Effect of different mouthrinses on morning breath

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.

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.

Efficacy of probiotics in the management of halitosis: a systematic review and meta-analysis

BACKGROUND

Halitosis is defined as a foul odour emitted from the oral cavity. Many interventions have been used to control halitosis from mouthwashes to chewing gums. Probiotics have been reported as an alternative method to alleviate halitosis.

OBJECTIVE

The present study aimed to investigate the effect of probiotics on halitosis from a time perspective.

DESIGN AND METHODS

This is a meta-analysis study performed in indexed databases up to February 2021. Randomised controlled trials that compared the effects of probiotics and placebo on primary outcomes (organoleptic (OLP) scores and volatile sulfur compound (VSC) levels) and secondary outcomes (tongue coating scores (TCS) and plaque index (PI)) were included. Data extraction and quality assessment were conducted independently by two reviewers. Publication bias and leave-one-out analyses were performed.

RESULTS

The standardised mean difference (SMD) and 95% CI were calculated to synthesise data. The data were subgrouped and analysed in the short term (≤4 weeks) and long term (>4 weeks) based on the follow-up time. Seven articles were included in this meta-analysis. The primary outcomes, OLP scores (SMD=-0.58; 95% CI -0.87 to -0.30, p<0.0001) and VSC levels (SMD=-0.26; 95% CI -0.51 to -0.01, p=0.04), both decreased significantly in the probiotics group compared with the placebo group in the short term. However, a significant reduction was observed only in OLP scores (SMD=-0.45; 95% CI -0.85 to -0.04, p=0.03) in the long term. No significant differences were observed in secondary outcomes. There was no evidence of publication bias. The leave-one-out analysis confirmed that the pooled estimate was stable.

CONCLUSIONS

According to the results of this work, it seems that probiotics (eg, Lactobacillus salivarius, Lactobacillus reuteri, Streptococcus salivarius and Weissella cibaria) may relieve halitosis in the short term (≤4 weeks). The results of the biased assessment, limited data and heterogeneity of the clinical trials included might reduce the reliability of the conclusions.

Revisiting Standard and Novel Therapeutic Approaches in Halitosis: A Review

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

Efficacy of Arabic Coffee and Black Tea in Reducing Halitosis: A Randomized, Double-Blind, Controlled, Crossover Clinical Trial

The aim of the study was to objectively evaluate the short-term effect of Arabic coffee and black tea on oral halitosis. This study was a single-center, randomized, double-blind, placebo-controlled, crossover clinical trial on 17 healthy individuals. During the initial visit, pre-treatment breath samples were collected from each subject and analyzed using portable gas chromatography (OralChroma™). Four interventions were evaluated, with Arabic coffee and black tea as the test intervention tools, mouthwash containing a solution (0.05% chlorhexidine, 0.05% cetylpyridinium chloride, and 0.14% zinc lactate (CHX-CPC-Zn)) as a positive control, and drinking water as a negative control. Halitosis was induced by rinsing with 10 mL solution of L-cysteine for 30 s. Twenty minutes later, a breath sample was taken to record the baseline volatile sulfur compounds (VSC) levels (T0). Then, the participants were asked to rinse with 10 mL of a randomly-assigned solution for 30 s. Sixty minutes later, another breath sample was recorded (T1). Finally, after 120 min, the final breath sample was recorded (T2). It was found that rinsing with Arabic coffee decreased the level of H2S both in the first hour (T1) and the second hour (T2). The reduction was significantly greater at T1 (p = 0.017). There was a similar result after the volunteers rinsed with black tea. At T2, Arabic coffee showed a substantially greater reduction in H2S (p < 0.001). On the contrary, using CHX-CPC-Zn showed a significant and continuous decrease in H2S values in the breath throughout the experiment (p < 0.001). Water showed no significant impact on the level of VSC (p = 0.71). This study demonstrates that black tea and Arabic coffee had inhibitory effects on halitosis that was greater in the first hour and was not sustained over a long period. Additionally, Arabic coffee had a greater inhibitory effect on halitosis than black tea.

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.

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.

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.

Do fixed orthodontic appliances cause halitosis? A systematic review

Objective

To examine: (I) the current evidence of the impact of fixed orthodontic appliances on the development of halitosis in patients undergoing orthodontic treatment, and (II) the influence of different orthodontic bracket systems on halitosis.

Material and methods

Three electronic databases (PubMed, Scopus, and Cochrane Library) were searched prior to March 15, 2018. The review was systematically conducted and reported according to the Cochrane Handbook and the PRISMA statement. Only Randomised Clinical Trials (RCTs) were considered. Selected full-text papers were independently assessed by four investigators and any disagreements were resolved by consensus. The Cochrane Handbook was used to grade the risk of bias and the quality of evidence was rated according to GRADE.

Results

Out of 363 identified studies, three RCTs on halitosis and fixed orthodontic appliances met the inclusion criteria. The risk of bias in the three studies was rated as high and the quality of evidence was rated as very low.

Conclusions/clinical implications

There is a lack of scientific evidence that subjects with fixed orthodontic appliances develop halitosis during treatment. Additional well-conducted RCTs with extended periods of assessment are needed as well as consensus concerning cut-off values for the diagnosis 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.

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

INTRODUCTION

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

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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.

Alcohol-free essential oils containing mouthrinse efficacy on three-day supragingival plaque regrowth: a randomized crossover clinical trial

Background

To evaluate the antiplaque effects of an alcohol-free mouthrinse containing essential oils—Listerine Zero (LZ)—and an alcohol-based essential oils mouthrinse (EO+) compared with a positive control of 0.20% chlorhexidine mouthrinse (CHX) and a negative control of a placebo solution (saline), using an in vivo plaque regrowth model of three days.

Methods

The study was designed as a double-masked, randomized, crossover clinical trial, involving 21 volunteers to compare four different mouthrinses, using a three-day plaque regrowth model. After receiving thorough professional prophylaxis at baseline, over the next three days each volunteer refrained from all oral hygiene measures and performed two daily rinses with 15 mL of the test mouthrinses. EO+ was compared with LZ. CHX rinse served as a positive control and a placebo solution as a negative control. At the end of each experimental period, the Plaque Index (PI) was assessed and a panelist completed through a visual analogue scale (VAS) questionnaire evaluating the organoleptic properties of each product. Each participant underwent a 14-day washout period and then there was another allocation.

Results

LZ showed the same inhibitory activity on plaque regrowth compared with EO+ in the whole mouth (PI = 1.72 versus 1.65, respectively), but there was less of an effect compared to the CHX (overall PI of 1.07) and a more efficient activity than the saline solution negative control (PI = 2.31). The difference of 0.07 between LZ and EO+ was not statistically significant.

Conclusions

LZ seems to have the same inhibiting effect on plaque regrowth as EO+ and a less inhibiting effect than the CHX control. Both LZ and EO+, as well as the CHX control, show a better inhibiting effect on plaque regrowth than the placebo solution.

Trial registration

ClinicalTrials.gov, NCT02894593. Registered on 4 September 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-1901-z) contains supplementary material, which is available to authorized users.

WITHDRAWN: Mouthrinses for the treatment of halitosis

Cochrane Oral Health withdrew this review as of Issue 5, 2016.
 This review is being updated and replaced following the publication of a new expanded protocol on the effects of different interventions for the management of halitosis (Pedrazzi V, do Nascimento C, Mardegan Issa JP, Fedorowicz Z. Interventions for managing halitosis (Protocol). Cochrane Database of Systematic Reviews 2016, Issue 5. Art. No.: CD012213. DOI: 10.1002/14651858.CD012213.). It will remain withdrawn when the new review is published.

The effectiveness of a dentifrice without sodium lauryl sulphate on dental plaque and gingivitis - a randomized controlled clinical trial

OBJECTIVES

The purpose of the study was to evaluate the effect on dental plaque and gingivitis of a dentifrice without sodium lauryl sulphate (SLS) compared to two SLS-containing dentifrices.

MATERIAL AND METHODS

For this double-blind, parallel study, 90 volunteers having moderate gingival inflammation (≥40%) were randomly divided among three groups: one group using non-SLS dentifrice containing enzymes, colostrum and low concentrations of zinc and two control groups each using different SLS-containing dentifrices. Dental plaque scores (Turesky modification of Quigley & Hein) and gingivitis scores (Bleeding On Marginal Probing) were assessed at baseline, after 2 and 4 weeks.

RESULTS

Eighty-nine participants provided evaluable data. A slight decrease in gingivitis scores was observed for all groups over 4 weeks, which was statistically significant for the non-SLS group. Mean values for dental plaque scores did not show major differences over 4 weeks. For both parameters, no significant differences between groups could be observed at any time point. Patient appreciation was in favour of the SLS groups especially regarding the foaming effect.

CONCLUSION

No significant differences could be observed with respect to the effect on plaque and gingivitis between SLS-containing and SLS-free dentifrice containing enzymes, colostrum and low concentration zinc. Patients enjoyed the duration of taste and the 'foaming effect' of SLS-containing dentifrices better.

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.

Correlations between Perceived Oral Malodor Levels and Self-Reported Oral Complaints

Objectives. Even though objective data indicating the absence of oral malodor are presented to patients, they may be skeptical about the results, possibly due to the presence of some discomfort in the oral cavity. The objective of this study was to investigate whether there is an association among self-perceptions of oral malodor, oral complaints, and the actual oral malodor test result. Materials and Methods. Questions concerning self-perceptions of oral malodor and subjective intraoral symptoms were extracted from a questionnaire on oral malodor completed by 363 subjects who visited the clinic for oral malodor of Tokyo Dental College Chiba Hospital and gave consent to this study. In addition, the association of self-perception of oral malodor with values obtained after organoleptic and OralChroma measurement was analyzed. Results. No correlation between 195 subjects (54%) who were judged "with oral malodor" (organoleptic score of ≥1) and 294 subjects (81.6%) who had a self-perceptions of oral malodor was observed. Self-perception of oral malodor was significantly correlated with tongue coating (p = 0.002) and a strange intraoral taste (p = 0.016). Conclusions. Subjects with a self-perception of oral malodor were not necessarily consistent with those actually having an oral malodor. In addition, it was suggested that patients became aware of oral malodor when they felt oral complaints.

The effect of water on morning bad breath: a randomized clinical trial

OBJECTIVES

To assess the effects of water on the parameters of 'morning bad breath' (MBB) and to evaluate whether there is a difference between rinsing with water and drinking a glass of water.

MATERIALS AND METHODS

A total of 50 participants were recruited and were randomly divided into two equal groups. One group rinsed with 15 ml of water for 30 s, and another group drank 200 ml of water within 30 s. Clinical assessments were carried out during one visit between 7:30 am and 12:00 pm. Pre- and post-intervention measures were assessed organoleptically as primary outcome parameters, and a secondary outcome parameter was assessed using both the Halimeter(®) and OralChroma(™) apparatuses to evaluate volatile sulphur compounds (VSCs), hydrogen sulphide (H2 S), methyl mercaptan (CH3 SH) and dimethyl sulphide ((CH3 )2 S). In addition, the presence of tongue coating (discoloration/thickness) and tongue fissures was assessed.

RESULTS

All 50 participants completed the study. In both groups, a significant reduction in the organoleptic score and the OralChroma(™) H2 S and CH3 SH readings was obtained after the intervention. Both regimens resulted in a CH3 SH reduction of approximately 60%, whereas the reduction in H2 S was between 30% and 50%. The acceptable change between pre- and post-assessments of the clinical parameters was not significantly different between the drinking and rinsing groups.

CONCLUSION

Rinsing with water or drinking a glass of water had a statistically significant effect on the MBB parameters. No significant difference was obtained between the two regimens.

Comparative effect of a new mouthrinse containing chlorhexidine, triclosan and zinc on volatile sulphur compounds: a randomized, crossover, double-blind study

AIM

The aims of this study were to compare the volatile sulphur compounds (VSC)-reducing effect of two commercial mouthrinses using a morning bad breath model and to assess the role of mechanical plaque control (MPC) when performed previously to mouthrinse use.

PATIENTS AND METHODS

Eleven volunteers with good oral health were enrolled in a double-blind, randomized, six-step crossover design study with a 7-day washout period. Two commercial mouthrinses were tested using a saline solution (NaCl 0.9%) as a negative control: one mouthrinse contained 0.05% chlorhexidine, 0.05% cetylpyridinium chloride and 0.14% zinc lactate (CHX-CPC-Zn), while the other contained 0.05% chlorhexidine, 0.15% triclosan and 0.18% zinc pidolate (CHX-triclosan-Zn). A portable sulphide monitor (Halimeter(®) ) was used for VSC quantification. Measurements were made at baseline, and 1, 3 and 5 h after rinsing. Significant differences were detected by analysis of variance.

RESULTS

No significant differences between groups were detected at baseline. We were unable to demonstrate a significant influence of mechanical plaque control on the reduction of VSC levels when performed before mouthrinse use (P = 0.631). Both mouthrinses effectively lowered VSC levels in all test intervals (P < 0.05). No statistically significant differences were found between mouthrinses in any of the test intervals (P = 0.629, 0.069 and 0.598 at 1, 3 and 5 h).

CONCLUSION

This study demonstrated that CHX-CPC-Zn and CHX-triclosan-Zn have significant and similar effects in reducing VSC levels, which persist for at least 5 h. Such effects were independent of previous MPC, which failed to improve on the results of mouthrinse use alone.

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.

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.

Prevalence of halitosis in children considering oral hygiene, gender and age

BACKGROUND

To date, few studies have addressed halitosis in the paediatric population. As such, the aim of the present study was to investigate symptoms, signs and risk factors associated with halitosis in healthy children and to present a model based on the clinical data that predicts the presence of halitosis.

METHODS

A total of 101 individuals were included. All patients received a questionnaire that queried on sociodemographic characteristics, self-reported halitosis and dental treatment history. Individuals received a thorough intra-oral examination, and the volatile sulphur compounds (VSC) were measured to test the presence of halitosis with a portable sulphide monitor (Halimeter(®); Interscan Co., Chatsworth, CA, USA). The distribution of the sociodemographic characteristics, self-reported halitosis, dental treatment history and other oral features was evaluated. Finally, a statistical model was constructed with the best set of features to predict halitosis in children.

RESULTS

The median age was 12.0 years (mean: 11.7 ± SD 2.7) with 54.5% males. Halitosis (VSC > 100 parts per billion, or ppb) was objectively measured in 37.6% of patients. For comparison purposes, Bayesian network was obtained using clinical and demographic data. The model consisted of four variables (sex, age, oral hygiene status and self-reported halitosis) directly related to the presence of halitosis (VSC > 100 ppb). This model achieved 76.4% area under receiver operating characteristics curve (AUROC). Overall, female patients or individuals with dental plaque on more than 25% of the dental surfaces or patients older than 13 year old were more prone to present with halitosis.

CONCLUSIONS

The results suggest that halitosis in the paediatric population is related to poor oral hygiene and may be more common in females and older individuals. This specific predictive model may be useful to identify subgroups to target for intervention to treat oral halitosis.

Use of Oral Chroma™ in the assessment of volatile sulfur compounds in patients with fixed protheses

Prosthetic rehabilitation improves the patient's quality of life and oral health. The purpose of the present study was to assess the production of volatile sulfur compounds (VSCs) using Oral Chroma™ in patients wearing provisional and permanent fixed prosthesis, who were treated or not, with supportive non-surgical periodontal therapy. A total of 10 healthy patients not affected by periodontal disease and who needed the restoration of at least two edentulous single sites were included in the present study. Registrations of VSCs were carried out with a Gas Chromatograph OralChroma™ (Oral Chroma™, Abimedical, Abilit Corp., Osaka, Japan) one month after placement of the provisional restoration (group 1) and one month after placement of the final restoration (group 3). After each measurement, professional oral hygiene was carried out both on patients with provisional (group 2) and permanent prostheses (group 4) and VSC values were registered. The results showed that there were no statistical significant differences in the VSC quantity between groups with temporary or permanent prostheses. Meanwhile, statistically significant differences were found in VCS values between groups before and after the professional health care session (p less than 0.05). Also it was observed that dimethyl sulphide (CH3)2S was present in all the study groups. The present preliminary study suggests that OralChroma™ produce a comprehensive assessment of VSC in the clinical diagnosis of halitosis and that professional oral hygiene seems to influence VSC production. However, further clinical long-term studies with a larger sample size are necessary for a better understanding of halitosis manifestation in patients wearing provisional and permanent fixed prosthesis.

Instrumental assessment of halitosis for the general dental practitioner

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

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

Context:

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

Aims:

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

Settings and Design:

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

Materials and Methods:

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

Statistical Analysis Used:

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

Results:

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

Conclusions:

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

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

AIMS

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

MATERIAL & METHODS

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

RESULTS

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

CONCLUSION

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

Comparison of different treatment modalities for oral halitosis

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

In vitro antimicrobial comparison of chlorhexidine, persica mouthwash and miswak extract

AIM

Herbal mouthwashes, such as persica (Salvadora persica, mint and yarrow extracts) and miswak extract have been shown to decrease gingival inflammation and plaque accumulation. The aim of this study was to compare the antimicrobial activities of persica and miswak extract with the conventional mouthwash chlorhexidine against Streptococcus salivarius, Streptococcus sanguis, Lactobacillus vulgaris and Candida albicans.

MATERIALS AND METHODS

In this in vitro study, blood-agar culture (Merk, Germany) was used to grow the streptococcus strains, saburd-dextrose culture (Merk, Germany) was used to grow C. albicans and MRS-agar was used to grow L. vulgaris. Various concentrations of these substances (0.1, 0.05 and 0.025% of miswak extract, 0.1, 0.05, 0.025 and 0.0125% of persica, 0.2, 0.1, 0.05 and 0.025% of chlorhexidine) were added to paper disks, separately, inserted into culture plates and transferred into the incubator. The inhibition zone around each disk was measured after 24 hours and the data was analyzed by the Kruskal-Wallis test.

RESULTS

Chlorhexidine possessed antibacterial activity at all concentrations tested. It was more effective than persica and miswak at all concentrations on S. salivarius (p = 0.022 for 0.1%, 0.009 for 0.05 and 0.025%). It had greater effect than the other two tested material on S.sanguis only at concentration 0.01%. Chlorhexidine was the most effective against S.salivarius; persica was the most effective against Lactobacillus (p = 0.005) and the least effective against S. salivarius; and miswak extract was the most effective against S. salivarius and S. sanguis at concentrations 0.1 and 0.05% (p = 0.005) and ineffective against L. vulgaris. None of these mouthwashes were effective against C. albicans.

CONCLUSION

This study revealed that chlorhexidine remains the gold standard as an antimicrobial agent, although herbal based mouthwashes do have marginal antimicrobial activities. It is necessary to conduct more clinical and microbiological studies focusing on periodontal pathogens and anaerobic microorganisms.

CLINICAL SIGNIFICANCE

Mechanical plaque control is the main way for periodontal disease prevention and mouthrinses are used to improve its efficacy. Based on the results of this study, chlorhexidine has the most antibacterial effect and although persica mouthwash and miswak are routinely used in some Asian countries their antibacterial efficacies are suspected.

Tablets containing a cysteine protease, actinidine, reduce oral malodor: a crossover study

Tongue coating (TC) mainly consists of protein mostly from exfoliated epithelial cells. Until now, to reduce TC accumulation, only mechanical measures have been available, and the procedure involves unpleasant side effects, such as gagging reflex or carcinogenesis related to mechanical stimulation. We expected that protease might be effective in reducing the accumulation of TC causing oral malodor. The purpose of this study was to determine the effect of long-term use of candy tablets containing protease, actinidine, on both TC accumulation and concentration of volatile sulfur compounds (VSCs) in mouth air. We employed 14 subjects aged 24 to 54 years old for this study, and conducted a double-blind randomized crossover trial. The subjects sucked the tablets containing actinidine three times a day until the sixth day after starting the study. The tablets without actinidine were utilized as a placebo. Measurements of VSC concentration and TC accumulation were carried out before and after chewing tablets on the first day, and also on the seventh day. The levels of VSC and TC significantly (p < 0.05) decreased after tablets were taken on the first day in both the test and placebo groups. There was a statistically significant decrease (p < 0.05) in VSC after seven days of use only in the test group. The results of the study suggest that the tablets containing actinidine had an accumulative effect in reducing VSC in mouth air with long-term use.

Evaluation of two mouth rinses in reduction of oral malodor using a spectrophotometric technique

Background:

Various mouth rinses have been used in the treatment of halitosis, but most of the evidence for the efficacy of mouth rinses is anecdotal. In the present study, 0.2% chlorhexidine rinse and an essential oil mouth rinse are compared for their efficacy in reducing the breath mercaptan levels.

Materials and Methods:

Fifteen patients with the chief complaint of oral malodor were randomly divided into 3 groups and were provided with the respective mouth rinses. Pre rinsing measurements were performed on the Day 1 and no other periodontal treatment was instituted. Post rinsing estimation of mercaptan levels was performed after 7 days.

Results:

When comparing chlorhexidine with the essential oil mouth rinse, the reduction in VSCs was highly significant in the chlorhexidine group (P<0.01). However, the reduction in the organoleptic scores was not significant among the two groups. Organoleptic scores showed very highly significant correlations with the VSC concentrations measured by the spectrophotometric method.

Conclusion:

The spectrophotometric technique employed in this study appears to be a promising new method for evaluation of oral malodor. Chlorhexidine still appears to be the agent of choice as a short term regimen in cases of oral malodor.

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.

Saliva and tongue coating pH before and after use of mouthwashes and relationship with parameters of halitosis

OBJECTIVES

The aim of this work was to evaluate saliva and tongue coating pH in oral healthy patients with morning bad breath before and after use of different oral mouthrinses.

MATERIAL AND METHODS

Saliva and tongue coating pH of 50 patients allocated in 5 groups were measured respectively by a digital pHmeter and color pH indicators, before, immediately after and 30 min after rinsing 5 different mouthrinses: cetilpiridine chloride associated with sodium chloride, triclosan, enzymatic solution, essential oil and distilled water.

RESULTS

Only triclosan and essential oil increased salivary pH immediately after rising. The enzymatic solution decreased salivary and tongue coating pH immediately after rinsing.

CONCLUSIONS

Salivary pH tended to be acidic while tongue coating pH tended to be alkaline, even after rising. Triclosan and essential oil mouthrinses increased salivary pH immediately after rinsing. Enzymatic solution decreased saliva and tongue coating pH immediately after rising.

Halitosis: A frequently ignored social condition

Halitosis is a common complaint of one third of the population. It is commonly known as ‘bad breath’. The causes of halitosis can both be intraoral (90%) as well as extraoral (10%). Malodor of oral etiology results from the oral cavity itself. Non oral etiology may include various systemic diseases and use of certain drugs. Halitosis can act as a biomarker for various systemic diseases. Organoleptic examination, gas chromatography and portable sulfide monitors are the common methods of measurement of halitosis. Brushing twice daily with tongue cleaning can sufficiently manage halitosis in majority of the population while antimicrobial oral rinses can be prescribed to the non respondents. Necessary investigations and treatment should follow for those having extra oral cause of halitosis.

Halitosis, oral health and quality of life during treatment with Invisalign(®) and the effect of a low-dose chlorhexidine solution

AIM

This study examined how halitosis, oral dryness and general oral health were impacted during treatment with the Invisalign(®) system. Furthermore, the effect of a lowdose chlorhexidine solution (CHX) was evaluated.

PATIENTS AND METHODS

Thirtyone patients with good periodontal health participated in this crossover study and were divided into two groups (group 1: CHX/no CHX, group 2: no CHX/CHX). The following parameters were recorded during the first 8 months of Invisalign(®) treatment: stimulated saliva flow rate, organoleptic index, tongue coating index, measurement of the oral volatile sulfur compound level (ppb), modified gingival and plaque index and bleeding on probing index. Professional oral cleaning was performed at the beginning of each period lasting 3 months. The patients received a questionnaire at the first, third, fourth, sixth and eighth control visits.

RESULTS

The very low volatile sulfur compound level was significantly decreased by CHX (0.06%) during the first examination period (p = 0.02), i.e. for the first group of patients only. Neither halitosis, nor oral dryness, nor high plaque or gingival index measurements were observed. Oral health-related quality of life was hardly influenced by wearing aligners and oral hygiene habits were very good.

CONCLUSIONS

This study provides evidence that Invisalign(®) treatment is characterized by only minimal impairment of overall oral health and the associated quality of life. Consequently, it appears unnecessary to recommend the general adjunctive use of a low-dose chlorhexidine mouthwash during treatment with Invisalign(®).

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

Background

Previous research has shown the oxidizing properties and microbiological efficacies of chlorine dioxide (ClO₂). Its clinical efficacies on oral malodor have been evaluated and reported only in short duration trials, moreover, no clinical studies have investigated its microbiological efficacies on periodontal and malodorous bacteria. Thus, the aim of this study was to assess the inhibitory effects of a mouthwash containing ClO₂ used for 7 days on morning oral malodor and on salivary periodontal and malodorous bacteria.

Methods/Design

A randomized, double blind, crossover, placebo-controlled trial was conducted among 15 healthy male volunteers, who were divided into 2 groups. Subjects were instructed to rinse with the experimental mouthwash containing ClO₂ or the placebo mouthwash, without ClO₂, twice per day for 7 days. After a one week washout period, each group then used the opposite mouthwash for 7 days. At baseline and after 7 days, oral malodor was evaluated with Organoleptic measurement (OM), and analyzed the concentrations of hydrogen sulfide (H₂S), methyl mercaptan (CH₃SH) and dimethyl sulfide ((CH₃)₂S), the main VSCs of human oral malodor, were assessed by gas chromatography (GC). Clinical outcome variables included plaque and gingival indices, and tongue coating index. The samples of saliva were microbiologically investigated. Quantitative and qualitative analyses were performed using the polymerase chain reaction-Invader method.

Results and Discussion

The baseline oral condition in healthy subjects in the 2 groups did not differ significantly. After rinsing with the mouthwash containing ClO₂ for 7 days, morning bad breath decreased as measured by the OM and reduced the concentrations of H₂S, CH₃SH and (CH₃)₂S measured by GC, were found. Moreover ClO₂ mouthwash used over a 7-day period appeared effective in reducing plaque, tongue coating accumulation and the counts of Fusobacterium nucleatum in saliva. Future research is needed to examine long-term effects, as well as effects on periodontal diseases and plaque accumulation in a well-defined sample of halitosis patients and broader population samples.

Trial registration

ClinicalTrials.gov NCT00748943

A randomized double blind crossover placebo-controlled clinical trial to assess the effects of a mouthwash containing chlorine dioxide on oral malodor

Background

Previous research has shown the oxidizing properties and microbiological efficacies of chlorine dioxide (ClO₂), however, its clinical efficacies on oral malodor have been evaluated only with organoleptic measurements (OM) or sulphide monitors. No clinical studies have investigated the inhibitory effects of ClO₂ on volatile sulfur compounds (VSCs) using gas chromatography (GC). The aim of this study was to assess the inhibitory effects of a mouthwash containing ClO₂ on morning oral malodor using OM and GC.

Methods

A randomized, double blind, crossover, placebo-controlled clinical trial was conducted among 15 healthy male volunteers, who were divided into 2 groups. In the first test phase, the group 1 subjects (N = 8) were instructed to rinse with the experimental mouthwash containing ClO₂, and those in group 2 (N = 7) to rinse with the placebo mouthwash without ClO₂. In the second test, phase after a one week washout period, each group used the opposite mouthwash.

Oral malodor was evaluated before rinsing, right after rinsing and every 30 minutes up to 4 hours with OM, and concentrations of hydrogen sulfide (H₂S), methyl mercaptan (CH₃SH) and dimethyl sulfide ((CH₃)₂S), the main VSCs of human oral malodor, were evaluated with GC.

Results

The baseline oral condition in the subjects in the 2 groups did not differ significantly. The mouthwash containing ClO₂ improved morning bad breath according to OM and reduced concentrations of H₂S, CH₃SH and (CH₃)₂S according to GC up to 4 hours after rinsing. OM scores with ClO₂ were significantly lower than those without ClO₂ at all examination times. Significant reductions in the concentrations of the three kinds of VSCs measured by GC were also evident at all examination times. The concentrations of the three gases with ClO₂ were significantly lower than those without ClO₂ at most examination times.

Conclusion

In this explorative study, ClO₂ mouthwash was effective at reducing morning malodor for 4 hours when used by healthy subjects.

Trial registration

ClinicalTrials.gov NCT00655772