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

Hyperpure chlorine dioxide versus chlorhexidine in intra-oral halitosis (ODOR trial) - protocol of a double-blinded, double-arm, parallel non-inferiority pilot randomized controlled trial

INTRODUCTION

Intra-oral halitosis (IOH) is the most common type of bad breath; its consequences impair quality of life. However, evidence-based treatment protocols and guidelines are lacking. Our aim is to investigate the effectiveness of chlorine dioxide as an applicable complementary treatment modality in IOH after tongue cleaning.

METHODS AND ANALYSIS

The ODOR trial will be a single-center, double-blinded, parallel-group, double-armed pilot randomized controlled trial with a non-inferiority design. The efficacy of hyperpure chlorine dioxide will be compared to chlorhexidine mouthwash. We plan to investigate the short-term effects of the intervention over a 3-h period. The primary endpoint will be changes in organoleptic test scores. At the end of the pilot investigation of the first 30 patients each, sample size calculation will be performed. If feasible, the investigators will continue the study by enrolling more patients.

TRIAL REGISTRATION

The trial has been registered at ClinicalTrials.gov (NCT06219226).

The effect of mastic mouthwash on halitosis and oral hygiene in orthodontic patients: a randomized clinical trial

BACKGROUND/OBJECTIVES

The aim of this trial was to investigate the effect of mastic mouthwash on halitosis using as a proxy the levels of the Volatile Sulfur Compounds (VSCs), and the effect on plaque and gingival indices in adolescents undergoing orthodontic treatment with fixed conventional labial appliances.

SUBJECTS/METHODS

The study was a double-blinded, placebo-controlled, parallel-group, randomized clinical trial. Thirty patients with fixed orthodontic appliances were randomly allocated at a 1:1 ratio, to either the mastic-mouthwash or the placebo-mouthwash group. Eligibility criteria included ages between 13 and 18, active orthodontic treatment with fixed appliances, good general health, and total initial VSCs levels above 150 ppb. The primary outcome was the objective hydrogen sulfide (H2S) level, measured with the Oral ChromaTM device. The secondary outcomes were (1.) the methyl-mercaptan (CH3SH) and (2.) dimethyl sulfide [(CH3)2S] levels, measured with the same device, (3.) the subjective perception of the own malodour via questionnaires, and (4.) the oral hygiene assessed with the use of the Modified Silness and Löe Plaque Index (PI-M) and the Silness and Löe Gingival Index (GI) at baseline (T0) and after 2 weeks (T1). Stratified randomization by gender was used, and allocation was concealed with opaque numbered sealed envelopes.

RESULTS

H2S level dropped from 221.00 ppb (T0) to 125.00 ppb (T1), and the difference between treatment groups was statistically significant in favour of the mastic group (coef: 72.34, 95% CI: 8.48, 136.27, P = 0.03). The levels of the other VSCs, the subjective measurements of oral malodour, and the oral hygiene indices did not differ between treatment arms.

LIMITATIONS

The objective organoleptic assessment by a calibrated examiner was not performed.

CONCLUSIONS/IMPLICATIONS

Mastic mouthwashes could be an alternative treatment for adolescent patients suffering from halitosis during orthodontic treatment with fixed appliances.

REGISTRATION

The trial was registered at ClinicalTrials.gov (identifier: NCT05647369).

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.

Daily use of chlorine dioxide effectively treats halitosis: A meta-analysis of randomised controlled trials

OBJECTIVES

We aimed to conduct a systematic review on published data in order to investigate the efficacy of mouthwash products containing chlorine dioxide in halitosis.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

Our search was conducted on 14th October 2021. We searched the following electronic databases: MEDLINE, Embase, Scopus, Web of Science, and CENTRAL. We analysed data on adults with halitosis, included only randomised controlled trials and excluded in vitro and animal studies. The interventional groups used chlorine dioxide, and the comparator groups used a placebo or other mouthwash. Our primary outcomes were changes in organoleptic test scores (OLS) and Volatile Sulfur Compound (VSC) levels from baseline to the last available follow-up.

RESULTS

We found 325 articles in databases. After the selection process, ten articles were eligible for qualitative synthesis, and 7 RCTs with 234 patients were involved in the meta-analysis. Our findings showed a significant improvement in the parameters of the chlorine dioxide group compared to the placebo group in OLS one-day data (mean difference (MD): -0.82; 95% confidence intervals (95% CIs): [-1.04 --0.6]; heterogeneity: I2 = 0%, p = 0.67); and one-week OLS data (MD: -0.24; 95% CIs: [-0.41 --0.07]; I2 = 0%, p = 0.52); and also changes in H2S one-day data (standardised mean difference (SMD): -1.81; 95% CIs: [-2.52 --1.10]); I2 = 73.4%, p = 0.02).

CONCLUSION

Our data indicate that chlorine dioxide mouthwash may be a good supportive therapy in oral halitosis without known side effects.

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.

Does a diluted chlorhexidine-based orthodontic mouthwash cause less discoloration compared to chlorhexidine mouthwash in fixed orthodontic patients? A randomized controlled trial

OBJECTIVE

Chlorhexidine gluconate is currently the most effective oral antimicrobial agent against microorganisms, but discoloration of the teeth prevents its long-term use and can reduce patient cooperation. In this study, the effect of chlorhexidine and a diluted chlorhexidine-based, fluoride, cetylpyridinium and vitamin added mouth rinse (Orthokin) on stain index in fixed orthodontic patients was compared.

MATERIALS AND METHODS

This study was performed as a double blind randomized controlled trial on 50 patients undergoing fixed orthodontic treatment in the age group of 14-30 years. The patients were categorized as two groups of chlorhexidine and Orthokin mouth rinses and were asked to use mouthwash for eight weeks. Groups were matched according to colouring food consumption. Extrinsic staining index was assessed by modified Loben technique. Data was analysed by SPSS software. P value was set to be 0.05.

RESULTS

In the chlorhexidine group, the stain extent index and overall stain index were increased significantly at 8 weeks (P<0.001 and P=0.002, respectively). However, the increase in stain intensity index was insignificant (P=0.07). In Orthokin group, the changes in stain extent, stain intensity and overall stain were insignificant (P=0.66, P=1.000, P=0.47, respectively).

CONCLUSION

According to the results of the present study, chlorhexidine mouthwash causes more staining of teeth compared to Orthokin mouthwash. It seems that lower concentrations of chlorhexidine can be prescribed to orthodontic patients. Although these compounds are effective in sense of oral hygiene, they do not cause significant discoloration.

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.

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.

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.

Effect of Halita mouthwash on oral halitosis treatment: A randomized triple-blind clinical trial

Background. Halitosis (oral malodor) is a common problem all over the world and its prevalence has been estimated at 23‒ 50%. Halitosis originates from oral cavity in 85% of patients. This clinical trial was conducted to evaluate the efficacy of the Halita mouthwash in oral halitosis treatment. Methods. Fifty subjects with an organoleptic score of >2 at baseline participated in this triple-blinded clinical trial. Subjects were divided into 2 groups. Group I subjects (N=25) were instructed to rinse with 0.2% chlorhexidine (CHX) mouthwash twice a day for 1 week. Group II subjects (N=25) used Halita mouthwash with the same instruction. Halitosis was evaluated at baseline and one week after using the mouthwashes by organoleptic method. Data were analyzed with chi-squared and Mann-Whitney U tests (P<0.05). Results. In the Halita group subjects exhibited 2.04±0.65 reduction in OLS. OLS reduction in the chlorhexidine group was 1.95±0.74. Statistical analysis showed no significant difference between the two groups (P>0.05). Conclusion. Based on the results, Halita mouthwash has the same effect on oral halitosis as routine 0.2% CHX mouthwash. Halita mouthwash has fewer side effects because of lower concentration of chlorhexidine. Therefore 0.2% CHX mouthwash could be replaced by Halita mouthwash for the treatment of halitosis.

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.

Effect of Halita mouthwash on oral halitosis treatment: A randomized triple-blind clinical trial

Background . Halitosis (oral malodor) is a common problem all over the world and its prevalence has been estimated at 23‒ 50%. Halitosis originates from oral cavity in 85% of patients. This clinical trial was conducted to evaluate the efficacy of the Halita mouthwash in oral halitosis treatment. Methods . Fifty subjects with an organoleptic score of >2 at baseline participated in this triple-blinded clinical trial. Subjects were divided into 2 groups. Group I subjects (N=25) were instructed to rinse with 0.2% chlorhexidine (CHX) mouthwash twice a day for 1 week. Group II subjects (N=25) used Halita mouthwash with the same instruction. Halitosis was evaluated at baseline and one week after using the mouthwashes by organoleptic method. Data were analyzed with chi-squared and Mann-Whitney U tests (P<0.05). Results . In the Halita group subjects exhibited 2.04±0.65 reduction in OLS. OLS reduction in the chlorhexidine group was 1.95±0.74. Statistical analysis showed no significant difference between the two groups (P>0.05). Conclusion . Based on the results, Halita mouthwash has the same effect on oral halitosis as routine 0.2% CHX mouthwash. Halita mouthwash has fewer side effects because of lower concentration of chlorhexidine. Therefore 0.2% CHX mouthwash could be replaced by Halita mouthwash for the treatment of halitosis.

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.

The effect of a tooth/tongue gel and mouthwash regimen on morning oral malodour: A 3-week single-blind randomized clinical trial

AIM

To compare the effects of a regimen consisting of a tooth/tongue gel, tongue cleaner and mouthwash with the effects of using standard fluoride dentifrice on the organoleptic oral malodour score (ORG) and volatile sulphur compounds (VSCs).

MATERIALS AND METHODS

A total, 66 non-dental students participated in a 3-week parallel, single-blind, randomized, controlled clinical trial. The test group used a tongue cleaner, a tooth/tongue gel and mouthwash containing amine fluoride/stannous fluoride and zinc lactate as oral malodour counteractive. The control group used a standard fluoride dentifrice. Measurements were taken in the morning at baseline, at days 1, 7 and 21. The primary outcome was the ORG score. The secondary outcome, the VSC measurement, was assessed using OralChroma™ (H₂ S, CH₃ SH, (CH₃ )₂ S) and Halimeter^® . Tongue coating thickness and tongue discoloration were scored. At baseline and day 21, the participants' self-perceptions were assessed.

RESULTS

At day 1 for the ORG, H₂ S, CH₃ SH and Halimeter^® readings, a significant decrease was observed in the test group. At day 21, the decrease in H₂ S and the Halimeter^® outcomes were maintained for the test group, and a significant increase in tongue surface discoloration was observed. The test group evaluated their "morning breath upon awakening" as significantly better (P=.001) after 21 days.

CONCLUSION

A significant overnight effect on morning oral malodour was observed for most of the parameters in favour of the test group. At day 21, the effect of prolonged use was significant for H₂ S and the Halimeter^® readings, although not for the primary ORG outcome parameter.

Assessment of oral malodor and tonsillar microbiota after gargling with benzethonium chloride

The oropharyngeal area can be a source of halitosis. However, the relationship between healthy tonsillar microbiota and halitosis is poorly understood. We conducted a pilot clinical study to clarify the effect of gargling with an antiseptic agent on tonsillar microbiota in patients with halitosis. Twenty-nine halitosis patients who did not have otolaryngologic disease or periodontitis were assigned randomly to one of three groups: benzethonium chloride (BZC) gargle; placebo gargle; no gargle. Concentrations of volatile sulfur compounds (VSCs) in mouth air, the organoleptic score (ORS) and tongue-coating score (TCS) were measured before and after testing. Tonsillar microbiota were assessed by detection of periodontal pathogens, and profiling with terminal-restriction fragment length polymorphism (T-RFLP) analysis and sequencing of 16SrRNA clone libraries for taxonomic assignment. Gargling with BZC reduced the concentrations of methyl mercaptan and hydrogen sulfide and the ORS, but did not affect the TCS or prevalence of periodontal pathogens. T-RFLP analyses and 16SrRNA clone sequencing showed a tendency for some candidate species to decrease in the test group. Although gargling of the oropharyngeal area with an antiseptic agent can reduce oral malodor, it appears that tonsillar microbiota are not influenced greatly. (J Oral Sci 58, 83-91, 2016).

Decreased Diversity of the Oral Microbiota of Patients with Hepatitis B Virus-Induced Chronic Liver Disease: A Pilot Project

Increasing evidence suggests that altered gut microbiota is implicated in the pathogenesis of hepatitis B virus-induced chronic liver disease (HBV-CLD). However, the structure and composition of the oral microbiota of patients with HBV-CLD remains unclear. High-throughput pyrosequencing showed that decreased oral bacterial diversity was found in patients with HBV-CLD. The Firmicutes/Bacteroidetes ratio was increased significantly, which indicated that dysbiosis of the oral microbiota participated in the process of HBV-CLD development. However, the changing patterns of the oral microbiota in patients with HBV-induced liver cirrhosis (LC) were almost similar to patients with chronic hepatitis B (CHB). HBV infection resulted in an increase in potential H₂S- and CH₃SH-producing phylotypes such as Fusobacterium, Filifactor, Eubacterium, Parvimonas and Treponema, which might contribute to the increased oral malodor. These key oral-derived phylotypes might invade into the gut as opportunistic pathogens and contribute to altering the composition of the gut microbiota. This study provided important clues that dysbiosis of the oral microbiota might be involved in the development of HBV-CLD. Greater understanding of the relationships between the dysbiosis of oral microbiota and the development of HBV-CLD might facilitate the development of non-invasive differential diagnostic procedures and targeted treatments of HBV-CLD patients harbouring specific oral phylotypes.

Efficacy of two mouthwashes on 3-day supragingival plaque regrowth: a randomized crossover clinical trial

BACKGROUND

The aim of this study was to evaluate the antiplaque effects of an alcohol-free essential oil (alcohol-free EO) mouthwash and an amine fluoride/stannous fluoride with zinc lactate (SnFl-Zn) mouthwash compared to a positive control of chlorhexidine (CHX) mouthwash, using an in vivo plaque regrowth model of 3 days.

MATERIALS AND METHODS

The study was designed as a double-masked, randomized, crossover clinical trial, involving 20 volunteers to compare two different mouthwashes, using a 3-day plaque accumulation model. After receiving thorough professional prophylaxis at baseline, over the next 3 days, each volunteer refrained from all oral hygiene measures and performed two daily rinses with 20 ml of the test mouthwashes. A 0.20% CHX rinse served as a positive control. At the end of each experimental period, plaque was assessed, and the panellists completed a questionnaire. Each subject underwent a 14-day washout period, and then, there was another allocation.

RESULTS

The SnFl-Zn mouthwash has shown a better inhibitory activity on plaque regrowth compared to the alcohol-free EO mouthwash in the whole mouth (plaque index = 1.93 against 2.45, respectively), but there was less of an effect compared to the CHX group, with an overall plaque index of 1.41. The differences of 0.52 between alcohol-free EO and SnFl-Zn and between SnFl-Zn and CHX and of 0.96 between alcohol-free EO and CHX were all statistically significant (P < 0.001).

CONCLUSION

The alcohol-free EO mouthwash seemed to have less of an inhibiting effect on plaque regrowth than the amine fluoride/SnFl-Zn mouthwash and the CHX control.

The efficacy of two oral hygiene regimens in reducing oral malodour: a randomised clinical trial

OBJECTIVES

This study compared the efficacy of two oral hygiene regimens in reducing oral malodour and the proportions of bacterial species involved in the production of volatile sulphur compounds.

MATERIAL AND METHODS

Seventy subjects who participated in a halitosis-induction phase and achieved an organoleptic score of ≥ 3.0 [time point 0 (T0)] randomised into two groups: brushing with regular fluoride toothpaste alone (control group) or brushing with regular fluoride toothpaste followed by rinsing with a 0.075% cetylpyridinium chloride (CPC) mouthwash (CPC group). Subjects followed their assigned oral hygiene regimen for 21 days. Then, they underwent an organoleptic examination and measurement of volatile sulphur compounds (VSCs) using a portable gas chromatograph, 12 hours after their last oral hygiene procedure (T1) and 4 hours after an on-site oral hygiene (T2). Microbiological samples (supragingival biofilm, tongue coating and saliva) were analysed using checkerboard DNA-DNA hybridisation.

RESULTS

Both therapies statistically significantly improved the organoleptic scores (P < 0.05), but the VSC levels and/or concentrations were reduced only in the CPC group (P < 0.05). In subjects rinsing with CPC, oral malodour scores were reduced by 49% at the 4-hour assessment (T2) compared with those not rinsing (P < 0.05). Red-complex pathogens were reduced more effectively in the CPC group than in the control group.

CONCLUSIONS

Brushing followed by rinsing with a 0.075% CPC mouthwash provided statistically significantly greater reductions in oral malodour, measured organoleptically and instrumentally, and in the proportions of red-complex species when compared with brushing alone.

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.