Effects of a mouthwash with chlorine dioxide on oral malodor and salivary bacteria: a randomized placebo-controlled 7-day trial

Oral Microbiome: A Review of Its Impact on Oral and Systemic Health

PURPOSE OF REVIEW

This review investigates the oral microbiome's composition, functions, influencing factors, connections to oral and systemic diseases, and personalized oral care strategies.

RECENT FINDINGS

The oral microbiome is a complex ecosystem consisting of bacteria, fungi, archaea, and viruses that contribute to oral health. Various factors, such as diet, smoking, alcohol consumption, lifestyle choices, and medical conditions, can affect the balance of the oral microbiome and lead to dysbiosis, which can result in oral health issues like dental caries, gingivitis, periodontitis, oral candidiasis, and halitosis. Importantly, our review explores novel associations between the oral microbiome and systemic diseases including gastrointestinal, cardiovascular, endocrinal, and neurological conditions, autoimmune diseases, and cancer. We comprehensively review the efficacy of interventions like dental probiotics, xylitol, oral rinses, fluoride, essential oils, oil pulling, and peptides in promoting oral health by modulating the oral microbiome.

SUMMARY

This review emphasizes the critical functions of the oral microbiota in dental and overall health, providing insights into the effects of microbial imbalances on various diseases. It underlines the significant connection between the oral microbiota and general health. Furthermore, it explores the advantages of probiotics and other dental care ingredients in promoting oral health and addressing common oral issues, offering a comprehensive strategy for personalized oral care.

Effect of Antimicrobial Photodynamic Therapy on the Tongue Dorsum on Reducing Halitosis and the Duration of the Effect: A Randomized Clinical Trial

Antimicrobial photodynamic therapy (PDT) is a treatment that is gaining popularity in modern clinical medicine. However, little is known about the effect of PDT alone on reducing oral halitosis and the duration of the effect. This trial examined the effect of PDT on the tongue dorsum on reducing oral halitosis and the duration of the effect. This study was approved by the Ethics Committee of Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, and Okayama University Hospital (CRB20-015), and it was registered in the Japan Registry of Clinical Trials (jRCTs061200060). Twenty-two participants were randomly assigned to two groups: an intervention group and control group. PDT was performed in the intervention group using red laser emission and methylene blue gel on the middle and posterior area of the tongue dorsum. The concentration of volatile sulfur compounds, bacterial count on the tongue dorsum, probing pocket depth, bleeding on probing, and simplified oral debris index score were determined before and 1 week after PDT. The Mann-Whitney U test was used to assess the significance of the differences in each parameter between the two groups. We found that the hydrogen sulfide concentration and bacterial count on the tongue dorsum were decreased in the intervention group, but there was no statistically significant difference between the two groups. These results indicated that performing only PDT on the tongue dorsum may not contribute to reducing halitosis.

A pilot study comparing the disinfecting effects of commercialized stable ClO2 solution (free of activation) with conventional H2O2 on dental unit waterlines in the dental practice setting

Disinfection of dental unit waterlines (DUWLs) plays a key role in control and prevention of nosocomial infection in a dental clinic. The most conventional disinfectant is hydrogen peroxide (H2O2), while chlorine dioxide (ClO2) has been considered however was limited by the "activation" procedures. With the availability of commercialized stable ClO2 solution (free of activation), direct application of ClO2 in the dental practice became possible. This study was designed to compare the disinfecting effects of stable 5 ppm of ClO2 solution with conventional 0.24% of H2O2 on DUWLs in dental practice. Studies of colony-forming units (CFUs), confocal laser scanning microscopy (CLSM) and scanning electron microscope (SEM) were employed for evaluation. In CFUs studies, we found that the efficiency of ClO2 was no less than those of H2O2. In the morphological studies, the stronger disinfecting effects of ClO2 was verified by both CLSM and SEM studies for removal and prevention of biofilm. Importantly, ClO2 solution achieved a better disinfecting efficiency not only at the surface of bacterial biofilm, but also, it has penetrating effects, presented disinfecting effects from the surface to the bottom of the biofilm. This pilot study provided evidence regarding the efficiency of stable ClO2 solution on disinfection of DUWLs in the dental practice setting. Application of stable ClO2 solution in dental practice is therefore become possible.

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.

Lactobacillus paracasei ET-22 and derived postbiotics reduce halitosis and modulate oral microbiome dysregulation - a randomized, double-blind placebo-controlled clinical trial

Oral microbial dysbiosis is the primary etiologic factor for halitosis and may be the critical preventive target for halitosis. This study included randomized controlled trials (RCTs) assessing the effects of Lactobacillus paracasei ET-22 live and heat-killed bacteria on halitosis and the related oral microbiome. 68 halitosis subjects were divided into placebo, ET-22 live (ET-22.L) and ET-22 heat-killed (ET-22.HK) groups. Subjects took different lozenges three times a day for 4 weeks and underwent saliva collection and assessment of breath volatile sulfur compound (VSC) levels at the beginning and end of the intervention. Salivary volatile organic compounds were measured using HS-SPME-GC/MS, and the microbiome profile was determined by 16S rRNA gene amplicon sequencing. A positive decrease in breath volatile sulfur compound (VSC) levels was observed in the means of both ET-22.L and ET-22.HK groups after 4 weeks of intervention, being more marked in the ET-22.L group (p = 0.0148). Moreover, ET-22.L and ET-22.HK intervention remarkably changed the composition of total salivary volatile organic compounds (VOCs) and aroma-active VOCs. Key undesirable VOCs, such as indole, pyridine, nonanoic acid, benzothiazole, and valeric acid, were significantly reduced. Meanwhile, ET-22.L or ET-22.HK also altered the taxonomic composition of the salivary microbiome. The halitosis pathogens Rothia and Streptococcus were significantly reduced in the ET-22.HK group and the pathogenic Solobacterium and Peptostreptococcus were significantly inhibited in the ET-22.L group. Collectively, our study suggests that both ET-22.L and ET-22.HK can significantly inhibit the production of undesirable odor compounds in subjects with halitosis, which may be related to the changes of the oral microbiome.

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.

Concerning perceived and clinically-measured levels of halitosis

The different types of self-reported halitosis complaints include those where one feels that one’s breath smells bad, where one feels that one has bad breath because of the attitudes of others, and where others have pointed out the presence of bad breath. The results of previous studies comparing the objective and subjectives measures of halitosis are inconsistent, and few studies have used gas chromatography (GC) to measure halitosis in a large sample. This study aimed to examine the objectively measured halitosis levels based on the reasons individuals are concerned about halitosis. We included 2063 patients who visited the halitosis clinic at a university dental hospital. Halitosis was assessed using GC, self-administered questionnaires, and oral examinations. Levels of volatile sulphur compounds (VSCs; H2S, CH3SH, and (CH3)2S) were set as objective measures of halitosis. Patients were grouped based on their answers to ‘What made you concerned about bad breath?’ into groups: ‘self-perceived,’ ‘attitudes of others,’ ‘told by others,’ and other reasons. Univariate and multivariable linear regression analyses were performed to examine factors associated with VSCs and objective halitosis levels. Age, sex, oral health status, smoking, drinking, and breakfast habits were used as confounders. Patients who answered ‘told by others’ (n = 691, 33.5%) showed the highest VSCs. Individuals whose halitosis was pointed out by others had higher objectively measured halitosis levels, while those concerned about the attitudes of others or perceived their own halitosis had lower objectively measured halitosis levels. These results suggest that the objective level of halitosis can differ on the basis of the reason underlying an individual’s concern about their bad breath. Categorizing halitosis complaints and comparing them with objective halitosis levels may help reduce the anxiety of those who are concerned about halitosis and confirm the need for intervention for those with objective halitosis.

Can nasal irrigation with chlorine dioxide be considered as a potential alternative therapy for respiratory infectious diseases? The example of COVID-19

Chlorine dioxide (ClO₂) is a high-level disinfectant that is safe and widely used for sterilization. Due to the limitations on preparing a stable solution, direct use of ClO₂ in the human body is limited. Nasal irrigation is an alternative therapy used to treat respiratory infectious diseases. This study briefly summarizes the available evidence regarding the safety/efficacy of directly using ClO₂ on the human body as well as the approach of nasal irrigation to treat COVID-19. Based on the available information, as well as a preliminary experiment that comprehensively evaluated the efficacy and safety of ClO₂, 25-50 ppm was deemed to be an appropriate concentration of ClO₂ for nasal irrigation to treat COVID-19. This finding requires further verification. Nasal irrigation with ClO₂ can be considered as a potential alternative therapy to treat respiratory infectious diseases, and COVID-19 in particular.

Surface Free Energy and Composition Changes and Ob Cellular Response to CHX-, PVPI-, and ClO2-Treated Titanium Implant Materials

The study evaluated the interaction of a titanium dental implant surface with three different antibacterial solutions: chlorhexidine, povidone-iodine, and chlorine dioxide. Implant surface decontamination is greatly challenging modern implant dentistry. Alongside mechanical cleaning, different antibacterial agents are widely used, though these could alter implant surface properties. Commercially pure (CP) grade 4 titanium (Ti) discs were treated with three different chemical agents (chlorhexidine 0.2% (CHX), povidone-iodine 10% (PVPI), chlorine dioxide 0.12% (ClO₂)) for 5 min. Contact angle measurements, X-ray photoelectron spectroscopy (XPS) analysis, and cell culture studies were performed. Attachment and proliferation of primary human osteoblast cells were investigated via MTT (dimethylthiazol-diphenyl tetrazolium bromide), alamarBlue, LDH (lactate dehydrogenase), and fluorescent assays. Contact angle measurements showed that PVPI-treated samples (Θ = 24.9 ± 4.1) gave no difference compared with controls (Θ = 24.6 ± 5.4), while CHX (Θ = 47.2 ± 4.1) and ClO₂ (Θ = 39.2 ± 9.8) treatments presented significantly higher Θ values. All samples remained in the hydrophilic region. XPS analysis revealed typical surface elements of CP grade 4 titanium (Ti, O, and C). Both MTT and alamarBlue cell viability assays showed similarity between treated and untreated control groups. The LDH test revealed no significant difference, and fluorescent staining confirmed these results. Although there was a difference in surface wettability, a high proliferation rate was observed in all treated groups. The in vitro study proved that CHX, PVPI, and ClO₂ are proper candidates as dental implant decontamination agents.

More Than Just a Periodontal Pathogen –the Research Progress on Fusobacterium nucleatum

Fusobacterium nucleatum is a common oral opportunistic bacterium that can cause different infections. In recent years, studies have shown that F. nucleatum is enriched in lesions in periodontal diseases, halitosis, dental pulp infection, oral cancer, and systemic diseases. Hence, it can promote the development and/or progression of these conditions. The current study aimed to assess research progress in the epidemiological evidence, possible pathogenic mechanisms, and treatment methods of F. nucleatum in oral and systemic diseases. Novel viewpoints obtained in recent studies can provide knowledge about the role of F. nucleatum in hosts and a basis for identifying new methods for the diagnosis and treatment of F. nucleatum-related diseases.

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusion

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

The effectiveness of a desensitization technique for mitigating oral and facial tactile hypersensitivity in institutionalized older persons: A randomized controlled trial

Background/purpose

Oral health care provision in long-term care settings is often limited by specific behaviors exhibited by residents, which may be interpreted as a refusal of care. Such behaviors can be attributed to oral tactile hypersensitivity (TH), which is characterized by aberrations in the perception of oral stimuli. TH is also associated with a decline in ingestion and swallowing function. The purpose of this study was to examine the effectiveness of a technique for mitigating TH (TMH) among institutionalized older persons.

Materials and methods

In this study, 18 institutionalized older persons (Mean age, 90.6 ± 4.5 years; 92.9% females) with TH were randomized to a control group or an intervention group. Pre- and post-intervention assessments were conducted for seven participants in each group. Routine oral care was provided by the facility's staff in both groups. TMH in the intervention group was performed by a dental hygienist over a 3-month period.

Results

In the intervention group, the number of areas with TH was significantly reduced (P = 0.027). No significant change was observed in the control group.

Conclusion

The results of this study suggest that TMH can effectively mitigate TH. Our findings provide clinicians with an additional treatment option for hypersensitivity in older patients. Additional long-term studies with larger sample sizes are required to confirm the effectiveness of this technique.

Infection control in dentistry during COVID - 19 pandemic: what has changed?

The novel coronavirus (COVID-19) pandemic has emerged disrupting many socio-economical and healthcare aspects across the world. This virus can be transmitted by symptomatic and asymptomatic individuals through saliva and contact. Due to its airborne transmission, aerosols created by natural activities and during dental treatment of infected individuals have become a potential vehicle of transmission and threat. The objective of this review was to assess the existing infection control measures taken in dental health-care settings and suggest modifications to reduce the transmission of novel coronavirus. This is a general review publication. Literature search was made at National Library of Medicine, Pubmed using key words such as "dentistry and COVID", "dentistry and COVID and infection control". Publications related to behaviour, education, ethics, treatment and childcare were excluded. Publications describing general aspects of infection control were reviewed. Keyword "Dentistry and COVID and Infection control" generated 70 publications which were reviewed. Infection control measures in dentistry are designed to minimise cross transmission mainly of blood borne pathogens. The unique nature of COVID-19 including highly infectious and transmissibility, and the ability to survive for a long time in the environment requires special attention and modification to the existing infection control measures which are highlighted here. In conclusion, a modified infection prevention and control (IPC) regime will protect the dental practitioner, assistant and staff, patients and the community. During the pandemic, drastic measures are necessary, however, during an endemic period measures can be remodified as necessary.

Characterization of oral bacteria in the tongue coating of patients with halitosis using 16S rRNA analysis

There are many studies on the relationship between the tongue coating and halitosis, but few have evaluated the bacterial community present in the tongue coating. This study identified bacteria in the tongue coating in individuals with and without halitosis using 16S rRNA analysis. Forty subjects (mean age, 46.1 ± 15.8 years) who visited the halitosis clinic at the University Dental Hospital between 2016 and 2017 were divided into halitosis (n = 32) and non-halitosis (n = 8) groups according to results from an organoleptic test (OT). Additional measurements via gas chromatography (GC) and the Breathtron® instrument confirmed the groupings as the H₂S, CH₃SH, (CH₃)₂S, and total volatile sulphur compounds (VSC) levels were significantly higher in the halitosis group than in the non-halitosis group. Bacterial diversity was higher in the halitosis group; the median (quartile) values of the Shannon index were 4.46 (4.21, 4.67) in the halitosis group and 3.80 (3.45, 4.30) in the non-halitosis group. Additionally, the median (quartile) values of the Chao-1 index were 84.0 (77.2, 95.0) in the halitosis group and 71.3 (65.0, 81.5) in the non-halitosis group. These differences in bacterial composition and diversity may further the understanding of causes and treatments for halitosis.

Microbiota and Malodor-Etiology and Management

Accumulating evidence indicates that microbiota plays a critical role in physiological processes in humans. However, it might also contribute to body malodor by producing numerous odorous molecules such as ammonia, volatile sulfur compounds or trimethylamine. Although malodor is commonly overlooked by physicians, it constitutes a major problem for many otherwise healthy people. Thus, this review aims to investigate most common causes of malodor and describe potential therapeutic options. We searched PUBMED and Google Scholar databases to identify the clinical and pre-clinical studies on bad body smell, malodor, halitosis and microbiota. Unpleasant smell might originate from the mouth, skin, urine or reproductive fluids and is usually caused by odorants that are produced by resident bacterial flora. The accumulation of odorous compounds might result from diet, specific composition of microbiota, as well as compromised function of the liver, intestines and kidneys. Evidence-based guidelines for management of body malodor are lacking and no universal treatment exists. However, the alleviation of the symptoms may be achieved by controlling the diet and physical elimination of bacteria and/or accumulated odorants.

A simplified in vitro model for investigation of the antimicrobial efficacy of various antiseptic agents to prevent peri-implantitis

The biofilm formation by oral bacteria on the implant surface is one of the most remarkable factors of peri-implant infections, which may eventually lead to bone resorption and loss of the dental implant. Therefore, the elimination of biofilm is an essential step for the successful therapy of implant-related infections. In this work we created a basic in vitro model to evaluate the antibacterial effect of three widely used antiseptics.Commercially pure (CP4) titanium sample discs with sand blasted, acid etched, and polished surface were used. The discs were incubated with mono-cultures of Streptococcus mitis and Streptococcus salivarius. The adhered bacterial biofilms were treated with different antiseptics: chlorhexidine-digluconate (CHX), povidone-iodine (PI), and chlorine dioxide (CD) for 5 min and the control discs with ultrapure water. The antibacterial effect of the antiseptics was tested by colorimetric assay.According to the results, the PI and the CD were statistically the most effective in the elimination of the two test bacteria on both titanium surfaces after 5 min treatment time. The CD showed significant effect only against S. salivarius.Based on our results we conclude that PI and CD may be promising antibacterial agents to disinfecting the peri-implant site in the dental practice.

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.

Halitosis And Its Associated Factors Among Kermanshah High School Students (2015)

Introduction

Halitosis as a common dental problem results in psychological social problems and relates to many factors. The aim of this study was to evaluate the prevalence of halitosis and its associated factors among students aged from 14 to 18 years in Kermanshah in 2015.

Materials and methods

The study was conducted in high school students of Kermanshah city in 2015. The questionnaire including questions about bad breath and other associated factors (demographic information, background diseases, oral and dental problems, decay-missing-filled (DMF) index, etc.) was completed by students or determined by the examiner. Organoleptic evaluation was conducted. Prevalence of organoleptic and self-reported halitosis and related factors was reported. The relationship between malodor and variables was evaluated and the most important factor was determined by multiple logistic regression analysis. The diagnostic agreement between self-perception and organoleptic halitosis was assessed using Kappa coefficient as well.

Results

The prevalence of halitosis in the organoleptic evaluation was 29.75% and higher in boys (32.6% male vs. 25.2% female) and 27.47% in self-perception (32.9% male vs. 19% female). The diagnostic agreement between organoleptic and self-perception halitosis was moderate or poor. Among the studied factors, the most important factor related to the organoleptic evaluation of halitosis was DMF≥4 (P<0.001 and OR=2.253).

Conclusion

The DMF index was the factor most strongly associated with organoleptic halitosis in this sample of high school students. Other factors with significant association included parent's lower education level, not brushing, not flossing, bleeding gums, tongue coating, pericoronitis, and plaque index. Also, older age, male gender, and gastrointestinal disease increased the possibility for halitosis.

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.

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.

Induction and inhibition of oral malodor

Volatile sulfur compounds (VSCs) such as hydrogen sulfide (H₂ S) and methyl mercaptan (CH₃ SH) are the main components of oral malodor, and are produced as the end products of the proteolytic processes of oral microorganisms. The main pathway of proteolysis is the metabolism of sulfur-containing amino acids by gram-negative anaerobic bacteria. Gram-positive bacteria may promote VSC production by gram-negative anaerobes by cleaving sugar chains from glycoproteins and thus providing proteins. A large variety of bacteria within the oral microbiota are thought to be involved in the complex phenomenon of halitosis. Oral microbiota associated with a lack of oral malodor, oral microbiota associated with severe and H₂ S-dominant oral malodor, and oral microbiota associated with severe and CH₃ SH-dominant oral malodor have been distinguished through molecular approaches using the 16S rRNA gene. Pathological halitosis may primarily be addressed through treatment of causative diseases. In all cases, plaque control is the basis of oral malodor control, and dentifrices, mouthwashes, and functional foods play a supplementary role in addition to brushing. Recently, the use of natural ingredients in products tends to be favored due to the increase in antibiotic-resistant strains and the side effects of some chemical ingredients. In addition, probiotics and vaccines are expected to offer new strategies for improving the oral conditions through mechanisms other than antibacterial agents.

Rethinking the Dental Amalgam Dilemma: An Integrated Toxicological Approach

Mercury (Hg) has been identified as one of the most toxic nonradioactive materials known to man. Although mercury is a naturally occurring element, anthropogenic mercury is now a major worldwide concern and is an international priority toxic pollutant. It also comprises one of the primary constituents of dental amalgam fillings. Even though dental mercury amalgams have been used for almost two centuries, its safety has never been tested or proven in the United States by any regulatory agency. There has been an ongoing debate regarding the safety of its use since 1845, and many studies conclude that its use exposes patients to troublesome toxicity. In this review, we present in an objective way the danger of dental amalgam to human health based on current knowledge. This dilemma is addressed in terms of an integrated toxicological approach by focusing on four mayor issues to show how these interrelate to create the whole picture: (1) the irrefutable constant release of mercury vapor from dental amalgams which is responsible for individual chronic exposure, (2) the evidence of organic mercury formation from dental amalgam in the oral cavity, (3) the effect of mercury exposure on gene regulation in human cells which supports the intrinsic genetic susceptibility to toxicant and, finally, (4) the availability of recent epidemiological data supporting the link of dental amalgams to diseases such as Alzheimer’s and Parkinson.

Efficacy of chlorine dioxide mouthwash in reducing oral malodor: A 2-week randomized, double-blind, crossover study

The aim of this clinical trial was to assess the inhibitory effects of a mouthwash containing 0.1% ClO2 used for 2 weeks on oral malodor, periodontal and salivary parameters, tongue coating, and Gram-negative and Gram-positive bacteria in saliva. Thirty-nine subjects with oral malodor were randomly assigned into two groups. In the first stage, one group was instructed to rinse with the experimental mouthwash (containing 0.1% ClO2), whereas the other group was instructed to rinse with the control mouthwash (sodium chloride 0.9%) for 2 weeks. After 4 weeks of washing out, in the second stage, each group then used the other mouthwash for 2 weeks. Oral malodor, periodontal status, tongue coating, salivary pH and flow rate, and the amounts of the salivary bacteria Aggregatibacter actinomycetemcomitans, Fusobacterium nucleatum, Porphyromonas gingivalis, Solobacterium moorei, Streptococcus salivarius, Treponema denticola, and Tannerella forsythia were evaluated at baseline and after 2 weeks of mouthwash use. After 12 hr and after 2 weeks, organoleptic scores and the levels of H2S and CH3SH were significantly lower in the experimental group compared with those in the control group. After 2 weeks, the experimental mouthwash appeared significantly effective in reducing plaque index, tongue-coating score, and the amounts of F. nucleatum, S. moorei, T. denticola, and T. forsythia in the whole saliva, compared with those at baseline. Mouthwash containing 0.1% ClO2 is effective in reducing oral malodor, dental plaque, tongue-coating accumulation, and the amounts of F. nucleatum, S. moorei, T. denticola, and T. forsythia in saliva.

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.

Genotoxicity of non-alcoholic mouth rinses: A micronucleus and nuclear abnormalities study with fluorescent microscopy

AIM

The aim of the present study was to evaluate the genotoxicity of non-alcoholic mouth rinses on buccal epithelial cells using a micronucleus test.

METHODS

A total of 105 patients were selected and randomly divided into five groups. Four different mouth rinses and normal saline were given for 2 weeks' duration, and cytological smears were collected before and after exposure. These smears were subjected to micronucleus (MN) and other nuclear abnormalities (ONA) tests using acridine orange stain, and their frequencies were obtained in 500 buccal epithelial cells. The statistical analysis included mean, χ² -test, analysis of variance, and post-hoc analysis by Bonferroni test.

RESULTS

Micronucleated cells (P < .00) and MN (P < .00) were higher in individuals exposed to chlorhexidine (CHX), followed by chlorine dioxide (ClO₂ ), potassium nitrate (KNO₃ ), and sodium fluoride (NaF), amine fluoride (AmF), and normal saline. ONA were greater (P < .00) in individuals exposed to CHX, followed by ClO₂ , AmF, KNO₃ , and NaF and normal saline. Overall, the results showed that genotoxic damage was greater in the case of CHX, followed by ClO₂ , KNO₃ , and NaF, AmF, and normal saline.

CONCLUSION

Chronic exposure to mouth rinses can cause genotoxic damage to buccal epithelial cells. Long-term injudicious and inadvertent use of mouth rinses should be discouraged.

Antibacterial Activity of Freshly Prepared Ozonated Water and Chlorhexidine on Mutans Streptococcus When Used as an Oral Rinse - A Randomised Clinical Study

INTRODUCTION

Dental caries is one of the most common causes of morbidity of the tooth. Attempts have been made to reduce the pathogen population size i.e., Mutans Streptococci (MS) to demote the incidence of caries and increase the resistance of the tooth to cariogenic attack.

AIM

To evaluate the antibacterial efficacy of freshly prepared ozonated water, in proposing it as an alternative mouth rinse on MS in comparison to Chlorhexidine (CHX).

MATERIALS AND METHODS

Subjects with high caries incidence and MS counts more than 105 Colony Forming Unit (CFU) were selected and divided by block randomization into two groups of 23 subjects each. The subjects were advised to use the respective mouth rinses under the operator surveillance, consecutively for 14 days. Stimulated salivary samples were collected from the subjects on the first day, 7^th and 14^th day to analyse the changes in MS counts during the course of use of oral rinses. The obtained data was tabulated and statistically analysed.

RESULTS

Freshly prepared ozonated water showed a statistically significant reduction in MS counts after an interval of 7 days and 14 days when compared to CHX.

CONCLUSION

Ozonated water when consecutively used as a mouth rinse resulted in a significant reduction of MS counts. Hence, it can be used as an alternative to chlorhexidine.

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

Objectives:

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

Materials and Methods:

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

Results:

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

Conclusions:

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

A randomized, double-blind, crossover, placebo-controlled clinical trial to assess effects of the single ingestion of a tablet containing lactoferrin, lactoperoxidase, and glucose oxidase on oral malodor

Background

The main components of oral malodor have been identified as volatile sulfur compounds (VSCs) including hydrogen sulfide (H₂S) and methyl mercaptan (CH₃SH). VSCs also play an important role in the progression of periodontal disease. The aim of the present study was to assess the effects of the single ingestion of a tablet containing 20 mg of lactoferrin, 2.6 mg of lactoperoxidase, and 2.6 mg of glucose oxidase on VSCs in the mouth.

Method

Subjects with VSCs greater than the olfactory threshold in their mouth air ingested a test or placebo tablet in two crossover phases. The concentrations of VSCs were monitored at baseline and 10 and 30 min after ingestion of the tablets using portable gas chromatography.

Results

Thirty-nine subjects were included in the efficacy analysis based on a full analysis set (FAS). The concentrations of total VSCs and H₂S at 10 min were significantly lower in the test group than in the placebo group (−0.246 log ng/10 ml [95 % CI −0.395 to −0.098], P = 0.002; −0.349 log ng/10 ml; 95 % CI −0.506 to −0.192; P < 0.001, respectively). In the subgroup analysis, a significant difference in the concentration of total VSCs between the groups was also observed when subjects were fractionated by sex (male or female) and age (20–55 or 56–65 years). The reducing effect on total VSCs positively correlated with the probing pocket depth (P = 0.035).

Conclusions

These results suggest that the ingestion of a tablet containing lactoferrin, lactoperoxidase, and glucose oxidase has suppressive effects on oral malodor.

Trial registration

This trial was registered with the University Hospital Medical Information Network Clinical Trial Registry (number: UMIN000015140, date of registration: 16/09/2014).

Electronic supplementary material

The online version of this article (doi:10.1186/s12903-016-0199-7) contains supplementary material, which is available to authorized users.

Effect of Aloe vera, chlorine dioxide, and chlorhexidine mouth rinses on plaque and gingivitis: A randomized controlled trial

OBJECTIVE

To evaluate the effect of Aloe vera, chlorine dioxide, and chlorhexidine mouth rinses on plaque and gingivitis in orthodontic treatment.

MATERIALS AND METHODS

A randomized single-center, single-blind, parallel group, controlled trial was conducted among 90 subjects undergoing fixed orthodontic treatment. The subjects were randomly divided into one of the three study groups (Aloe vera, chlorhexidine, chlorine dioxide). Plaque and gingivitis were assessed using modified Silness and Loe Plaque Index and Gingival Index at baseline and at follow-up after 15 days. Paired t-test and ANOVA with post hoc Dunnett test were used. A p-value of <0.05 was considered statistically significant.

RESULTS

A total of 85 participants completed the study; among them, 40 were male and 45 were female. There was significant reduction in mean plaque and gingival scores in all the 3 groups at follow-up when compared to baseline. A significantly higher reduction (plaque and gingival scores) was found in chlorhexidine when compared with the Aloe vera group. However, no significant difference was seen between chlorhexidine and chlorine dioxide with respect to mean reduction in plaque and gingival scores.

CONCLUSION

Chlorine dioxide can be a suitable and economical alternative for chlorhexidine. Further long-term studies are recommended for evaluating their effectiveness.

[The effects of an aroma candy on oral Candida albicans colony-forming units (CFU) and oral hygiene states in healthy elderly carrying Candida albicans]

In a preceding paper, we showed that aroma candy containing oligonol, capric acid, and cinnamon (cassia) powder had potent inhibitory activity against mycelial growth of Candida albicans in vitro and protective activity against murine oral candidiasis. In order to assess the effects of this candy (the test candy) on oral C. albicans colony-forming units (CFU) and oral hygiene states, a placebo-controlled double-blind crossover comparative study was performed. Twenty subjects were divided into two groups. One group ingested the test candy in the first 7 days followed by 2 weeks washing-off period, then ingested the placebo candy (control candy) for 7 days. The other group was vice versa. C. albicans CFU in all oral rinse samples from the subjects before and after 7 days ingestion of candy was measured. The degree of oral malodor in all subjects was monitored using a portable measuring instrument. The results showed no statistically significant difference between test-candy group and placebo group for C. albicans CFU. However, C. albicans CFU in test-candy group with>4,000 CFUs was significantly decreased after 7 days ingestion of test-candy (p<0.05). Scores of oral malodor in the test-candy group was significantly decreased after 7 days ingestion of test-candy (p<0.05). A questionnaire survey of oral hygiene states indicated that in the test-candy group, oral malodor, glutinous feeling, and refreshing feeling significantly improved in comparison with control-candy group (p<0.05). Our study suggests that the aroma candy is effective in oral health care of elderly carrying C. albicans.

Effectiveness of three oral hygiene regimens on oral malodor reduction: a randomized clinical trial

Background

Breath odor is a nuisance problem for many people around the world. Bad breath affects social interactions of people in daily life by causing personal discomfort and emotional stress. There are chemical and mechanical methods for controlling oral malodor. Many studies of various mouth rinse applications and tongue cleaning procedures have been conducted. However, few studies have compared the effect of simultaneous chemical and mechanical procedures on the reduction of volatile sulfur compounds (VSCs) in subjects with oral malodor. The purpose of this study was to assess the effects of different oral hygiene procedures on reduction of VSCs in subjects with oral malodor.

Methods

Thirty male volunteers who matched with study criteria were divided randomly into two groups. Both groups performed tooth brushing, mouth washing with chlorine dioxide, tongue cleaning and combination of those in different sequence for five weeks. Total VSCs of subjects were measured with a Breathtron®, and oral health status was also examined. Quantitative analyses were performed using the Statistical Package for Social Science (SPSS 16.0).

Results

There were no significant differences in oral health status between the two groups at the baseline. No significant decrease in oral malodor was detected after one week of tooth brushing. Significant reductions in VSCs were shown by adding mouthwash or tongue cleaning to tooth brushing from the second week to fourth week (P <0.01). The greatest reduction in VSCs was found at the fifth week after the practice of all three oral hygiene regimens.

Conclusions

Tooth brushing alone does not significantly reduce oral malodor. Mouth washing and tongue cleaning significantly reduce oral malodor, but combining tooth brushing, mouth washing and tongue cleaning regimens is most effective for oral malodor reduction. The results of this study could contribute to the formulation of appropriate preventive strategies against oral malodor not only for the general public but also for dental professionals serving as oral malodor-related service providers.

Trial registration

Registration number - ClinicalTrials.gov NCT02113137. Registration date – April 7th, 2014.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-0549-9) contains supplementary material, which is available to authorized users.

Prevalence and awareness of halitosis in a sample of Jordanian population

Objectives:

This study was conducted to estimate the prevalence and awareness of halitosis among the subjects of a population, and also to compare the results of Halimeter^® readings to self-estimation of halitosis and to assess the relationship between halitosis and oral health.

Materials and Methods:

A sample of 205 employees from the Jordan University for Science and Technology (JUST) were selected as study subjects. A standardized questionnaire focusing on dental hygiene, self-reported halitosis, and smoking was filled by all participants. In the clinical examination, the objective values for assessment of oral health and the presence of halitosis were gathered through an organoleptic test (OLT) and the measurement of volatile sulfur compound (VSC) level by Halimeter for each participant.

Results:

The prevalence of halitosis was 78%, with low rate of awareness (20.5%). The amount of TC played the most important role in increasing the concentration of VSCs in mouth air (P < 0.001).

Conclusion:

A statistically significant correlation was found between OLT and Halimeter values (P < 0.001). Subjective patients’ opinion did not correlate with the objective evaluation of halitosis. TC scores and smoking were the factors significantly associated to halitosis. The Halimeter showed promising characteristics regarding diagnosis of halitosis for clinical setting and field surveys.

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.

Direct effect of chlorine dioxide, zinc chloride and chlorhexidine solution on the gaseous volatile sulfur compounds

OBJECTIVE

This study focused on the ability of aqueous anti-volatile-sulfur-compound (VSC) solutions to eliminate gaseous VSCs by direct contact in a sealed space to describe possible mode of action of anti-VSC agents.

MATERIALS AND METHODS

Twenty milliliters of each experimental solution, 0.16% sodium chlorite, 0.25% zinc chloride, 0.1% chlorhexidine and distilled water, was injected into a Teflon bag containing mixed VSCs, hydrogen sulfide, methyl mercaptan and dimethyl sulfide and mixed vigorously for 30 s. The VSC concentration was measured by gas chromatography before, immediately after, 30 min and 60 min after mixing.

RESULTS

The sodium chlorite solution reduced the VSC concentration remarkably. After mixing, nearly all VSCs were eliminated immediately and no VSCs were detected at 30 and 60 min post-mixing. However, in the other solutions, the VSC concentration decreased by ∼30% immediately after mixing and there was no further decrease.

CONCLUSION

The results suggest that sodium chlorite solution has the effect of eliminating gaseous VSCs directly. This must be because it can release chlorine dioxide gas which can react directly with gaseous VSCs. In the case of other solutions that have been proved to be effective to reduce halitosis clinically, it can be proposed that their anti-VSC effect is less likely due to the direct chemical elimination of gaseous VSCs in the mouth.

Chemometric analysis of the consumption of oral rinse chlorite (ClO2-) by human salivary biomolecules

OBJECTIVES

Oral rinse formulations containing chlorite anion (ClO(2)(-)) as an active agent exert a range of valuable oral healthcare activities. However, salivary biomolecules which chemically react with this oxidant can, at least in principle, serve as potentially significant barriers to these therapeutic properties in the oral environment. Therefore, in this investigation, we have explored the extent of ClO(2)(-) consumption by biomolecules which scavenge this agent in human salivary supernatants (HSSs) in vitro.

MATERIALS AND METHODS

HSS samples were equilibrated with oral rinse formulations containing this active agent (30 s at 35 °C in order to mimic oral rinsing episodes). Differential spectrophotometric and ion-pair reversed-phase high-performance liquid chromatographic analyses were employed to determine residual ClO(2)(-) in these admixtures.

RESULTS

Bioanalytical data acquired revealed the rapid consumption of ClO(2)(-) by biomolecular electron donors and/or antioxidants present in HSS samples. Mean ± 95 % confidence interval (CI) consumption levels of 7.14 ± 0.69 and 5.34 ± 0.69 % of the total ClO(2)(-) available were found for oral rinse products containing 0.10 and 0.40 % (w/v) ClO(2)(-), respectively. A mixed model analysis-of-variance performed on experimental data acquired demonstrated highly-significant differences between oral rinse ClO(2)(-) contents (p < 0.0001), trial participants (p < 0.001) and sampling days-within-participants (p < 0.001), and also revealed non-additive ClO(2)(-)-scavenging responses of participants' HSSs to increases in the oral rinse content of this oxidant (p < 0.0001). A slower, second phase of the reaction process (t (1/2) = 1.7-2.8 h) involved the oxidative consumption of salivary urate.

CONCLUSIONS

These data clearly demonstrate that for recommended 30 s oral rinsing episodes performed at physiological temperature, <10 % of the total oral rinse ClO(2)(-) available is chemically and/or reductively consumed by HSS biomolecules for both oral rinse formulations investigated.

CLINICAL RELEVANCE

These observations are of much clinical significance in view of the retention of these products' active agent, i.e. <10 % of ClO(2)(-) is consumed by HSS biomolecules within recommended 30 s oral rinsing episodes, and hence, the bulk of this oxyhalogen oxidant (>90 %) may effectively exert its essential microbicidal, anti-periodontal and oral malodour-neutralising actions.

The effect of mouthrinses on oral malodor: a systematic review

OBJECTIVE

The objective of this study is to systematically review the literature regarding the impact of mouthrinses on oral malodor and present evidence for the treatment effects of mouthrinses on oral malodor.

MATERIAL AND METHODS

PubMed-MEDLINE, the Cochrane-CENTRAL and EMBASE were searched through February 10, 2012 to identify appropriate studies. Volatile sulphur compound measurements, organoleptic measurements and tongue coating were selected as outcome variables. SEARCH RESULTS: The independent screenings of 333 unique titles and paper abstracts revealed 12 publications (12 experiments) that met the eligibility criteria. Means and standard deviations were extracted. The results were separated into short-term (<3 weeks) and longer-term (≥3 weeks) studies.

CONCLUSION

In this review, nearly all mouthwashes with active ingredients had beneficial effects in reducing oral malodor in both short- and longer-term studies. The most compelling evidence was provided for chlorhexidine mouthwashes, and those that contained a combination of cetyl pyridinum chloride and zinc provided the best evidence profile on oral malodor. Little data with respect to tongue coating were available, and none of the studies showed a beneficial effect for this parameter.

Social anxiety disorder in genuine halitosis patients

Background

There is a possibility that genuine halitosis patients' anxiety do not recover after oral malodor treatment due to their social anxiety disorder. The objective of this study was to investigate the influence of social anxiety disorder on the level of anxiety in genuine halitosis patients before and after treatment for oral malodor.

Methods

The subjects were 262 genuine halitosis patients who visited the Fresh Breath Clinic from March, 2008 to October, 2009. The subjects who had score 2 or higher by the organoleptic test were diagnosed as genuine halitosis patients. Gas chromatography (GC) was conducted before and after oral malodor treatment for the oral malodor measurement. Based on their risk of social anxiety disorder, subjects were divided into low- and high-risk groups using the Liebowitz Social Anxiety Scale (LSAS). The questions related to oral malodor and the clinical oral examination were both conducted before oral malodor treatment. The level of anxiety before and after oral malodor treatment was evaluated using the Visual Analogue Scale of Anxiety (VAAS).

Results

More than 20% of subjects had a score of 60 or more on the LSAS (high LSAS group). The mean age and the percentage of females were significantly higher in the high LSAS group compared to the low LSAS group. The high LSAS group was more likely to have problems associated with oral malodor and to adopt measures against oral malodor compared to the low LSAS group. The mean concentrations of H₂S and CH₃SH by GC significantly decreased after the oral malodor treatment in both LSAS groups. VAAS scores also significantly decreased after treatment in both LSAS groups. The logistic regression analysis indicated that the high LSAS group had a 2.28 times higher risk of having a post-VAAS score of 50 or more compared to the low LSAS group.

Conclusions

This study revealed that genuine halitosis patients with a strong trait of social anxiety disorder have difficulty overcoming their anxiety about oral malodor. Oral malodor treatment of genuine halitosis patients requires not only regular oral malodor treatment but also attention to social anxiety disorder.

Closure of an open wound associated with bisphosphonate-related osteonecrosis of the jaw in a breast cancer patient

BACKGROUND AND OBJECTIVE

Many clinicians will not treat patients presenting with bisphosphonate-related osteonecrosis of the jaw following long-term use of bisphosphonates because of the lack of predictable outcomes. MATERICAL AND METHODS: The patient presented with pain from a nonhealing lesion in the posterior maxilla following extraction of the maxillary right third molar. The lesion had not responded to any conventional dental treatment. The patient had suffered from breast cancer, and her treatment included several years of therapy with Zometa (zoledronic acid), a bisphosphonate.

RESULTS

The patient stopped taking Zometa and commenced rinsing with phosphate buffer-stabilized 0.1% chlorine dioxide-containing mouthwash. After 5 months, changes in the morphology of the lesion were noted and the soft tissue had closed over the open wound.

CONCLUSION

Cessation of bisphosphonate therapy and usage of a phosphate buffer-stabilized 0.1% chlorine dioxide-containing mouthwash lessened the patient's pain and resulted in closure of the soft tissue lesion.

Diet and halitosis

PURPOSE OF REVIEW

The present article reviews the current knowledge of halitosis with particular emphasis upon the interplay of diet and disease of the gastrointestinal tract upon oral malodour.

RECENT FINDINGS

Transient-altered breath smell usually reflects the effects of foodstuffs, whereas longstanding halitosis is almost always because of oral disease such as gingivitis or periodontitis. There is, however, increasing evidence that upper gastrointestinal tract disease may give rise to halitosis and that extracts of foodstuffs may be future therapeutic agents for the treatment of halitosis derived from the mouth or upper gastrointestinal tract.

SUMMARY

There is some interplay between the halitosis and the gastrointestinal tract, and it is possible that the therapy of halitosis may be aided by investigations of the effects of foodstuffs upon bacteria that give rise to volatile sulphur compounds.

A new portable monitor for measuring odorous compounds in oral, exhaled and nasal air

Background

The B/B Checker^®, a new portable device for detecting odorous compounds in oral, exhaled, and nasal air, is now available. As a single unit, this device is capable of detecting several kinds of gases mixed with volatile sulfur compounds (VSC) in addition to other odorous gasses. The purpose of the present study was to evaluate the effectiveness of the B/B Checker^® for detecting the malodor level of oral, exhaled, and nasal air.

Methods

A total of 30 healthy, non-smoking volunteers (16 males and 14 females) participated in this study. The malodor levels in oral, exhaled, and nasal air were measured using the B/B Checker^® and by organoleptic test (OT) scores. The VSCs in each air were also measured by gas chromatography (GC). Associations among B/B Checker^® measurements, OT scores and VSC levels were analyzed using Spearman correlation coefficients. In order to determine the appropriate B/B Checker^® level for screening subjects with malodor, sensitivity and specificity were calculated using OT scores as an identifier for diagnosing oral malodor.

Results

In oral and nasal air, the total VSC levels measured by GC significantly correlated to that measured by the B/B Checker^®. Significant correlation was observed between the results of OT scores and the B/B Checker^® measurements in oral (r = 0.892, p < 0.001), exhaled (r = 0.748, p < 0.001) and nasal air (r = 0.534, p < 0.001). The correlation between the OT scores and VSC levels was significant only for oral air (r = 0.790, p < 0.001) and nasal air (r = 0.431, p = 0.002); not for exhaled air (r = 0.310, p = 0.096). When the screening level of the B/B Checker^® was set to 50.0 for oral air, the sensitivity and specificity were 1.00 and 0.90, respectively. On the other hand, the screening level of the B/B Checker^® was set to 60.0 for exhaled air, the sensitivity and specificity were 0.82 and 1.00, respectively.

Conclusion

The B/B Checker^® is useful for objective evaluation of malodor in oral, exhaled and nasal air and for screening subjects with halitosis.

Trial registration

ClinicalTrials.gov: NCT01139073