Clinical trial of oral malodor treatment in patients with periodontal diseases

The association between halitosis and periodontitis: a systematic review and meta-analysis

OBJECTIVES

The purpose of this systemic review and meta-analysis was to explore the association between halitosis and periodontitis in observational studies.

MATERIALS AND METHODS

A systematic search covered PubMed, Web of Science, Embase, Scopus, and Cochrane Library until August 18, 2023. Nine observational studies (585 cases, 1591 controls) were analyzed using Stata 17, with odds ratios (ORs) and 95% confidence intervals (CIs). Subgroup analyses considered halitosis assessment methods.

RESULTS

The review found a positive association between halitosis and periodontitis. Significant differences were observed with organoleptic test (OR = 4.05, 95% CI: 1.76, 9.30, p < 0.01) and volatile sulfur compound readings (OR = 4.52, 95% CI: 1.89, 10.83, p < 0.01).

CONCLUSIONS

A positive association was observed between halitosis and periodontitis, supported by significant differences in both organoleptic and volatile sulfur compound readings. However, conclusive findings are limited by statistical heterogeneity, emphasizing the need for additional research.

CLINICAL RELEVANCE

Understanding the halitosis and periodontitis association is clinically significant, informing potential interventions for improved oral health. Further research is vital to refine understanding and guide effective clinical strategies, acknowledging the limitations in current findings.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

TRIAL REGISTRATION

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

(No) Oral Health in Palliative Care Patients: Predisposing Factors and Treatment

OBJECTIVE

To describe mouth disorders in patients undergoing palliative care (PC); to identify predisposing factors for oral disorders and pharmacological and nonpharmacological strategies.

METHODS

Observational, exploratory, correlational, and descriptive study about mouth disorders of patients admitted to a hospital specializing in PC in Portugal, between November 6, 2019, and July 31, 2020. The data collection instrument was a questionnaire and the consultation of the patient's clinical file. It was obtained the previous authorization of the ethics committee and the patient's informed consent. Data were analyzed using the SPSS® software (V.26).

RESULTS

The sample was 46, 56.52% were over 71 years old, and the male sex ratio of 63.04%. Most of the patients had an advanced oncological disease, were polymedicated, had missing teeth, and no regular hygiene habits. Xerostomia and oral candidiasis were the most identified problems. Patients with oncological diseases have more probability to suffer from mouth disorders (P = .047), compared to noncancer patients. Patients with frequent oral hygiene have fewer mouth disorders (rp = -0.304; P = .040). There is a considerable improvement in the tongue coating with an increase in oral hygiene (P = .005). Mouth care plays is important in patient comfort (n = 45; 97.83%) and nonpharmacological strategies are effective for the relief of xerostomia (n = 35; 94.59%).

CONCLUSIONS

Nonpharmacological strategies are effective in the treatment of xerostomia and tongue coating. More information to determine the effectiveness of the strategies in the treatment of mouth disorders is necessary.

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.

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.

The Effect of Mechanical Tongue Cleaning on Oral Malodor and Tongue Coating

Background: Mechanical tongue cleaning is an important oral hygiene procedure; it is known that a significant cause of volatile sulfur compounds (VSCs), a major component of bad breath, is due to the bacteria coating the tongue. This study was conducted to identify the effect of mechanical tongue cleaning on reducing bad breath and tongue coating. Methods: Various mechanical tongue-cleaning methods were studied, including removing tongue coating using a toothbrush, removing tongue coating using a tongue scraper, and removing tongue coating using a toothbrush and a tongue scraper together. The results were as follows. Results: First, the organic bad breath measurement value after cleaning the tongue significantly decreased in the group using only the toothbrush, the group using only the tongue scraper, and the group using both the toothbrush and the tongue scraper. However, there was no difference between the groups. Second, after cleaning the tongue, the measured values of the tongue coating in the values of WTCI (Winkel’s tongue coating index) and Qray view were significantly reduced in all three groups, and there was no difference between the groups. Third, the gas measurement value in the oral cavity using a machine significantly decreased only the H₂S value of the group using the tongue scraper immediately after the mechanical tongue cleaning. Conclusions: From these results, it can be confirmed that mechanical tongue cleaning is effective at reducing bad breath and tongue coating. However, in this study, there was no difference in the reduction effect according to the tools (groups) used for mechanical tongue cleaning. It can therefore be seen that wiping accurately from the rear of the tongue to the front is more effective at reducing bad breath and tongue coating.

A Literature Review and Framework Proposal for Halitosis Assessment in Cigarette Smokers and Alternative Nicotine-Delivery Products Users

Halitosis is a health condition which counts cigarette smoking (CS) among its major risk factors. Cigarette smoke can cause an imbalance in the oral bacterial community, leading to several oral diseases and conditions, including intraoral halitosis. Although the best approach to decrease smoking-related health risks is quitting smoking, this is not feasible for many smokers. Switching to potentially reduced-risk products, like electronic vapor products (EVP) or heated tobacco products (HTP), may help improve the conditions associated with CS. To date, there have been few systematic studies on the effects of CS on halitosis and none have assessed the effects of EVP and HTP use. Self-assessment studies have shown large limitations owing to the lack of reliability in the participants' judgment. This has compelled the scientific community to develop a strategy for meaningful assessment of these new products in comparison with cigarettes. Here, we compiled a review of the existing literature on CS and halitosis and propose a 3-layer approach that combines the use of the most advanced breath analysis techniques and multi-omics analysis to define the interactions between oral bacterial species and their role in halitosis both in vitro and in vivo. Such an approach will allow us to compare the effects of different nicotine-delivery products on oral bacteria and quantify their impact on halitosis. Defining the impact of alternative nicotine-delivery products on intraoral halitosis and its associated bacteria will help the scientific community advance a step further toward understanding the safety of these products and their potentiall risks for consumers.

Comparison of the Effect of Er,Cr:YSGG Laser and Halita Mouthwash on Oral Malodor in Patients With Chronic Periodontitis: A Randomized Clinical Trial

Introduction: Periodontal disease and tongue coatings are among the major factors associated with oral malodor. The present study, comparatively evaluated the effects of the Er,Cr:YSGG laser and Halita mouthwash as adjunctive treatments to nonsurgical periodontal debridement on oral malodor reduction in chronic periodontitis patients. Methods: Sixty patients with stage II and III chronic periodontitis and bad breath. The patients were randomly divided into two groups (n=30). After conventional scaling and root planing, patients in group 1 underwent Er,Cr:YSGG laser (Waterlase; Biolase, San Clemente, CA, USA) irradiation of the internal surface of the pockets (1.5 W, 30 Hz, 20% A, 40% W) and the dorsum of the tongue (1 W, 30 Hz, 20% A, 40% W) immediately after SRP and on the third and seventh days. Group 2 patients were asked to use Halita mouthwash twice daily for one week. Baseline, 1 and 3-month post-treatment measurements of plaque index (PI), probing pocket depth (PPD), clinical attachment level (CAL), gingival index (GI), bleeding on probing (BOP) and organoleptic assessment of Halitosis severity were performed. Results: Significant improvement in all parameters was noted in both groups after 1 and 3 months, compared with baseline (P < 0.05). The two groups had significant reductions which occurred in PPD, CAL and BOP levels and the organoleptic score in 1 and 3 months after the intervention (P < 0.05). Conclusion: Er,Cr:YSGG laser irradiation and Halita mouthwash as adjuncts to non-surgical periodontal therapy are both effective in the treatment of oral malodor and improvement of periodontal parameters.

Tongue cleaning in the elderly and its role in the respiratory and swallowing functions: Benefits and medical perspectives

Oral dysfunction, including oral uncleanness and decline in tongue motor function, tongue pressure and swallowing function, precedes frailty. The tongue's dorsum is a reservoir of oral microbiota, desquamated epithelial mucosa and leukocytes due to the multi-papillate anatomy, and leads to tongue coating. The tongue coating is frequently found in older adults because of hyposalivation, immunity's hypoactivity, diminished motor function and compromised tongue's pressure with age. Anaerobe-driven volatile sulphur compounds in tongue coating are a major cause of intra-oral malodor. Dysbiosis of the tongue-coating microbiome rather than the amount of microorganisms is associated with a risk of aspiration pneumonia. Daily tongue cleaning with a brush or scraper is an easy way to control tongue coating deposits and quality. Using mouth wash or rinse-containing germicides is also a way to control the microbiota of tongue coating. The tongue function is closely related to swallowing. Tongue and suprahyoid muscles are linked with respiratory muscles through the endothoracic fascia. The mechanical stimulation during the cleaning of the tongue may stimulate the respiratory muscles. An intervention trial revealed that tongue cleaning by mucosal brush improves tongue pressure, swallowing and respiratory function in old residents of nursing homes, suggesting a rehabilitative effect of tongue cleaning on the swallowing and respiratory functions, preventing aspiration pneumonia. This narrative review assesses the tongue-cleaning benefits for respiratory and swallowing functions and the possibility of preventing aspiration pneumonia.

Interdental and subgingival microbiota may affect the tongue microbial ecology and oral malodour in health, gingivitis and periodontitis

BACKGROUND AND OBJECTIVE

Oral malodour is often observed in gingivitis and chronic periodontitis patients, and the tongue microbiota is thought to play a major role in malodorous gas production, including volatile sulphur compounds (VSCs) such as hydrogen sulphide (H₂ S) and methanethiol (CH₃ SH). This study aimed to examine the link between the presence of VSCs in mouth air (as a marker of oral malodour) and the oral bacterial ecology in the tongue and periodontal niches of healthy, gingivitis and periodontitis patients.

METHODS

Participants were clinically assessed using plaque index, bleeding on probing (BOP) and periodontal probing depths, and VSC concentrations in their oral cavity measured using a portable gas chromatograph. Tongue scrapings, subgingival and interdental plaque were collected from healthy individuals (n = 22), and those with gingivitis (n = 14) or chronic periodontitis (n = 15). The bacterial 16S rRNA gene region V3-V4 in these samples was sequenced, and the sequences were analysed using the minimum entropy decomposition pipeline.

RESULTS

Elevated VSC concentrations and CH₃ SH:H₂ S were observed in periodontitis compared with health. Significant ecological differences were observed in the tongue microbiota of healthy subjects with high plaque scores compared to low plaque scores, suggesting a possible connection between the microbiota of the tongue and the periodontium and that key dysbiotic changes may be initiated in the clinically healthy individuals who have higher dental plaque accumulation. Greater subgingival bacterial diversity was positively associated with H₂ S in mouth air. Periodontopathic bacteria known to be prolific VSC producers increased in abundance on the tongue associated with increased bleeding on probing (BOP) and total percentage of periodontal pockets >6 mm, supporting the suggestion that the tongue may become a reservoir for periodontopathogens.

CONCLUSION

This study highlights the importance of the periodontal microbiota in malodour and has detected dysbiotic changes in the tongue microbiota in periodontitis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Novel oral biomarkers predicting oral malodor

OBJECTIVE

We sought new markers to predict oral malodor.

STUDY DESIGN

Seventy-five adults complaining of oral malodor were classified into 3 groups clinically: no oral malodor, physiologic oral malodor, and periodontitis-derived oral malodor. In addition to conventional clinical parameters, 7 salivary components, occlusal force, and lip-closing force were compared among the groups.

RESULTS

Concerning the salivary components, cariogenic bacteria, occult blood, leukocytes, and ammonia differed significantly among the groups. Multiple logistic regression analyses indicated that tongue-coating scores and ammonia levels were significantly associated with genuine oral malodor, including physiologic oral malodor and periodontitis-derived oral malodor, and the tongue-coating score, plaque index, and occult blood level were significantly associated with periodontitis-derived oral malodor. Occlusal force and lip-closing force did not differ among the groups. However, there was a statistically significant interaction between occlusal force and lip-closing force in oral malodor in women (P = .019).

CONCLUSIONS

Novel salivary markers, ammonia levels, and occult blood levels may predict genuine oral malodor and periodontitis-derived oral malodor, respectively. An interaction effect between occlusal force and lip-closing force on oral malodor was identified in women.

The Role of Oral Microbiota in Intra-Oral Halitosis

Halitosis is a common ailment concerning 15% to 60% of the human population. Halitosis can be divided into extra-oral halitosis (EOH) and intra-oral halitosis (IOH). The IOH is formed by volatile compounds, which are produced mainly by anaerobic bacteria. To these odorous substances belong volatile sulfur compounds (VSCs), aromatic compounds, amines, short-chain fatty or organic acids, alcohols, aliphatic compounds, aldehydes, and ketones. The most important VSCs are hydrogen sulfide, dimethyl sulfide, dimethyl disulfide, and methyl mercaptan. VSCs can be toxic for human cells even at low concentrations. The oral bacteria most related to halitosis are Actinomyces spp., Bacteroides spp., Dialister spp., Eubacterium spp., Fusobacterium spp., Leptotrichia spp., Peptostreptococcus spp., Porphyromonas spp., Prevotella spp., Selenomonas spp., Solobacterium spp., Tannerella forsythia, and Veillonella spp. Most bacteria that cause halitosis are responsible for periodontitis, but they can also affect the development of oral and digestive tract cancers. Malodorous agents responsible for carcinogenesis are hydrogen sulfide and acetaldehyde.

The association between periodontal diseases and halitosis among Saudi patients

Objectives

To assess the relationship between the presence of periodontal disease and halitosis.

Methods

A total of 120 patients were enrolled and divided into 2 groups, 60 patients with probing depth (PD) > 3.0 mm (group 1) and 60 patients with PD ≤ 3.0 mm (group 2). Clinical parameters including, plaque index (PI), bleeding index (BI), and PD were obtained. Breath samples were collected and analyzed using a portable gas chromatograph to measure the concentration of volatile sulfur compounds (VSC).

Results

Halitosis was found to affect 58.3% of the total patients. The means of PI, BI, and VSC were significantly higher in group 1 (PD > 3.0 mm) than in group 2 (PD ≤ 3 mm).

Conclusions

The percentage of patients suffering from halitosis in the Saudi population are comparatively high. In addition, there was a positive association between periodontal disease and halitosis.

Tongue coating in relationship to gender, plaque, gingivitis and tongue cleaning behaviour in systemically healthy young adults

OBJECTIVES

The purpose of this observational study was to investigate the relationship between tongue coating (thickness [Tc] and surface discoloration [Td]) and gender, plaque, gingivitis (bleeding on marginal probing [BOMP] and bleeding on pocket probing [BOPP]) and tongue cleaning behaviour.

MATERIALS AND METHODS

A total of 336 participants were screened for this cross-sectional study, from which 268 (150 male, 118 female) were found to be eligible. Aspects of tongue coating were visually assessed. Additionally, BOMP, BOPP and the plaque index (PI) were scored. To ascertain the tongue cleaning behaviour, the Oral Hygiene Behavior questionnaire was used.

RESULTS

Most tongue coating was found at the posterior sections of the tongue surface. A thin coating and white discoloration were most prevalent as highest score for both males (92.7%) and females (87.4%), as well as white discoloration for the whole group of participants (50.2%). A gender difference was observed for TC and Td (P < .001). Analysis did not reveal a relationship between Tc and PI and between Td and PI. Also, no relation was detected between tongue cleaning behaviour and Tc or Td. However, tongue cleaning was associated with lower BOMP and BOPP scores.

CONCLUSION

BOMP, BOPP or PI score did not appear to be linked to Tc and Td. A significant gender difference was found for Tc and Td. Self-reported tongue cleaning behaviour was associated with slightly lower BOMP and BOPP scores.

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.

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.

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

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

The effect of professional tooth cleaning or non-surgical periodontal therapy on oral halitosis in patients with periodontal diseases. A systematic review

OBJECTIVE

The aim of this systematic review was to give the best available evidence on the impact of professional tooth cleaning (PTC) and scaling and root planing (SRP) on oral halitosis in patients with periodontal diseases.

MATERIAL AND METHODS

Three databases were screened for relevant studies. Only randomized controlled trials (RCTs) or controlled clinical trials (CCT) were included. The primary outcome in all included studies was volatile sulphur compounds (VSC) measured by Halimeter or OralChroma and organoleptic scores as secondary outcome. Only studies investigating healthy adults except for periodontitis or gingivitis were included. The considered intervention strategies were professional tooth cleaning and non-surgical periodontal treatment. For both strategies, additional oral hygiene instructions (OHI) were possible. Two independent reviewers performed the study selection and quality assessment.

SEARCH RESULTS

After abstract and title screening and subsequent full-text reading of potential papers, a placebo-controlled RCT could not be found. However, eight studies or particular arms used PTC or SRP as sole interventions and were included in this review. All trials or study arms included showed a positive effect on VSC levels or organoleptic scores after intervention.

CONCLUSIONS

Based on best available evidence, PTC and SRP in combination with oral hygiene instructions reduced VSC values in patients with oral halitosis and/or periodontal diseases, independent of tongue cleaning and the use of mouth rinses.

Effect of photodynamic therapy for the treatment of halitosis in adolescents - a controlled, microbiological, clinical trial

Halitosis can exert a negative influence on the social relations of adolescents and affect one's self-image. The aim of this study was to evaluate the clinical and microbiological effect of antimicrobial photodynamic therapy (aPDT) on halitosis in adolescents. Forty-six individuals aged 12 to 19 years were randomly allocated: Group 1 - treatment with photodynamic therapy; Group 2 - treatment with a tongue scraper and Group 3 - treatment with a tongue scraper and photodynamic therapy. The count of bacterial colony-forming units per milliliter was used for the microbiological analysis. Statistical analysis involved the Kruskal-Wallis test followed by the Student-Newman-Keuls test. ANOVA was used for the determination of colony-forming units after treatment. The level of significance for all statistical tests was 5% (p < 0.05). After treatment, a statistically significant reduction in total volatile sulfur compounds was found in all groups (p < 0.001), with the largest reduction (median: 0) found in Group 3 (tongue scraper and photodynamic therapy). Moreover, a statistically significant difference was found between treatment with aPDT and a tongue scraper alone (p < 0.001). The present findings demonstrate an option for the treatment of halitosis in adolescents, with an immediate effect and without the mechanical aggression to the toungue. Clinical Trials: NCT02007993.

An objective assessment of halitosis in children with adenoid vegetation during pre- and post-operative period

OBJECTIVES

Although most specialists in otorhinolaryngology and pediatrics find halitosis to be a common problem in children with adenoid hypertrophy, there are no objective data on this topic in the literature. Whether adenoid hypertrophy is a risk factor for halitosis or whether halitosis is a sign of adenoid hypertrophy remains unclear. Thus, the aim of this study was to investigate whether children diagnosed with adenoid hypertrophy have a higher probability of halitosis than do children in the normal population and whether adenoidectomy can decrease oral malodor.

METHODS

Forty children with adenoid hypertrophy and 40 healthy subjects aged 5-15 years were included in the study. The children with adenoid hypertrophy underwent adenoidectomy operations and were followed for 3 months. We measured volatile sulfur compounds (VSCs), hydrogen sulfide (H2S), methyl mercaptan (CH3SH), and dimethyl sulfide (CH3)2S using an objective method, a portable gas chromatograph (OralChroma; AbiMedical, Osaka, Japan).

RESULTS

The mean CH3SH and (CH3)2S levels were significantly different (p < 0.05) between the adenoid hypertrophy group and the controls. The H2S, CH3SH, and (CH3)2S levels in the third postoperative month were significantly lower (p < 0.05) than those in the preoperative period, and there was no significant difference postoperatively between the patients with adenoid hypertrophy and controls. There was a positive correlation between age and VSC levels, and CH3SH levels were significantly higher in patients with ventilation tube insertion, rather than just adenoidectomy.

CONCLUSIONS

There was a statistically significant association between halitosis and adenoid hypertrophy, and a significant improvement in halitosis was obtained following adenoidectomy. The present study provides an association between halitosis and adenoid hypertrophy. If there is no other oral pathology causing halitosis, halitosis can be a sign of adenoid hypertrophy in children.

The efficacy of Er,Cr:YSGG laser supported periodontal therapy on the reduction of peridodontal disease related oral malodor: a randomized clinical study

Background

This study aims to evaluate the efficacy of Er,Cr:YSGG laser assisted periodontal therapy on the reduction of oral malodor and periodontal disease.

Methods

Sixty patients with chronic periodontitis were included in the study and allocated into two groups each containing 30 patients. The study was planned in a double blind fashion. Conventional periodontal therapy was performed in group 1 and conventional periodontal therapy was performed in association with Er,Cr:YSGG application in group 2. Periodontal parameters of probing depth, clinical attachment level, plaque index and bleeding on probing were measured with a periodontal probe. Quantitative analysis of volatile sulphure compunds (VSCs) were measured with a calibrated halimeter at baseline level and at post-treatment 1st, 3rd and 6th months. P values <0.05 were accepted as statistically significant.

Results

There was a statistical significant reduction in VSC values in group 2 at post-treatment 3rd and 6th months (p < 0.05). Pocket depth values at post-treatment 1st month and bleeding on probing values at post-treatment 3rd and 6th months were significantly decreased in group 2 (p < 0.05). Intragroup statistical analysis revealed that there were statistically significant differences for all parameters (p < 0.01).

Conclusions

Er,Cr:YSGG laser assisted conventional periodontal therapy is more effective in reducing oral malodor and improving periodontal healing compared to conventional periodontal therapy alone.

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

AIM

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

MATERIAL & METHODS

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

RESULTS

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

CONCLUSIONS

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

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

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Immediate results of photodynamic therapy for the treatment of halitosis in adolescents: a randomized, controlled, clinical trial

Light with or without chemical agents has been used to induce therapeutic and antimicrobial effects. With photodynamic therapy, the antimicrobial effect is confined to areas covered by a photosensitive dye and irradiated with light. The aim of the present study was to evaluate the effect of photodynamic therapy for the treatment of halitosis in adolescents through the analysis of volatile sulfur compounds, especially sulfide. A controlled, clinical trial was conducted with 45 adolescents randomly allocated to three groups: group 1, photodynamic therapy administered to the dorsum of the tongue; group 2, treatment with a tongue scraper; and group 3, treatment with a tongue scraper combined with photodynamic therapy. The diagnosis of halitosis was performed using gas chromatography before and after treatment. Comparisons were made using the Kruskal-Wallis test followed by the Student-Newman-Keuls test, with the level of significance set at 5 % (p < 0.05). After treatment, a statistically significant reduction in halitosis was found in all groups (p < 0.001). The greatest reduction in total sulfides (median = 0) occurred with the combination of tongue scraper and photodynamic therapy. The present study describes a novel option for the treatment of halitosis in adolescents with an immediate effect that does not involve the mechanical aggression of the lingual papillae that occurs with conventional treatment.

TRIAL REGISTRATION

Photodynamic Therapy in Adolescents Halitosis ( https://clinicaltrials.gov/ct2/show/NCT02007993?term=NCT02007993&rank=1 )Number: NCT02007993FUNDING:FAPESPNumber: 2013/13032-8.

Avaliação da percepção pessoal em relação à condição de halitose e confirmação clínica

ResumoIntroduçãoA halitose é uma condição em que o hálito se apresenta de forma desagradável, acometendo milhares de pessoas e causando impacto negativo para as mesmas.ObjetivoA presente pesquisa em campo buscou avaliar a percepção pessoal em relação à condição de halitose por meio de aplicação de questionário específico e confirmação clínica.Material e métodoA amostra foi composta por 59 indivíduos entre 20 e 60 anos de idade, usuários de Unidades Básicas de Saúde de Araraquara, que foram selecionados de forma aleatória. A metodologia empregada constituiu-se de: i) Assinatura do Termo de Consentimento Livre e Esclarecido; ii) Aplicação de questionário especialmente elaborado para esta pesquisa; iii) Confirmação clínica, com a aplicação do teste com halímetro (Tanita Breath Alert CHC-212S). Após o experimento, todos receberam folhetos informativos com dados gerais sobre halitose. Os resultados obtidos foram agrupados em tabelas de contingência, construídas pelo Microsoft Excel, sendo então analisados pelo teste do Qui-quadrado.Resultado e conclusãoApós análises, conclui-se que as pessoas perderam a capacidade de perceber o próprio hálito quando tinham halitose; não tiveram condições de se autoavaliarem de forma eficaz; os fatores de riscos que influenciaram na halitose foram: idade superior aos 40 anos, uso de alguns tipos de medicamentos, algumas patologias, frequência de visita ao Dentista e falhas em procedimentos de higiene bucal, tais como escovação dentária, uso do fio dental, limpeza da língua e limpeza de próteses. Os outros fatores pesquisados não se mostraram estatisticamente suficientes para estabelecerem relação de influência na halitose.

The differential expression of mgl mRNA by Porphyromonas gingivalis affects the production of methyl mercaptan

OBJECTIVE

A large number of individuals have halitosis. The total amount of volatile sulfur compounds, which are the main cause of halitosis, has been correlated with periodontitis following bacterial infection. In this study, Porphyromonas gingivalis (Pg), a major periodontopathogenic bacterium, was isolated from patients with halitosis by the amplification of 16S rRNA, and the ability of isolated Pg to produce methyl mercaptan (CH3 SH) was determined to clarify the relationship between halitosis and Pg infection.

MATERIALS AND METHODS

CH3 SH concentrations were measured in patients using Oral Chroma. The production of CH3 SH by Pg standard and clinical strains was also measured in vitro. Real-time PCR was performed to compare the expression of mgl mRNA (which encoded l-methionine-a-deamino-g-mercaptomethane-lyase) among the Pg strains. The production of CH3 SH and the expression of mgl mRNA were also determined to assess the effects of oriental medicine.

RESULTS

The production of CH3 SH and the expression of mgl mRNA strongly correlated with each other in the presence of l-methionine. The expression of mgl mRNA by Pg W83 was strongly inhibited by magnoliaceae.

CONCLUSION

The production of CH3 SH was correlated with the expression of mgl. Furthermore, the oriental medicine, magnoliaceae, may represent a potential treatment for halitosis.

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

Background

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

Methods/Design

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

Discussion

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

Trial registration

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

Halitosis: a review of the etiologic factors and association with systemic conditions and its management

Halitosis is a general term defined as an unpleasant or offensive odor emanating from the breath, arising from either oral or nonoral sources. Extraoral factors, such as ear-nose-throat conditions or gastrointestinal, respiratory, and systemic diseases, may also contribute to oral malodor. Although, halitosis has a multifactorial etiology, local factors play an important role in the majority of cases. Halitosis may lead to significant personal discomfort and social embarrassment. Assessment of halitosis can be performed using organoleptic measurements, sulfide monitoring, gas chromatography, microbial testing and chemical test strips. Management approaches are based on masking oral malodor, reducing the levels of volatile organic compounds (VOCs) and volatile sulfur compounds (VSCs), and mechanical and/or chemical treatment. This review aims to identify the etiology of oral halitosis, describe the methods available for assessment and differential diagnosis and introduce a variety of management strategies. The importance of a multidisciplinary approach for the improvement of overall health and for the management and prevention of halitosis is highlighted.

Relationship between genuine and pseudohalitosis and social anxiety disorder

Halitosis is described as offensive breath caused by various factors such as periodontal diseases, bacterial coating of tongue, systemic disorders and different types of foods. Pseudohalitosis is a situation that patients complain of oral malodor even though they do not have offensive odour. The purpose of this study was to compare the relationships between social anxiety estimations and both pseudohalitosis and genuine halitosis cases. Liebowitz Social Anxiety Scale (LSAS) and questionnaire regarding halitosis were applied to 100 participants. Halitosis was determined using organoleptic method, gas chromatography and portable sulphur monitor. anova test and 2-tailed Spearman's rank-order correlation coefficient were used to determine the differences and relations between groups. With reference to LSAS, 62% of participants had anxiety. Among these patients, 98% had genuine halitosis (P < 0·05). The mean measurements of VSC values were 248·65 ppm in halimeter, 298·02 ppm of H2 S, 95·33 ppm of CH3 SH and 47·00 ppm of (CH3 )2 S in gas chromatography. Halitosis was present in 90% of participants, and it was absent in 10% by organoleptic assessment. There was a significant correlation between organoleptic and halimeter measurements. Moreover, statistically significant relationship was detected between anxiety and halitosis. Genuine halitosis patients exhibit social anxiety, so it can be said that there is a causal relationship between halitosis and anxiety. Comparison of the results of objective measurements (sulphur monitor, gas chromatography, organoleptic method) was statistically significant; therefore, it can be said that these methods can be used in diagnosis of halitosis with high accuracy.

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.

Comparison between self-estimated and clinical oral malodor

OBJECTIVES

The aims were to evaluate the validity of patients' self-estimation and clinical diagnosis of oral malodor and to examine the relationship of oral malodor with oral health status.

METHODS

The subjects were 252 patients (mean age 43.7 ± 10.7 years) who complained of oral malodor. Oral malodor was assessed by patients' self-estimation, organoleptic test and Oral Chroma. Oral health status, including dental and periodontal conditions, oral hygiene status and flow rate of saliva, was examined. The N-benzoyl-DL-arginine-2-napthilamide (BANA) positive bacteria in tongue coating were evaluated by BANA test. A Spearman's correlation coefficient was used to test correlation between self-perceived and clinical oral malodor. The stepwise multiple regression analysis was used to assess predictors of patients' self-estimated and clinical oral malodor.

RESULTS

The percentage of patients who were diagnosed with pseudo-halitosis was 38.5%. Patients' self-estimated oral malodor was significantly correlated with organoleptic test (r = 0.61), H(2)S (r = 0.50) and CH(3)SH (r = 0.46). There were 47.1% of patients who estimated correctly their oral malodor's scores with those by examiner. The highest correspondence was found in patients without oral malodor (52.6%), followed by in those with moderate or strong oral malodor (46.7%) and in those with slight oral malodor (33.3%). The significant predictors of patients' self-estimated and clinical oral malodor were bleeding on probing, tongue coating, BANA test and flow rate of saliva.

CONCLUSION

Patients' self-estimated oral malodor was found to correspond significantly with clinical oral malodor and be associated with oral health status. Current findings suggest that self-estimation can be used to judge one's own oral malodor.