caries prevalence and dentin sensitivity; in addition, an inappropriate diet was related to oral manifestations; following a gluten-free diet could be important to control the gingival bleeding levels and to manage oral symptoms associated to coeliac disease. In general, the presence of inflammatory symptoms in the mouth seems to be associated with general symptoms of inflammation related to coeliac disease.

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 antimicrobial photodynamic therapy against halitosis in adolescent patients undergoing orthodontic treatment

PURPOSE

The aim of the present randomized controlled clinical trial was to evaluate the efficacy of photodynamic therapy (PDT) on halitosis in adolescent patients undergoing fixed orthodontic treatment.

MATERIALS AND METHODS

Forty-five adolescents with halitosis undergoing orthodontic treatment were equally randomized into three groups: Group - I: provision of treatment through PDT on dorsum of tongue; Group - II: provision of treatment with the help of tongue scrappers (TS); Group - III: provision of treatment with the help of TS and adjunctive PDT. Presence of halitosis confirmed on the basis of gas chromatography and estimation of oral malodour with a cysteine challenge and H₂S values recorded ≥112 parts per billion (ppb). A portable device Oral Chroma™ was used for performing breath analysis. A total of 5 bacterial species including P. gingivalis, F. nucleatum, P. intermedia, T. forsythia and T. denticola were studied as the proportion of sites defined as having ≥1.0 × 10⁵ bacterial cells.

RESULTS

The mean age of the participants in Group-I, II and III were 15.4 years, 13.8 years, and 14.2 years, respectively. The median values for Group-I, II and III at initial breath analysis were 874 ppb, 613 ppb and 1089 ppb, respectively. After treatment with the respective therapeutic modalities, a statistically significant difference was seen among groups after 2-weeks (p < 0.0001) (Table 3). After applying Kruskal-Wallis test, group-III showed the highest amount of reduction in H₂S concentration (100 %) at final 2-weeks breath analysis compared to group-I and group-II (p = 0.0001). Descriptive statistics for all bacteria showed that group-III (TS + PDT) statistically significantly reduced the proportional distribution of all bacteria at 2-week follow-up (p < 0.0001) compared to group-I or group-II.

CONCLUSION

PDT along with tongue scrapping showed effective immediate reduction of H₂S concentration and reduction of oral pathogens in adolescent patients undergoing fixed orthodontic treatment with short-term follow up. Long-term evaluation and complete eradication of halitosis needs to be explored in further clinical trials. In addition, the cost of PDT and its potential side effects should not be disregarded.

The Relationship between Volatile Sulfur Compounds and the Severity of Chronic Periodontitis: A Cross-sectional Study

Background:

Halitosis is a problem that is often ignored or undervalued. It is not considered a major clinical issue; thus, little is carried out to eradicate it. Little is known about the relationship of malodorous breath with the severity of periodontitis. Hence, the study aimed to investigate the relationship between volatile sulfur compounds (VSCs) and chronic periodontitis.

Materials and Methods:

According to the severity of chronic periodontitis, 80 patients were categorized into four groups (mild, moderate, severe, and control). Probing depth and clinical attachment level were measured. Portable sulfide monitor (Halimeter) is used to assess VSCs. Statistical analyses were conducted using R studio (Northern Ave, Boston).

Results:

The differences in the VSC levels among the four groups were found to be statistically significant. The greater the severity of periodontitis, the higher the VSC levels found (P < 0.001). Male had higher levels of VSCs than female (225 and 180.53 parts per billion [ppb], respectively). The lowest mean level of VSCs was found in the subjects aged 15–29 years (161.79 ppb); the mean values increased with the age, reaching 282.89 ppb in subjects aged >59 years.

Conclusion:

Highly significant differences were found in the VSC levels among different severities of chronic periodontitis. Moreover, an age-related increase in the VSC levels was determined. In addition, male had higher concentration of VSCs than female.

Etiology and characteristics of halitosis in patients of a halitosis center in Northern Italy

BACKGROUND

As there are few studies in Europe describing characteristics of breath malodor for large groups of patients, this retrospective study was designed to analyse the etiology of halitosis among patients attending a breath malodor center in Northern Italy.

METHODS

Clinical records of 547 consecutive patients were reviewed and data on self-perceived halitosis, organoleptic scores, volatile sulphur compound (VSC) levels, and oral health condition were extracted and analysed.

RESULTS

The prevalence of intra-oral halitosis was 90.7%. In 21 patients no objective signs of breath malodor could be found. Periodontitis and gingivitis were the main cause of bad breath in 33.9% of subjects and in combination with tongue coating in 55.2%. Only eight subjects have tongue coating as the only cause of halitosis. Ear, nose and throat (ENT)/extra-oral causes were found in 5.2% of the patients. VSC concentrations were lower in the psychogenic halitosis group, whereas no statistically significant differences were detected when comparing intra-oral and extra-oral halitosis except for (CH3)2S.

CONCLUSIONS

Psychogenic halitosis is a rare condition among subjects complaining of suffering from bad breath. The most prevalent cause of halitosis is intra-oral, in particular a combination of tongue coating and periodontal disease. Tongue coating is rarely the primary cause of oral malodor.

Factors influencing breath analysis results in patients with diabetes mellitus

Breath analysis is used to detect the composition of exhaled gas. As a quick and non-invasive detection method, breath analysis provides deep insights into the progression of various kinds of diseases, especially those with metabolism disorders. Abundant information on volatile compounds in diabetic patients has been studied in numerous articles in the literature. However, exhaled gas in diabetic patients can be altered by various complications. So far, little attention has been paid to this alteration. In our paper, we found that under air pollution conditions, diabetic patients exhale more nitric oxide. Diabetic patients with heart failure exhale more acetone than those without heart failure. After ¹³C-labeled glucose intake, patients infected with Helicobacter pylori exhaled more ¹³C and less ¹⁸O than those without infection. Exhalation with chronic kidney disease changes volatile organic compounds on a large scale. Diabetic patients with ketoacidosis exhale more acetone than those without ketoacidosis. Some specific volatile organic compounds also emanate from diabetic feet. By monitoring breath frequency, diabetic patients with obstructive sleep apnea syndrome exhibit a unique breath pattern and rhythm as compared with other diabetic patients, and sleep apnea is prevalent among diabetic patients. In addition to clinical findings, we analyzed the underlying mechanisms at the levels of molecules, cells and whole bodies, and provided suggestions for further studies.

Reliability, Accuracy, and Use Frequency of Evaluation Methods for Amount of Tongue Coating

OBJECTIVE

To classify the evaluation methods for amount of tongue coating (TC) and investigate their reliability, accuracy, and frequency of use.

METHODS

Articles published from 1985 to 2015 were searched for evaluation methods for the amount of TC in PubMed and the Cochrane Library. Only clinical researches were included except protocol articles. The methods were classified according to their characteristics.

RESULTS

Finally, 113 articles were selected. The evaluation method for the amount of TC from the articles was classified into 4 types: intuitive, specificative, computerized, and weighing TC. The reliability in the intuitive and specificative methods (κ =0.33-0.92) showed varying levels among the studies. In general, the amount of TC calculated by the specificative method (Spearman's r=0.68-0.80) was more strongly related to the directly measured value than to the value estimated by the computerized method (Pearson's r=0.442). The number of articles published on this topic has increased consistently, and the specificative method was the most frequently used. Despite the higher reliability of the computerized method, it has not been widely used.

CONCLUSIONS

The high prevalence of the specificative method would continue in clinical practice because of its convenience and accuracy. However, to establish higher reliability, the limitation of the subjectivity of the assessors should be overcome through calibration training. In the computerized method, novel algorithms are needed to obtain a higher accuracy so that it can help the practitioners confidently estimate the amount of TC.

The long-term effect of a zinc acetate and chlorhexidine diacetate containing mouth rinse on intra-oral halitosis-A randomized clinical trial

AIM

To evaluate the long-term effects of a zinc acetate and chlorhexidine diacetate mouth rinse (Zn/CHX) on intra-oral halitosis.

MATERIALS AND METHODS

Forty-six adults with intra-oral halitosis were randomized into a 6-month, double-blind, placebo-controlled clinical study. The presence of intra-oral halitosis was evaluated at baseline, 3 and 6 months after treatment by assessment of organoleptic score (OLS) and by total volatile sulphur compounds (T-VSC), hydrogen sulphide (H₂ S) and methyl mercaptan (MM) concentrations in exhaled air.

RESULTS

A Zn/CHX mouth rinse provided significantly better control of intra-oral halitosis than a placebo mouth rinse. At 3 and 6 months, individuals rinsing with the Zn/CHX rinse presented with reductions of the OLS, T-VSC (p < .01, respectively), H₂ S (p < .001), and MM (p < .01) in subjects' exhaled air. At 6 months, 68.2% of individuals using the Zn/CHX rinse experienced a 1 or 2 category improvement in OLS compared with 19.1% of placebo-treated subjects. 91% of subjects in the Zn/CHX group were categorized as being effectively treated for intra-oral halitosis (i.e. H₂ S < 112 ppb), compared to 43% in the placebo group.

CONCLUSION

Zn/CHX mouth rinse provides effective long-term efficacy against intra-oral halitosis, assessed both objectively and subjectively. With regular rinsing, the effect was sustained for 6 months.

Comparison of oral malodors before and after nonsurgical periodontal therapy in chronic periodontitis patients

Background/purpose

Periodontal diseases have been considered as a source of oral malodor or halitosis. Improvement of oral malodor in chronic periodontitis patients has recently been observed after nonsurgical periodontal therapy in combination with tongue cleaning and/or chlorhexidine mouth rinsing. The present study, however, evaluated the impact of nonsurgical periodontal therapy alone on the oral malodor in chronic periodontitis patients by comparing the intraoral concentrations of volatile sulfur compounds (VSCs) before and after nonsurgical therapy.

Materials and methods

Using a sulfide monitor, the total VSCs in exhaled breath were measured in 80 patients with chronic periodontitis prior to and 1 month after nonsurgical periodontal therapy (re-evaluation phase). Malodor was defined as a VSC score > 75 parts per billion (ppb) and > 110 ppb, respectively.

Results

Significantly lower level of VSCs was recorded at periodontal re-evaluation (55 ± 9.7 ppb) than before treatment (89 ± 16.3 ppb). Before treatment, 27 (34%) patients were considered to have malodor, defined as VSCs > 75 ppb. After treatment, 16 patients (20%) had VSC scores > 75 ppb, including 10 of 27 patients with baseline VSC scores > 75 ppb and six of 53 patients with baseline scores ≤ 75 ppb. The risk of malodor differed significantly before and after treatment (P = 0.035, McNemar's test). However, when malodor was defined as VSCs > 110 ppb, the difference in risk showed only borderline significance (P = 0.077).

Conclusion

On the basis of our findings, we suggest that nonsurgical periodontal therapy has a mild impact on oral malodor.

Programmed cell death in periodontitis: recent advances and future perspectives

Periodontitis is a highly prevalent infectious disease, characterized by destruction of the periodontium, and is the main cause of tooth loss. Periodontitis is initiated by periodontal pathogens, while other risk factors including smoking, stress, and systemic diseases aggravate its progression. Periodontitis affects many people worldwide, but the molecular mechanisms by which pathogens and risk factors destroy the periodontium are unclear. Programmed cell death (PCD), different from necrosis, is an active cell death mediated by a cascade of gene expression events and can be mainly classified into apoptosis, autophagy, necroptosis, and pyroptosis. Although PCD is involved in many inflammatory diseases, its correlation with periodontitis is unclear. After reviewing the relevant published articles, we found that apoptosis has indeed been reported to play a role in periodontitis. However, the role of autophagy in periodontitis needs further verification. Additionally, implication of necroptosis or pyroptosis in periodontitis remains unknown. Therefore, we recommend future studies, which will unravel the pivotal role of PCD in periodontitis, allowing us to prevent, diagnose, and treat the disease, as well as predict its outcomes.

Assessment of the quantity of microorganisms associated with bronchiectasis in saliva, sputum and nasal lavage after periodontal treatment: a study protocol of a randomised controlled trial

INTRODUCTION

The association between periodontal disease (PD) and chronic obstructive pulmonary disease (COPD) has been widely studied, with aspiration of periodontal pathogens being one of the most accepted causal mechanisms for pulmonary exacerbation. Periodontal treatment (PT) was associated with a decrease in these exacerbations. Bronchiectasis is a pulmonary disease that has many similarities to COPD; however, there are no studies correlating this condition to PD thus far. This study will evaluate if PT reduces proinflammatory cytokines in serum and saliva, as well as halitosis and the amount of microorganisms associated with exacerbation of bronchiectasis in saliva, sputum and nasal lavage 3 months after PT.

METHODS AND ANALYSIS

A total of 182 patients with PD and bronchiectasis will be randomly allocated to group 1 (positive control; scaling and root planing (SRP)+oral hygiene (OH)) or group 2 (experimental; SRP+photodynamic therapy+OH). After 3 months, samples of saliva, nasal lavage and sputum will be collected to determine the level of Pseudomonas aeruginosa, Staphylococcus aureus and Porphyromonas gingivalis by quantitative PCR. This protocol will determine the efficacy of PT in reducing the most likely niches of bronchiectasis exacerbation by comparing pre- and post-treatment microbiology samples. Furthermore, there will be assessment of oral halitosis and verification of inflammatory cytokines in serum and saliva.

ETHICS AND DISSEMINATION

This protocol has been approved by the Research Ethics Committee of Universidade Nove de Julho. Data will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT02514226.

Changes of volatile sulphur compounds during therapy of a case series of patients with chronic periodontitis and halitosis

AIM

To assess the effect of different stages of intervention on volatile sulphur compounds (VSCs) of periodontitis patients with halitosis, before and after non-surgical periodontal therapy.

MATERIAL & METHODS

This clinical trial included 18 adults with chronic periodontitis and halitosis. After initial examination, patients received oral hygiene (OH) instructions and tongue cleaner. One week later, non-surgical periodontal therapy was completed within 48 h. Measurements were at baseline, 1 week after OH, 1 and 6 weeks post therapy. These included simplified plaque index (sPlI), probing pocket depth (PPD), bleeding on probing (BoP), Winkel Tongue Coating Index (WTCI), organoleptic scores (OLSs) of nose and mouth air and VSCs.

RESULTS

sPlI, BoP, WTCI, OLS of the mouth air and VSCs showed significant differences (p < 0.05), even after 1 week of OH. A further significant decrease was determined 1 week after non-surgical therapy for WTCI, OLS (nose and mouth air) and methyl mercaptan concentration. A significant decrease, 6 weeks post therapy, was observed for sPlI, BoP, WTCI, PPD, OLS of the nose and mouth air and VSCs (p < 0.05).

CONCLUSIONS

Oral hygiene and tongue cleaning improve the OLSs of the mouth air and reduce VSCs. Periodontal therapy further improves the OLSs and reduces the concentration of VSCs.

Prevalence estimation of halitosis and its association with oral health-related parameters in an adult population of a city in North Italy

AIM

No epidemiological data on halitosis are available from Italy. Thus, the aim of this population-based cross-sectional study was to estimate the prevalence of halitosis in an urban adult population from North Italy and to explore related oral risk indicators.

MATERIALS AND METHODS

The survey used a two-stage probability sampling method to collect a representative sample of inhabitants, aged between 20 and 75 years, in the city of Turin. Seven hundred and forty-four adults were clinically examined (47% of sampled subjects) for oral malodor and periodontal conditions. Using a standardized questionnaire social, health and halitosis-related parameters were collected. Logistic models with interaction terms between tongue coating scores (TCS) and periodontal status were used to explore halitosis risk indicators.

RESULTS

The prevalence estimate of halitosis according to the organoleptic assessment was 53.51% (95% CI: 48.55-58.50). A statistically significant correlation was found between organoleptic and gas chromatography measurements (p < 0.0001). Stronger associations between halitosis and periodontitis were observed in people having higher TCS: adjusted odds ratio considering low and high TCS in individuals with severe periodontitis were 2.95 and 20.77 (p ≤ 0.003).

CONCLUSIONS

Due to the high prevalence of halitosis in the Turin population, its diagnosis and management should be incorporated in comprehensive dental care.

Determining the association between oral malodor and periodontal disease: A case control study

Aim:

To assess the role of periodontal health in oral malodor causation and compare the two methods (organoleptic and Halimeter) of malodor measurement.

Materials and Methods:

A total of 240 subjects (60 subjects without any evidence of periodontal disease and 180 patients with gingivitis and periodontitis) were evaluated for periodontal and oral malodor parameters. Periodontal parameters included Plaque Index (PI), Gingival Index (GI), mSBI, calculus component of OHIS, pocket depth (PD), and clinical attachment level (CAL), and oral malodor was assessed by organoleptic scores, Halimeter readings, and Tongue Coating Index (TCI).

Results:

80% of the sample when assessed organoleptically (i.e. 192 subjects) and 74.6% when assessed with Halimeter (i.e. 179 subjects) presented with varying degrees of halitosis. All the clinical parameters were significantly associated with oral malodor (P < 0.001). The amount of tongue coating and bleeding on probing played the most important role in increasing VSC concentration, followed by periodontal status, plaque indices, and calculus component.

Conclusion:

There was a high prevalence of halitosis in the present study population. All the clinical parameters were significantly related to oral malodor in this study, and the results indicate that determining VSC levels with Halimeter is a useful means of diagnosing halitosis objectively.

Photodynamic therapy as a novel treatment for halitosis in adolescents: study protocol for a randomized controlled trial

Background

Halitosis is a common problem that affects a large portion of the population worldwide. The origin of this condition is oral in 90% and systemic in 10% of cases. The unpleasant odor is mainly the result of volatile sulfur compounds produced by Gram-negative bacteria. However, it has recently been found that anaerobic Gram-positive bacteria also produce hydrogen sulfide (H₂S) in the presence of amino acids, such as cysteine. Light, both with and without the use of chemical agents, has been used to induce therapeutic and antimicrobial effects. In photodynamic therapy, the antimicrobial effect is confined to areas covered by photosensitizing dye. The aim of the present study is to evaluate the antimicrobial effect of photodynamic therapy on halitosis in adolescents through the analysis of volatile sulfur compounds measured using gas chromatography and microbiological analysis of coated tongue.

Methods/Design

A quantitative clinical trial will be carried out involving 60 adolescents randomly divided into the following groups: group 1 will receive treatment with a tongue scraper, group 2 will receive photodynamic therapy applied to the posterior two-thirds of the dorsum of the tongue, and group 3 will receive combined treatment (tongue scraper and photodynamic therapy). Gas chromatography (OralChroma^TM) and microbiological analysis will be used for the diagnosis of halitosis at the beginning of the study. Post-treatment evaluations will be conducted at one hour and 24 hours after treatment. The statistical analysis will include the Shapiro-Wilk test for the determination of the distribution of the data. If normal distribution is demonstrated, analysis of variance followed by Tukey’s test will be used to compare groups. The Kruskal-Wallis test followed by the Student-Newman-Keuls test will be used for data with non-normal distribution. Either the paired t-test or the Wilcoxon test will be used to compare data before and after treatment, depending on the distribution of the data.

Discussion

The results of this trial will determine the efficacy of using photodynamic therapy alone or in combination with a tongue scraper to treat bad breath in adolescents.

Trial registration

The protocol for this study was registered with Clinical Trials (registration number NCT02007993) on 10 December 2013.

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.

Association between viral hepatitis B infection and halitosis

OBJECTIVE

Oral malodor can be increased in breath of liver patients. However, no study has been performed for the association between volatile sulfur compounds (VSCs) and viral hepatitis. The aim of the present study was to determine the relationship between viral hepatitis and VSCs.

METHODS

This study analyzed 182 subjects and measured hydrogen sulfide (H2S), methyl mercaptan (CH3SH) and dimethyl sulfide [(CH3)2S] using the OralChroma(®). Hepatitis type B was evaluated. Periodontal health was assessed using the Community Periodontal Index (CPI) and bleeding on probing (BOP). Tongue coating score (TCS) was evaluated. Multiple logistic regression analyses were conducted to evaluate the relationship.

RESULTS

Viral hepatitis had an elevated odds of dimethyl sulfide defined halitosis (OR = 9.22, 95% CI = 2.08-40.95) after controlling for age, gender, alcohol consumption, current smoking, periodontitis, BOP, TCS and tongue brushing habit. The magnitude of the association between viral hepatitis and VSCs defined halitosis attenuated with adjustment of mediators (alcohol consumption, periodontitis, BOP, TCS and tongue brushing habit for hydrogen sulfide defined halitosis; periodontitis, TCS and tongue brushing habit for methyl mercaptan defined halitosis; tongue brushing habit for dimethyl sulfide defined halitosis).

CONCLUSIONS

Findings of this study suggest that viral hepatitis may be associated with methyl mercaptan defined halitosis.

Instrumental assessment of halitosis for the general dental practitioner

At the moment there are no clear protocols for the assessment of bad breath. An organoleptic evaluation is still the reference. To date there are several tools available to detect and quantify specific compounds related to halitosis. This paper reviews the available information on three sulphur monitors (OralChroma™ (CHM-1), Halimeter® and Breathtron®), in order to suggest guidance for the general dental practitioner. All three devices showed an acceptable correlation with organoleptic scores. The Halimeter® and Breathtron® seem the most appropriate devices for a general dental practitioner, because they are easy to handle. Because of its capacity of distinguishing between different sulphur compounds and due to its time-consuming and complicated use, the OralChroma™ (CHM-1) seems more suitable in a research environment.

Comparison of different treatment modalities for oral halitosis

OBJECTIVES

To assess the effects on intra-oral halitosis by a mouth rinse containing zinc acetate (0.3%) and chlorhexidine diacetate (0.025%) with and without adjunct tongue scraping.

MATERIALS AND METHODS

Twenty-one subjects without a diagnosis of periodontitis were randomized in a cross-over clinical trial. Organoleptic scores (OLS) were assessed to define intra-oral halitosis by total volatile sulfur compound (T-VSC) measurements and by gas chromatography.

RESULTS

Twenty-one subjects with a mean age of 45.7 years (SD: ±13.3, range: 21-66). The OLS were significantly lower following active rinse combined with tongue scraping (p < 0.001) at all time points. Immediately after, at 30 min, and at day 14, the T-VSC values were lower in the active rinse sequence than in the negative rinse sequence (p < 0.001, p < 0.001 and p < 0.05, respectively). At 30 min and at day 14, the hydrogen sulfide (H(2)S) and methyl mercaptan (MM) values were lower in the active rinse sequence compared to the inactive rinse sequence (p < 0.001). The inactive rinse sequence with tongue scraping reduced T-VSC at 30 min (p < 0.001) but not at 14 days. Similar reductions in T-VSC, H(2)S and MM were found in the active rinse sequence with or without tongue scraping.

CONCLUSION

The use of a tongue scraper did not provide additional benefits to the active mouth rinse, but reduced OLS and tongue coating index.

Effectiveness of mechanical tongue cleaning on breath odour and tongue coating: a systematic review

BACKGROUND

The objective of this review was to summarize the available evidence regarding the effects of mechanical tongue cleaning compared with no mechanical tongue cleaning on breath odour and tongue coating (TC).

METHODS

PubMed-MEDLINE, EMBASE and Cochrane-CENTRAL were searched to identify potentially relevant studies. The inclusion criteria included the following: randomized controlled clinical trials (RCTs) or controlled clinical trials (CCTs) conducted in humans in good general health (no systemic disorders) and a patient age of ≥17 years. For the intervention, we considered tongue cleaning [the use of a tongue scraper (TS) or tongue brush (TB)] and for the control, brushing only (B) groups. Clinical parameters such as volatile sulphur compound concentration, organoleptic scores and TC were the outcome variables of interest. Study selection, quality assessment and data extraction were carried out by two independent reviewers.

RESULTS

After screening of the titles and abstracts and subsequent full text reading of the potential papers, we identified five publications that met the eligibility criteria and provided seven experiments. The five studies consisted of three RCTs and two CCTs. All experiments show a positive effect of mechanical tongue cleaning in addition to toothbrushing on various parameters of oral malodour.

CONCLUSIONS

This review demonstrated that mechanical approaches, such as tongue brushing or tongue scraping to clean the dorsum of the tongue, have the potential to successfully reduce breath odour and TC. However, data concerning the effect of mechanical tongue cleaning on chronic oral malodour (halitosis) are insufficient.

Actions and interactions of nitric oxide, carbon monoxide and hydrogen sulphide in the cardiovascular system and in inflammation--a tale of three gases!

Nitric oxide (NO), carbon monoxide (CO) and hydrogen sulphide (H(2)S) together make up a family of biologically active gases (the so-called 'gaseous triumvirate') with an increasingly well defined range of physiological effects plus roles to play in a number of disease states. Over the years, most researchers have concentrated their attention on understanding the part played by a single gas in one or more body systems. It is becoming more clear that all three gases are synthesised naturally in the body, often by the same cells within the same organs, and that all three gases exert essentially similar biological effects albeit via different mechanisms. Within the cardiovascular system, for example, all are vasodilators, promote angiogenesis and vascular remodelling and are protective towards tissue damage in for example, ischaemia-reperfusion injury in the heart. Similarly, all exhibit complex effects in inflammation with both pro- and anti-inflammatory effects recognised. It seems likely that cell function is controlled not by the activity of single gases working in isolation but by the concerted activity of all three of these gases working together.

Olfactory perception of cysteine-S-conjugates from fruits and vegetables

Volatile sulfur compounds have a low odor threshold, and their presence at microgram per kilogram levels in fruits and vegetables influences odor quality. Sensory analysis demonstrates that naturally occurring, odorless cysteine- S-conjugates such as S-( R/ S)-3-(1-hexanol)- l-cysteine in wine, S-(1-propyl)- l-cysteine in onion, and S-(( R/ S)-2-heptyl)- l-cysteine in bell pepper are transformed into volatile thiols in the mouth by microflora. The time delay in smelling these volatile thiols was 20-30 s, and persistent perception of their odor occurred for 3 min. The cysteine- S-conjugates are transformed in free thiol by anaerobes. The mouth acts as a reactor, adding another dimension to odor perception, and saliva modulates flavors by trapping free thiols.