Comparative analysis of some mouthrinses on the production of volatile sulfur-containing compounds

Evaluation of the Efficacy of Lacer HaliTM Treatment on the Management of Halitosis: A Randomized Double-Blind Clinical Trial

Background: Halitosis of oral origin is very common in the general population. Due to their antimicrobial properties, chlorhexidine-based products are widely used in the management of this condition, but these are associated with reversible side effects. In this study we evaluated the efficacy of Lacer Hali^TM mouthrinse and toothpaste in subjects with intraoral halitosis after several applications under normal conditions of use. Methods: In this randomized clinical trial with mouth rinse and toothpaste, single-center, double-blinded, parallel participants were assigned to an experimental group (Lacer Hali^TM,, n = 20), a positive control group (Halita^TM, n = 20), and a placebo group (n = 20). The active duration of the study was 18 days. The clinical follow-up evaluations were performed at five time points (T0, T1, T2, T3, and T4). The intensity of halitosis was evaluated by organoleptic measurement and the portable gas chromatograph OralChroma^TM. The data were analyzed using generalized mixed linear models. Results: Sixty patients completed the study. Lacer Hali^TM, in comparison with Halita^TM, did not show statistically significant differences at any time during the study except for the levels of hydrogen sulfide and total volatile sulfur compounds at 15 days, where Halita^TM was better. Compared to the placebo treatment, Lacer Hali^TM, was significantly more efficient, in terms of both the organoleptic evaluations at 8 days and the levels of hydrogen sulfide. Conclusions: Lacer Hali^TM is an alternative to chlorhexidine-based toothpaste and mouthwashes in the management of halitosis.

Alternative therapies in controlling oral malodour: a systematic review

Is there a role for alternative therapies in controlling intra-oral halitosis? Treatments other than tongue cleaning and anti-halitosis products containing zinc, chlorhexidine and cetylpyridinium chloride were considered as alternative therapies. Four databases were searched (PubMed, EMBASE, Web of Science and The Cochrane Library). Inclusion criteria were: examination of alternative halitosis therapies, study population with oral malodour, a (negative or positive) control group and evaluation of breath odour via organoleptic and/or instrumental assessment. Data were extracted for descriptive analysis. The screening of 7656 titles led to the inclusion of 26 articles. Analysis showed heterogeneity concerning the population of interest (from cysteine-induced to genuine halitosis), the examined treatment and the reported outcomes. This made a meta-analysis impossible. Essential oils, fluoride-containing products and herbal substances were the most studied. Results varied enormously and none of the active ingredients had an unambiguously positive effect on the malodour. The risk of bias was assessed as high in all articles. Given the fact that little evidence was found for each of the investigated treatments, it could be concluded that there is currently insufficient evidence that alternative therapies are of added value in the treatment of halitosis.Clinical relevanceScientific rationale:Halitosis is a common problem causing social isolation. Out of embarrassment, patients search the internet, leading to many questions about alternative solutions (e.g. oil pulling, herbs). This is the first systematic review on these alternative therapies.Principal findings: Results varied among studies. Some promising results were found for fluoride-containing toothpastes and probiotics. For other products (such as herbal and antibacterial products and essential oils) results were inconsistent. Long-term follow-up studies on these products are scarce. Moreover, the quality of the studies was poor.Practical implications:No clear evidence was found to support a certain alternative anti-halitosis therapy.

The effect of cetylpyridinium chloride mouthrinse as adjunct to toothbrushing compared to placebo on interproximal plaque and gingival inflammation-a systematic review with meta-analyses

OBJECTIVES

The present study aimed to systematically review the literature about the interproximal anti-plaque and anti-gingivitis efficacy of cetylpyrydinium chloride (CPC) mouthrinse compared to placebo solution.

MATERIALS AND METHODS

Three databases (PUBMED, SCOPUS, and EMBASE) were searched for randomized clinical trials that compared the interproximal anti-plaque and anti-gingivitis effect of CPC and placebo mouthrinses as an adjunct to toothbrushing, after a minimum of 6 weeks. Individuals with any periodontal diagnosis were considered. Two meta-analyses were performed for the Turesky modification of the Quigley-Hein plaque index and the Löe and Silness gingival index. For both analyses, the mean differences (MD) between baseline and 6-weeks were calculated using a random-effect model.

RESULTS

Eight studies were included. All included studies showed significant improvement in at least one of the parameters, favoring the CPC mouthrinse when compared to placebo. The meta-analysis demonstrated that groups that used CPC displayed a significantly greater reduction in the plaque index score (MD; 95% confidence interval [95%CI]: - 0.70; - 0.83 to - 0.57) and in the gingival index (MD; 95%CI: - 0.38; - 0.47 to - 0.28) when compared to placebo. However, high heterogeneity was observed in both analyses (I² = 89% and I² = 98%, respectively).

CONCLUSIONS

When considering interproximal surfaces, CPC is efficacious both in plaque and gingival inflammatory parameters, demonstrating the potential to compensate for the limitations of interproximal plaque control.

CLINICAL RELEVANCE

CPC may be a good alternative to compensate interproximal plaque removal, improving interproximal gingivitis.

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.

Daily variation of oral malodour and related factors in community-dwelling elderly Thai

OBJECTIVES

The purposes of this study were (i) to estimate the prevalence of oral malodour, (ii) to evaluate the daily variation of oral malodour and (iii) to assess associations of volatile sulphur compound (VSC) concentrations with socio-demographics, health behaviours and oral health status in community-dwelling elderly Thai.

METHODS

The subjects were 428 dentate elderly people (67.6 ± 5.6 years) living in Phitsaulok, Thailand. Information on their socio-demographics, general health and health behaviours was obtained by a questionnaire. Their dental condition, periodontal status and tongue coating were clinically examined. Their flow rates and the pH of unstimulated saliva were also assessed. Oral malodour was measured at four different times of day using an Oral Chroma™.

RESULTS

The proportions of subjects diagnosed with oral malodour using the thresholds of H(2)S, CH(3)SH and (CH(3))(2) S were 60.5%, 62.9% and 80.7%, respectively. Concentrations of H(2)S showed significant daily variation. Linear regression analysis demonstrated the following significant associations: (i) oral malodour from H(2)S and thickness of the tongue coating, (ii) oral malodour from CH(3)SH and periodontal pocket depth of 5 mm or more and the presence of gingival bleeding and (iii) oral malodour from (CH(3))(2)S and systemic disease, medications and thickness of the tongue coating.

DISCUSSION

Oral malodour was shown to be prevalent among the elderly. Daily variation was observed in the concentration of H(2)S. Tongue coating, periodontal disease, systemic diseases and medications were related to oral malodour. Therefore, these factors should be taken into consideration in oral malodour treatment and prevention programmes for the elderly.

Comparison of ninhydrin method of detecting amine compounds with other methods of halitosis detection

OBJECTIVES

Halitosis is a result of overactivity of Gram-negative bacteria for which protein amino acids are the major source of energy. Therefore, statistical correlation between concentrations of volatile sulphur compounds (VSCs) and low-molecular-weight amines should be expected.

MATERIALS AND METHODS

Eighty-four patients suffering from halitosis and 40 healthy volunteers aged 20-62 years (average 39.7) participated in the study. In all subjects low-molecular-weight amines were evaluated by the ninhydrin method. Patients with halitosis were randomized into treatment groups. Zinc tablets, tablets and mouthwash containing chlorhexidine or lyophilized lactic acid-forming bacteria were used.

RESULTS

Analysis showed that the level of amines was highest in subjects with halitosis (0.39, s.d. +/- 0.06, P < 0.001) and correlated significantly with results of VSC measurement and organoleptic scores (P < 0.001). Reduction of amine levels after treatment was statistically significant (P < 0.001). Three months following treatment the amine levels began to increase (0.37, s.d. +/- 0.05). The amine levels in healthy controls were lower (0.29, s.d. +/- 0.07) and remained at a stable level.

CONCLUSION

The salivary amine levels significantly correlated with VSC levels and organoleptic scores. Therefore, the ninhydrin method of detecting salivary amines may be an alternative or additional method of diagnosing halitosis. This method may also be used to evaluate treatment efficacy.

A review of the current literature on management of halitosis

Halitosis is an unpleasant or offensive odour, emanating from the oral cavity. In approximately 80% of all cases, halitosis is caused by microbial degradation of oral organic substrates. Major degradation products are volatile sulphur-containing compounds. In this review, the available management methods of halitosis and their effectiveness and significance are presented and discussed. Undoubtedly, the basic management is mechanically reducing the amount of micro-organisms and substrates in the oral cavity. Masking products are not, and antimicrobial ingredients in oral healthcare products are only temporary effective in reducing micro-organisms or their substrates. Good short-term results were reported with chlorhexidine. Triclosan seems less effective, essential oils and cetylpyridinium chloride are only effective up to 2 or 3 h. Metal ions and oxidizing agents, such as hydrogen peroxide, chlorine dioxide and iminium are active in neutralizing volatile sulphur-containing compounds. Zinc seems to be an effective safe metal at concentrations of at least 1%. The effectiveness of active ingredients in oral healthcare products is dependent on their concentration and above a certain concentration the ingredients can have unpleasant side effects. Tonsillectomy might be indicated if (i) all other causes of halitosis are managed properly; (ii) halitosis still persists and (iii) crypts in tonsils are found to contain malodorous substrates.

A review of the current literature on aetiology and measurement methods of halitosis

OBJECTIVES

This work reviews the current knowledge of aetiology and measurement methods of halitosis.

DATA

Halitosis is an unpleasant or offensive odour emanating from the breath. The condition is multifactorial and may involve both oral and non-oral conditions.

SOURCES

A private, monthly with keywords halitosis, malodo(u)r, (a)etiology, measurement, and management from Medline and Pubmed updated database of literature was reviewed.

CONCLUSIONS

In approximately 80-90% of all cases, halitosis is caused by oral conditions, defined as oral malodour. Oral malodour results from tongue coating, periodontal disease, peri-implant disease, deep carious lesions, exposed necrotic tooth pulps, pericoronitis, mucosal ulcerations, healing (mucosal) wounds, impacted food or debris, imperfect dental restorations, unclean dentures, and factors causing decreased salivary flow rate. The basic process is microbial degradation of organic substrates. Non-oral aetiologies of halitosis include disturbances of the upper and lower respiratory tract, disorders of the gastrointestinal tract, some systemic diseases, metabolic disorders, medications, and carcinomas. Stressful situations are predisposing factors. There are three primary measurement methods of halitosis. Organoleptic measurement and gas chromatography are very reliable, but not very easily clinically implemented methods. The use of organoleptic measurement is suggested as the 'gold standard'. Gas chromatography is the preferable method if precise measurements of specific gases are required. Sulphide monitoring is an easily used method, but has the limitation that important odours are not detected. The scientific and practical value of additional or alternative measurement methods, such as BANA test, chemical sensors, salivary incubation test, quantifying beta-galactosidase activity, ammonia monitoring, ninhydrin method, and polymerase chain reaction, has to be established.

Use of 0.1% chlorine dioxide to inhibit the formation of morning volatile sulphur compounds (VSC)

The aim of this study was to evaluate the VSC-inhibiting effect of a commercially available mouthrinse (0.1% chlorine dioxide) when compared to its placebo. A 2-step double blind, crossover, randomised study was conducted with 14 dental students with healthy periodontium, who refrained from any mechanical plaque and tongue coating control during two 4-day experimental periods. The subjects were instructed to rinse 3 times daily with the assigned product during each period. A 7-day washout interval was established. VSCs levels were measured by a sulphide monitor at the beginning (baseline) and at the end of each experimental period. Statistical analyses were performed using Wilcoxon's and Mann-Whitney's non-parametric tests. At baseline, intragroup analysis revealed that VSCs levels did not differ between groups (p > 0.05); at day 5, the use of the chlorine dioxide mouthrinse did not change the baseline VSCs scores in the control group (p > 0.05), while a 2-fold increase was observed with the use of the placebo mouthrinse (p < 0.05). Intergroup analysis showed a significant difference between the VSCs levels of the test and control groups (40.2 ± 30.72 and 82.3 ± 75.63 ppb, p < 0.001) at day 5. Within the limits of this study, the findings suggest that a mouthrinse containing chlorine dioxide can maintain VSCs at lower levels in the morning breath.

Relationship between volatile sulphide compounds concentration and oral bacteria species detection in the elderly

AIM

To evaluate the relationship between oral bacteria species detection and volatile sulphide compounds (VSC) concentration in the elderly.

DESIGN

Cross-sectional microbiological and clinical VSC examination of elderly.

PARTICIPANTS

Sixty-seven elderly people aged 75, who were functionally independent and dentate.

METHODS

VSC (H2S and CH3SH) concentrations in the mouth air of subjects were measured using portable gas chromatography. Oral bacteria samples were taken from dental plaque and identification of bacteria species was accomplished using standard methods.

RESULTS

Fewer than 20% of subjects showed more than 10 ng/10 ml of H2S (severe odour level). The detection rate of P. melaninogenica was significantly higher in elderly people with more than 10 ng/10 ml (p=0.043) levels. Fusobacterium had a tendency to be found in those with more than 10 ng/10 ml, but a significant relation was not found.

CONCLUSIONS

The results suggest that Fusobacterium and P. melaninogenica may be involved in the production of H2S in the oral cavity of elderly people.

Impact of mouthrinses on morning bad breath in healthy subjects

BACKGROUND

During sleep, a proliferation of oral bacteria is responsible for the release of offending gases in morning breath even in healthy people. Thus, the aim of this study was to evaluate the bad breath-inhibiting effect of four commercially available mouthrinses (0.03% triclosan, 0.12% chlorhexidine gluconate, 0.05% cetylpyridinium chloride and essential oils) on morning breath when compared with a positive and a negative control.

METHOD

A six-step double-blind, crossover, randomised study was conducted in 12 dental students with healthy periodontium, who refrained from mechanical plaque control during a 4-day period. The subjects were instructed to rinse twice daily with the assigned product during each period. Fifteen-day washout intervals were used. Before professional plaque and tongue coating removal (baseline), the morning breath was scored through volatile sulphur compounds (VSCs) level measured by a sulphide monitor. After 4 days, VSCs and plaque index (PI) were recorded.

RESULTS

Even in the absence of mechanical plaque control, there was a decrease in VSC level with the use of all mouthrinses, with the exception of an increase with the use of the negative control. The VSC formation was inhibited in descending order, by positive control (0.2% chlorhexidine), 0.12% chlorhexidine, triclosan and essential oils and cetylpyridinium chloride. Plaque formation was inhibited by chlorhexidine mouthrinses and essential oils.

CONCLUSIONS

These findings suggest that mouthrinses can reduce morning bad breath, and that such a reduction is not attributable only to the reduction of supragingival plaque formation.