今日の臨床サポート

口臭

著者: 角田衣理加1) 鶴見大学歯学部口腔微生物学講座

著者: 中川洋一2) 鶴見大学歯学部附属病院口腔機能診療科

監修: 近津大地 東京医科大学

著者校正/監修レビュー済:2022/04/27
患者向け説明資料

概要・推奨   

  1. 歯周病患者の口臭には、歯周治療が有効であり、歯肉炎患者の口臭には、舌清掃(ソフト歯ブラシ使用)が有効である。
  1. 舌ブラシや舌ヘラを用いた機械的な舌清掃は舌苔と口臭の減少に有効であるが、慢性口臭についてはデータが不十分である。
  1. 舌ヘラや舌清掃は歯ブラシに比べて成人の効果は小さいながらもVSC(硫化水素、メチルメルカプタン、ジメチルサルファイド)の減少に効果的である。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
角田衣理加 : 特に申告事項無し[2022年]
中川洋一 : 特に申告事項無し[2022年]
監修:近津大地 : 特に申告事項無し[2022年]

改訂のポイント:
  1.  定期レビューを行い、検査項目について加筆修正を行った。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 口臭は、「生体活動に関連して産生された気体のうち、生理的なもの病的なものを問わず口腔を通って排泄される社会的容認限度を超えた不快なにおい(悪臭)」と定義されている[1]
  1. 口臭は、真性口臭症、仮性口臭症、口臭恐怖症に分類される。また、真性口臭症は生理的口臭、口腔由来の病的口臭、全身由来の病的口臭に分けられる。
  1. 日本口臭学会では、臭気と疾病を明確に区別し、「口臭とは、本人あるいは第三者が不快と感じる呼気の総称である」とし、不快な臭気を指す。「口臭症とは、生理的・器質的(身体的)・精神的な原因により口臭に対して不安を感じる症状である」とし、その臭気があるかないかにかかわらず、気になり悩む病態が口臭症であるとしている[2]
  1. 1999年に実施された厚生省保健福祉動向調査では、一般市民の歯科に関する健康問題として「口臭」が第4位(14.5%)であったことから、推計1,000万人以上の日本人が口臭不安を抱えているとされる。
  1. 1992年に実施された口臭実態調査において、社会的容認限度を超える口臭原因物質濃度が検出された人は、日本人健常成人の6~23%(測定時間帯による)であることが明らかにされた[3]
  1. 口臭の80%以上は口腔由来であり、その主要原因物質は揮発性硫黄化合物(VSC:硫化水素、メチルメルカプタン、ジメチルサルファイド)である[4]
  1. 仮性口臭症とは、検査結果の説明を含むカウンセリングにより、口臭の訴えが消失するものをいう。
  1. 口臭恐怖症とは、真性口臭症、仮性口臭症への対応では、口臭の訴えが消失しないものをいう。口臭恐怖症の場合には、精神科、心療内科などへの紹介が必要である。心因性口臭の場合、コミュニケーション破壊が生じていることが多く、対応には配慮が必要である。
 
問診・診察のポイント  
  1. 口臭を主訴にして来院した場合、口臭症の国際分類に基づき、真性口臭症、仮性口臭症、口臭恐怖症に分類して診断を進める[5][6][7][8][9]
 
 
  1. 口臭についての医療面接を行う場合には面談室のような個室で行うのが望ましく、患者プライバシーへの配慮が必要である。また、患者との位置関係は90度法を用いることが最も好ましい[10]
  1. 正確な診断を行うため、被検者には測定条件が設定されている。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

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文献 

H Miyazaki, S Sakao, Y Katoh, T Takehara
Correlation between volatile sulphur compounds and certain oral health measurements in the general population.
J Periodontol. 1995 Aug;66(8):679-84. doi: 10.1902/jop.1995.66.8.679.
Abstract/Text Oral malodor was measured using a portable sulphide monitor in 2,672 individuals aged 18 to 64 years. In addition, dental (DMFT) and periodontal conditions (CPITN and attachment loss), dental plaque, and tongue coating status were assessed. Before clinical examination, subjects were interviewed about their oral health habits, smoking habits, and medical history. Data on volatile sulphur compounds (VSC) were analyzed by gender, age group, and time of measurement. There were no significant differences observed in the VSC between males and females in any age group. In each age group, the measured values of oral malodor were highest in the late morning group (58.6 ppb in average), followed by the late afternoon group (52.1 ppb), while lowest values were shown in the early afternoon group (39.4 ppb). Significant correlation was observed only between the VSC value and periodontal conditions and tongue coating status. The results also suggest that oral malodor might be caused mainly by tongue coating in the younger generation and by periodontal diseases together with tongue coating in older cohorts in the general population. Age was not a risk factor for increasing VSC.

PMID 7473010
Walter J Loesche, Christopher Kazor
Microbiology and treatment of halitosis.
Periodontol 2000. 2002;28:256-79.
Abstract/Text The prevalence of oral malodor is probably high in the United States, although precise epidemiological data are missing. The many thousands of individuals who experience oral malodor from the overgrowth of proteolytic, anaerobic bacteria on their tongue surfaces can be successfully treated by a regimen that includes tongue brushing, toothbrushing and possibly the usage of mouthrinses containing various agents. Several candidate mouthrinses containing essential oils (Listerine), ZnCl2, or an oil, water and cetylpyridum chloride mouthrinse have reduced the organoleptic scores of individuals with moderate levels of oral malodor in the absence of tongue brushing. Very few long-term data beyond 6 weeks of usage are available. Anecdotal evidence suggests that other agents such as chlorine dioxide may be helpful. These mouthrinses should be marketed as oral deodorants that are analogous in purpose to the usage of deodorant soaps to control and/or eliminate body malodors. In this way the mouthrinse could be considered as a cosmetic by the FDA, provided that there are data on the safety of the various ingredients in the mouthrinse. Mouthrinses containing zinc ions are able to reduce the levels of volatile sulfur compounds by converting these volatile compounds to non-volatile, and therefore, non-malodorous zinc sulfides, and this mode of action would appear to support a cosmetic claim.

PMID 12013345
K Yaegaki, J M Coil
Examination, classification, and treatment of halitosis; clinical perspectives.
J Can Dent Assoc. 2000 May;66(5):257-61.
Abstract/Text Patients with halitosis may seek treatment from dental clinicians for their perceived oral malodour. In this article, an examination protocol, classification system and treatment needs for such patients are outlined. Physiologic halitosis, oral pathologic halitosis and pseudo-halitosis would be in the treatment realm of dental practitioners. Management may include periodontal or restorative treatment or both, as well as simple treatment measures such as instruction in oral hygiene, tongue cleaning and mouth rinsing. Psychosomatic halitosis is more difficult to diagnose and manage, and patients with this condition are often mismanaged in that they receive only treatments for genuine halitosis, even though they do not have oral malodour. A classification system can be used to identify patients with halitophobia. Additionally, a questionnaire can be used to assess the psychological condition of patients claiming to have halitosis, which enables the clinician to identify patients with psychosomatic halitosis. In understanding the different types of halitosis and the corresponding treatment needs, the dental clinician can better manage patients with this condition.

PMID 10833869
K Yaegaki, J M Coil
Genuine halitosis, pseudo-halitosis, and halitophobia: classification, diagnosis, and treatment.
Compend Contin Educ Dent. 2000 Oct;21(10A):880-6, 888-9; quiz 890.
Abstract/Text Although tongue brushing and appropriate mouthrinses are both important and basic treatment measures for halitosis, other dental treatments are sometimes required. The treatment of genuine halitosis caused by oral conditions is not complex. In addition to genuine halitosis patients, psychosomatic halitosis patients also visit dental practitioners. Although psychosomatic halitosis is out of the treatment realm of dental practitioners, patients with this condition will still seek help from a dental practitioner. They often only receive treatment for genuine halitosis without referral to a psychological specialist. If these psychosomatic halitosis patients are incorrectly managed, the psychological condition might become worse than before the visit. To avoid the mismanagement of halitosis patients, classifications of halitosis patients have been established. Genuine halitosis was subclassified as physiologic halitosis and pathologic halitosis. Pathologic halitosis was further categorized to oral pathologic halitosis and extraoral pathologic halitosis. Both pseudo-halitosis and halitophobia patients complain of the existence of halitosis, which is not offensive. Pseudo-halitosis cannot be treated by dental practitioners, and halitophobia patients must be referred to psychological specialists. Clinicians need to examine the psychological condition of halitosis patients at the initial patient visit. A questionnaire prepared for the clinic at the University of British Columbia was found to be advantageous for this purpose.

PMID 11908365
T Murata, T Yamaga, T Iida, H Miyazaki, K Yaegaki
Classification and examination of halitosis.
Int Dent J. 2002 Jun;52 Suppl 3:181-6.
Abstract/Text In this paper, the classification of halitosis and the examination procedures used in diagnosing halitosis are outlined. Halitosis is classified into categories of genuine halitosis, pseudo-halitosis and halitophobia. Genuine halitosis is subclassified into physiologic halitosis and pathologic halitosis. Pathologic halitosis itself is subdivided into oral and extraoral halitosis. Patients diagnosed with pseudo-halitosis and halitophobia usually complain about having oral malodour that does not really exist. Pseudohalitosis can be treated by dental practitioners, but halitophobic patients must be referred to psychological specialists. Oral malodour can be measured using an organoleptic measurement or a gas chromatography analysis. The organoleptic measurement is the most practical procedure with which one can evaluate oral malodour. Gas chromatography (GC) analysis using a flame photometric detector has been shown to be the gold standard for measuring oral malodour, owing its reputation to its objectivity and reproducibility. Moreover, GC is specific for volatile sulphur compounds (VSC), which are the main causes of oral malodour. It has been demonstrated that there is a high correlation between the intensity of oral malodour and the VSC concentration as measured by GC.

PMID 12090449
J M Coil, K Yaegaki, T Matsuo, H Miyazaki
Treatment needs (TN) and practical remedies for halitosis.
Int Dent J. 2002 Jun;52 Suppl 3:187-91.
Abstract/Text Dental practitioners have traditionally neglected halitosis despite its high priority for the public, but practitioners' interest in halitosis has recently increased. Although oral pathologic or physiologic halitosis is easily reduced by a suitable treatment based on the treatment needs, systemic and psychological conditions sometimes confuse practitioners. Since a halitophobic patient never agrees with the result that his/her oral malodour has been reduced or eliminated after treatment, this may cause a dilemma for practitioners. Generally, halitosis patients, even genuine ones, have different psychological characteristics concerning their own breath than other individuals. Adverse psychological aspects of these patients are often promoted by the practitioner's mismanagement. Treatment Needs (TN) were, therefore, established to prevent practitioners' mismanagement of halitosis patients. By following these TN, patients can receive proper treatments for halitosis. However, to choose proper treatment measures, practitioners must refer to articles published in peer-reviewed journals, then use critical thinking to judge whether a product is effective in reducing oral malodour. Although it is challenging for dental practitioners to deal with patients with psychological conditions such as pseudo-halitosis or halitophobia, if appropriate treatments are administered accurately the practitioner does not risk mismanagement.

PMID 12090450
T L Outhouse, R Al-Alawi, Z Fedorowicz, J V Keenan
Tongue scraping for treating halitosis.
Cochrane Database Syst Rev. 2006 Apr 19;(2):CD005519. doi: 10.1002/14651858.CD005519.pub2. Epub 2006 Apr 19.
Abstract/Text BACKGROUND: Halitosis is used to describe any disagreeable odour of expired air regardless of its origin. Mouthwashes which disguise oral malodor are more socially acceptable and generally more popular than tongue scrapers.
OBJECTIVES: To provide reliable evidence regarding the effectiveness of tongue scraping versus other interventions (including mouthwashes) to control halitosis.
SEARCH STRATEGY: We searched the following databases: Cochrane Oral Health Group Trials Register (to 15th September 2005); the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3 2005); MEDLINE 1966 to September Week 1 2005; EMBASE 1974 to September 2005 (searched September 19th 2005).
SELECTION CRITERIA: Randomized controlled trials comparing different methods of tongue cleaning to reduce mouth odour in adults with halitosis.
DATA COLLECTION AND ANALYSIS: Clinical heterogeneity between the two included trials precluded pooling of data, therefore a descriptive summary is presented.
MAIN RESULTS: This review included two trials involving 40 participants. Both trials were methodologically sound but included no data for the primary outcomes specified in this review. Secondary outcomes expressed as volatile sulfur compound (VSC) levels were assessed by a portable sulfide monitor in both trials. One trial showed reductions of VSC levels of 42% with the tongue cleaner, 40% with the tongue scraper and 33% with the toothbrush. Reduced VSC levels persisted longer with the tongue cleaner than the toothbrush and could not be detected for more than 30 minutes after the intervention in any of the groups. Differences were assessed by the Friedman and Wilcoxon signed rank tests with the level of significance set at P < 0.05. The second trial, in which differences in totaled rank values between groups were compared by the Dunn method alpha = 0.01, showed a reduction of VSC levels compared with baseline measurements of 75% with the tongue scraper and 45% with the toothbrush. Adverse effects in one trial were nausea (60%) and trauma (10%) with the toothbrush and all participants receptive to using the tongue scraper. Based on the independent data from these two trials there was a statistically significant difference between the effectiveness of either the tongue cleaner or the tongue scraper in reducing VSC levels when compared with the toothbrush.
AUTHORS' CONCLUSIONS: There is weak and unreliable evidence to show that there is a small but statistically significant difference in reduction of VSC levels when tongue scrapers or cleaners rather than toothbrushes are used to reduce halitosis in adults. We found no high level evidence comparing mechanical with other forms of tongue cleaning.

PMID 16625641
R Seemann, A Kison, M Bizhang, S Zimmer
Effectiveness of mechanical tongue cleaning on oral levels of volatile sulfur compounds.
J Am Dent Assoc. 2001 Sep;132(9):1263-7; quiz 1318.
Abstract/Text BACKGROUND: Mechanical tongue cleaning may be an effective method for decreasing oral levels of volatile sulfur compounds, or VSC, and oral malodor. The authors conducted a study to compare the effectiveness of a specially designed tongue cleaner (One Drop Only Tongue Cleaner, One Drop Only, Berlin), a tongue scraper and a toothbrush in reducing oral VSC levels.
METHODS: In this balanced, crossover study, 30 subjects had four morning appointments each with a waiting period of one week between appointments. At each appointment, a dental professional performed a single standardized tongue cleaning procedure using one of the cleaning tools. The authors monitored the subjects' oral VSC values using a portable sulfide monitor until their baseline VSC values were reached.
RESULTS: The baseline values showed no significant difference between the three groups. The tongue cleaner and the tongue scraper (42 percent and 40 percent, respectively) reduced oral VSC levels more than the toothbrush (33 percent) did. Reduced VSC values could be detected significantly longer after using the tongue cleaner than after using the tongue scraper or the toothbrush. The authors, however, could not detect a significant VSC reduction for more than 30 minutes in any of the subjects.
CONCLUSIONS AND CLINICAL IMPLICATIONS: The tongue cleaner, a combination brush and scraper, was slightly more effective in reducing oral VSC levels than were the tongue scraper and a regular toothbrush. Because of the limited duration of the effect, however, the clinical efficacy on the reduction of oral malodor remains questionable.

PMID 11665351
K Yaegaki, J M Coil, T Kamemizu, H Miyazaki
Tongue brushing and mouth rinsing as basic treatment measures for halitosis.
Int Dent J. 2002 Jun;52 Suppl 3:192-6.
Abstract/Text Tongue brushing and mouth rinsing are basic treatment measures for halitosis, and as such are categorised as treatment needs (TN)-1. Although TN-1 is used for treatment of physiologic halitosis treatment, pseudo-, extra oral pathologic or halitophobic patients must also be managed with TN-1 as well as other treatments. Since the origin of physiological halitosis is mainly the dorso-posterior region of the tongue, tongue cleaning is more effective than mouth rinsing. However, practitioners should always instruct their patients on how to brush their tongues to prevent harmful effects. Another approach using a chlorhexidine mouthwash is most effective in reducing oral malodour. However, chlorhexidine should not be used routinely; therefore, zinc-containing mouthwashes have been recommended for use. People can also use chewing gum to reduce oral malodour. Surprisingly, however, it has been noted that sugarless chewing gum increased methyl mercaptan, one of the principal components of oral malodour. Mint did not reduce the concentration of methyl mercaptan either, although these products are widely used for their ability to mask oral malodour. There is a need for the development of a novel food or chewing gum that could considerably reduce VSC levels in mouth air to complement TN-1.

PMID 12090451
Seida Erovic Ademovski, G Rutger Persson, Edwin Winkel, Albert Tangerman, Peter Lingström, Stefan Renvert
The short-term treatment effects on the microbiota at the dorsum of the tongue in intra-oral halitosis patients--a randomized clinical trial.
Clin Oral Investig. 2013 Mar;17(2):463-73. doi: 10.1007/s00784-012-0728-y. Epub 2012 May 10.
Abstract/Text OBJECTIVES: This study aims to assess the effects of rinsing with zinc- and chlorhexidine-containing mouth rinse with or without adjunct tongue scraping on volatile sulfur compounds (VSCs) in breath air, and the microbiota at the dorsum of the tongue.
MATERIAL AND METHODS: A randomized single-masked controlled clinical trial with a cross-over study design over 14 days including 21 subjects was performed. Bacterial samples from the dorsum of the tongue were assayed by checkerboard DNA-DNA hybridization.
RESULTS: No halitosis (identified by VSC assessments) at day 14 was identified in 12/21 subjects with active rinse alone, in 10/21 with adjunct use of tongue scraper, in 1/21 for negative control rinse alone, and in 3/21 in the control and tongue scraping sequence. At day 14, significantly lower counts were identified only in the active rinse sequence (p < 0.001) for 15/78 species including, Fusobacterium sp., Porphyromonas gingivalis, Pseudomonas aeruginosa, Staphylococcus aureus, and Tannerella forsythia. A decrease in bacteria from baseline to day 14 was found in successfully treated subjects for 9/74 species including: P. gingivalis, Prevotella melaninogenica, S. aureus, and Treponema denticola. Baseline VSC scores were correlated with several bacterial species. The use of a tongue scraper combined with active rinse did not change the levels of VSC compared to rinsing alone.
CONCLUSIONS: VSC scores were not associated with bacterial counts in samples taken from the dorsum of the tongue. The active rinse alone containing zinc and chlorhexidine had effects on intra-oral halitosis and reduced bacterial counts of species associated with malodor. Tongue scraping provided no beneficial effects on the microbiota studied.
CLINICAL RELEVANCE: Periodontally healthy subjects with intra-oral halitosis benefit from daily rinsing with zinc- and chlorhexidine-containing mouth rinse.

PMID 22573244
Zbys Fedorowicz, Hamad Aljufairi, Mona Nasser, Trent L Outhouse, Vinícius Pedrazzi
Mouthrinses for the treatment of halitosis.
Cochrane Database Syst Rev. 2008 Oct 8;(4):CD006701. doi: 10.1002/14651858.CD006701.pub2. Epub 2008 Oct 8.
Abstract/Text BACKGROUND: Halitosis is an unpleasant odour emanating from the oral cavity. Mouthwashes, which are commonly used for dealing with oral malodour, can be generally divided into those that neutralize and those that mask the odour.
OBJECTIVES: To investigate the effects of mouthrinses in controlling halitosis.
SEARCH STRATEGY: We searched the following databases: Cochrane Oral Health Group Trials Register (to August 2008); the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 3); MEDLINE (1950 to August 2008); EMBASE (1980 to August 2008); and CINAHL (1982 to August 2008). There were no language restrictions.
SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing mouthrinses to placebo in adults over the age of 18 with halitosis and without significant other comorbidities or health conditions.The primary outcomes considered were self expressed and organoleptic (human nose) assessments of halitosis, and the secondary outcomes included assessment of halitosis as measured by a halimeter, portable sulphide monitor or by gas chromatography coupled with flame-photometric detection.
DATA COLLECTION AND ANALYSIS: Two independent review authors screened and extracted information from, and independently assessed the risk of bias in the included trials.
MAIN RESULTS: Five RCTs, involving 293 participants who were randomised to mouthrinses or placebo, were included in this review.In view of the clinical heterogeneity between the trials, pooling of the results and meta-analysis of the extracted data was not feasible and therefore only a descriptive summary of the results of the included trials is provided.0.05% chlorhexidine + 0.05% cetylpyridinium chloride + 0.14% zinc lactate mouthrinse significantly reduced the mean change (standard deviation (SD)) of organoleptic scores from baseline compared to placebo (-1.13 (1.1) P < 0.005 versus -0.2 (0.7)) and also caused a more significant reduction in the mean change (SD) in peak level of volatile sulphur compounds (VSC) (-120 (92) parts per billion (ppb) versus 8 (145) ppb in placebo). The chlorhexidine cetylpyridinium chloride zinc lactate mouthrinse showed significantly more tongue (P < 0.001) and tooth (P < 0.002) staining compared to placebo.However, in view of the incomplete reporting of results in three of the trials and the sole use of the halimeter for assessment of VSC levels as outcomes in two further trials, caution should be exercised in interpreting these results.
AUTHORS' CONCLUSIONS: Mouthrinses containing antibacterial agents such as chlorhexidine and cetylpyridinium chloride may play an important role in reducing the levels of halitosis-producing bacteria on the tongue, and chlorine dioxide and zinc containing mouthrinses can be effective in neutralisation of odouriferous sulphur compounds.Well designed randomised controlled trials with a larger sample size, a longer intervention and follow-up period are still needed.

PMID 18843727
D van Steenberghe, P Avontroodt, W Peeters, M Pauwels, W Coucke, A Lijnen, M Quirynen
Effect of different mouthrinses on morning breath.
J Periodontol. 2001 Sep;72(9):1183-91. doi: 10.1902/jop.2000.72.9.1183.
Abstract/Text BACKGROUND: Morning breath odor is an often-encountered complaint. This double-blind, crossover, randomized study aimed to examine the bad breath-inhibiting effect of 3 commercially available mouthrinses on morning halitosis during an experimental period of 12 days without mechanical plaque control.
METHODS: Twelve medical students with a healthy periodontium refrained from all means of mechanical plaque control during 3 experimental periods of 12 days (with intervening washout periods of at least 3 weeks). A professional oral cleaning preceded each period. During each experimental period, as the only oral hygiene measure allowed, the students rinsed twice a day with one of the following formulations in a randomized order: CHX-Alc (a 0.2% chlorhexidine [CHX] solution); CHX-NaF (CHX 0.12% plus sodium fluoride 0.05%); or CHX-CPC-Zn (CHX 0.05% plus cetylpyridinium chloride 0.05% plus zinc lactate 0.14%). After 12 days, morning breath was scored via volatile sulfur compound (VSC) level measurements of the mouth air and organoleptic ratings of the mouth air, the expired air, and a scraping of the tongue coating. At the 12-day visit, a questionnaire (subjective ratings) was completed and samples taken from both the tongue coating and the saliva for anaerobic and aerobic culturing and vitality staining. The de novo supragingival plaque formation was also recorded. All parameters were correlated with the baseline registrations.
RESULTS: Although oral hygiene during the 3 experimental periods was limited to oral rinses, bad breath parameters systematically improved, with the exception of a slight increase in VSC levels while using CHX-Alc, a finding which was associated with the direct influence of the CHX on the sulfide monitor. The oral microbial load after the use of CHX-NaF remained unchanged, while for the CHX-Alc and CHX-CPC-Zn, significant reductions in both aerobic and anaerobic colony forming units (CFU)/ml were noticed in comparison with baseline data for both tongue coating and saliva samples. The composition of microflora, on the other hand, did not reveal significant changes. The supragingival plaque formation was inhibited, in descending order, by CHX-Alc, CHX-CPC-Zn, and CHX-NaF. The subjective scores for the rinses indicated a higher appreciation for CHX-CPC-Alc and CHX-NaF because of a better taste and fewer side effects.
CONCLUSIONS: The results of this study demonstrate that morning halitosis can be successfully reduced via daily use of mouthrinses. CHX-Alc and CHX-CPC-Zn mouthrinses result in a significant reduction of the microbial load of tongue and saliva.

PMID 11577950
Abstract/Text OBJECTIVES: The aim of this double-blind, parallel study was to test the clinical efficacy of a newly developed mouthrinse in the treatment of oral halitosis in patients without periodontitis.
MATERIAL AND METHODS: Forty volunteers, recruited in two centers, participated in this study. Patients were selected on the basis of (1) halitosis of oral origin, (2) full-mouth organoleptic score>1, using an arbitrary 0-5 scale, (3) level of volatile sulfur compounds (VSC)>170 parts per billion (ppb) and (4) Winkel tongue coating index (WTCI)>4 (0-12). Intervention included gargling with a mouthrinse containing chlorhexidine (0.05%), cetylpyridinium chloride (0.05%) and zinc-lactate (0.14%) or with a placebo mouthrinse without active ingredients. At days 0 and 14 clinical variables were assessed in order of performance: (1) organoleptic assessments, (2) levels of VSC, and (3) WTCI.
RESULTS: Treatment with the active mouthrinse resulted in a significant mean reduction in the organoleptic score from 2.8 to 1.5 (p<0.005). In the placebo group, no significant reduction in the mean organoleptic score occurred. Consequently, this resulted, after 2 weeks, in a greater change of the organoleptic scores in the test group in comparison to the placebo group (p<0.005). The mean VSC scores were reduced from 292 to 172 ppb in the test group (p<0.005), whereas no reduction was observed in the placebo group. At the 2-week examination, the mean change of the VSC scores in the test group was significantly greater than the mean change in the placebo group (p<0.005). Neither in the test nor in the placebo group a significant reduction in tongue coating was observed.
CONCLUSIONS: In conclusion, the tested mouthrinse is effective in the treatment of oral halitosis.

PMID 12694427
Marc Quirynen, Hong Zhao, Catherine Soers, Christel Dekeyser, Martine Pauwels, Wim Coucke, Daniel van Steenberghe
The impact of periodontal therapy and the adjunctive effect of antiseptics on breath odor-related outcome variables: a double-blind randomized study.
J Periodontol. 2005 May;76(5):705-12. doi: 10.1902/jop.2005.76.5.705.
Abstract/Text BACKGROUND: Bad breath is often caused by periodontitis and/or tongue coating. This study followed the impact of initial periodontal therapy on several halitosis-related outcome variables over a 6-month period. Organoleptic ratings are often uncomfortable for the patient and have several disadvantages. They are, for instance, influenced by external parameters (e.g., food intake and cosmetics) and need to be calibrated among researchers worldwide. A second aim was to evaluate the reliability of saliva incubation as an in vitro indirect test for breath recording.
METHODS: In this double-blind, randomized, medium-term, parallel study 45 moderate periodontitis patients without obvious tongue coating were enrolled. Besides a one-stage, full-mouth disinfection and oral hygiene improvement (including daily tongue scraping), patients were instructed to rinse daily for 6 months with one of the following products (randomly allocated): chlorhexidine (CHX) 0.2% + alcohol, CHX 0.05% + cetyl pyridinium chloride (CPC) 0.05% without alcohol (a new formulation), or a placebo solution. At baseline and 3 and 6 months, a series of parameters were recorded including: concentration of volatile sulfide compounds (VSC), tongue coating, and an estimation of the microbial load (at anterior and posterior parts of the tongue, saliva, dental plaque). The intraoral VSC ratings were compared to in vitro VSC recordings and organoleptic evaluations of the headspace air from 1 and 2 hours incubated saliva (0.5 ml, 37 degrees C, anaerobic chamber).
RESULTS: Even though the initial VSC values were not high (+/-90 ppb with only 18 patients revealing more than 100 ppb), significant (P <0.05) reductions could be achieved in the CHX and CHX + CPC group, and to a lower extent in the placebo group (P = 0.10). Tongue scraping resulted in a significant reduction (P < or =0.05) of the tongue coating up to month 6 in the placebo and CHX + CPC group, but not in the CHX group (confusion due to staining). The CHX and CHX + CPC group showed, in comparison to baseline, significant (P <0.001) reductions in the number of anaerobic species in the supragingival plaque, in the saliva, and on the anterior part of the tongue. For the posterior part of the tongue the microbial changes remained < or =0.3 log values (P >0.05). For the placebo group, the microbial changes never reached a level of significance (< or =0.3 log values). A strong correlation was found between the intraoral VSC ratings and the 1-hour (r = 0.48, P <0.0001; r = 0.54, P = 0.0003 for baseline data only) and 2-hour (r = 0.43, P <0.0001) VSC production of incubated saliva. The latter also correlated very strongly (r = 0.71) with the number of anaerobic species in the saliva. The VSC values and organoleptic ratings of the incubated saliva also correlated strongly with each other (r = 0.64 for 1-hour and 0.73 for 2-hour incubation).
CONCLUSIONS: The results of this study indicate that in patients with moderate periodontitis, initial periodontal therapy including tongue scraping did not have a significant effect on the microbial load of the tongue and had only a weak impact on the VSC level, except when combined with a mouthrinse. Saliva incubation can be used as an indirect way to score breath odor. It offers simplicity, objectivity, and is less invasive.

PMID 15898930
Shinjiro Koshimune, Shuji Awano, Kenjiro Gohara, Eriko Kurihara, Toshihiro Ansai, Tadamichi Takehara
Low salivary flow and volatile sulfur compounds in mouth air.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003 Jul;96(1):38-41. doi: 10.1067/moe.2003.S1079210403001628.
Abstract/Text OBJECTIVE: The purpose of this study was to determine whether a reduction of salivary flow would influence the production of methylmercaptan (CH(3)SH) and hydrogen sulfide (H(2)S), which are volatile sulfur compounds (VSCs) known to cause oral malodor.
STUDY DESIGN: The VSCs in mouth air were measured by means of gas chromatography. Spitting and masticatory (stimulated) methods were used to determine the salivary flow rates of 174 patients.
RESULTS: There was no significant correlation between the level of VSCs and salivary flow rate. However, subjects with extremely low resting salivary flow rates had significantly higher CH(3)SH and H(2)S concentrations and tongue-coating scores than those with higher resting salivary flow rates. Moreover, logistic analyses revealed that extremely low resting salivary flow, the increase in tongue coating, and a probing pocket depth greater than 4 mm were strong explanatory factors for the generation of VSCs, which could have caused oral malodor.
CONCLUSIONS: These findings suggested that an extreme reduction in resting saliva influenced the generation of CH(3)SH and H(2)S in mouth air.

PMID 12847442
T A V Pham, M Ueno, T Zaitsu, S Takehara, K Shinada, P H Lam, Y Kawaguchi
Clinical trial of oral malodor treatment in patients with periodontal diseases.
J Periodontal Res. 2011 Dec;46(6):722-9. doi: 10.1111/j.1600-0765.2011.01395.x. Epub 2011 Jul 18.
Abstract/Text BACKGROUND AND OBJECTIVE: Only a few clinical research studies have assessed different therapeutic approaches to oral malodor in subjects affected by periodontal diseases. The aim of this study was to evaluate the effects of periodontal treatment and tongue cleaning on oral malodor parameters in periodontitis and gingivitis patients.
MATERIAL AND METHODS: The subjects were 102 periodontitis and 116 gingivitis patients with oral malodor. Oral malodor was measured by organoleptic test and Oral Chroma™. Oral health status, including tooth conditions, periodontal health, tongue coating and proteolytic activity of the BANA test in tongue coating were assessed. Subjects in each periodontal disease group were randomly assigned into two subgroups depending on the sequence of treatment: periodontal treatment and tongue cleaning. Oral malodor and oral health parameters were compared by groups and sequence of treatment.
RESULTS: For subjects in the periodontitis group, there were statistically significant reductions in oral malodor after periodontitis treatment or tongue cleaning; however, major reductions were found after periodontitis treatment. For those in the gingivitis group, there were also statistically significant reductions in oral malodor after gingivitis treatment or tongue cleaning, but the most marked reductions were observed after tongue cleaning. At the completion of treatment, all oral malodor parameters fell below the threshold levels in all subgroups.
CONCLUSION: The present study indicated that periodontal treatment played an important role and tongue cleaning contributed to a lesser extent to reduction in oral malodor in periodontitis patients. In contrast, tongue cleaning alone can be the primary approach to reduce oral malodor in gingivitis patients.

© 2011 John Wiley & Sons A/S.
PMID 21762407
H Takeuchi, M Machigashira, D Yamashita, S Kozono, Y Nakajima, M Miyamoto, N Takeuchi, T Setoguchi, K Noguchi
The association of periodontal disease with oral malodour in a Japanese population.
Oral Dis. 2010 Oct;16(7):702-6. doi: 10.1111/j.1601-0825.2010.01685.x.
Abstract/Text AIM: The purpose of this study was to evaluate the association between oral malodour and periodontal disease, and to determine the effect of periodontal therapy on oral malodour.
MATERIALS AND METHODS: Oral malodour parameters, including volatile sulphur compound (VCS) measurement, methyl mercaptan/hydrogen sulphide ratio by gas chromatography, organoleptic testing, tongue coating score, and periodontal parameters were evaluated in 823 patients complaining of oral malodour. Amongst these patients, 89 with oral pathogenic halitosis received tongue cleaning and periodontal therapy. Oral malodour and periodontal parameters were measured at baseline and after treatment.
RESULTS: Amongst 823 patients, 102 were diagnosed with gingivitis and 721 with periodontitis. VCS levels and periodontal parameters increased according to the severity of oral malodour. Organoleptic testing significantly correlated with periodontal probing depth and a percentage of periodontal pocket depth ≥4mm (r=0.40 and 0.39 respectively). There were significant correlations between methyl mercaptan/hydrogen sulphide ratio and periodontal parameters. Significant decrease in oral malodour and periodontal parameters in 89 patients with oral pathogenic halitosis was also observed after periodontal treatment.
CONCLUSIONS: Oral malodour is associated with periodontal disease, and periodontal therapy combined with tongue cleaning is beneficial for oral pathogenic halitosis.

© 2010 John Wiley & Sons A/S.
PMID 20561223
Abstract/Text Volatile sulfur compounds (VSC) in mouth air were estimated by gas chromatography. The amount of VSC and the methyl mercaptan/hydrogen sulfide ratio were significantly increased in patients with periodontal disease. These two parameters also increased in proportion to the bleeding index and probing depth. A study was also done on the effect of removal of tongue coating on VSC concentrations in mouth air from patients with periodontal involvement. VSC and the methyl mercaptan/hydrogen sulfide ratio were reduced to 49% and 35%, respectively, by removal of the tongue coating. The average amount of tongue coating removed from patients with periodontal disease was significantly higher than from controls (90.1 mg vs. 14.6 mg, p less than 0.01). Estimated production of VSC from tongue coating was 4 times higher than the control value, and the methyl mercaptan/hydrogen sulfide ratio was also markedly increased. However, a saliva putrefaction study suggested that saliva does not contribute to the elevated ratio of methyl mercaptan in mouth air. These results strongly suggest that, in addition to periodontal pockets, tongue coating has an important role in VSC production, in particular leading to an elevated concentration of methyl mercaptan, which is more pathogenic than hydrogen sulfide.

PMID 1640345
M I Van der Sleen, D E Slot, E Van Trijffel, E G Winkel, G A Van der Weijden
Effectiveness of mechanical tongue cleaning on breath odour and tongue coating: a systematic review.
Int J Dent Hyg. 2010 Nov;8(4):258-68. doi: 10.1111/j.1601-5037.2010.00479.x. Epub 2010 Sep 6.
Abstract/Text BACKGROUND: The objective of this review was to summarize the available evidence regarding the effects of mechanical tongue cleaning compared with no mechanical tongue cleaning on breath odour and tongue coating (TC).
METHODS: PubMed-MEDLINE, EMBASE and Cochrane-CENTRAL were searched to identify potentially relevant studies. The inclusion criteria included the following: randomized controlled clinical trials (RCTs) or controlled clinical trials (CCTs) conducted in humans in good general health (no systemic disorders) and a patient age of ≥17 years. For the intervention, we considered tongue cleaning [the use of a tongue scraper (TS) or tongue brush (TB)] and for the control, brushing only (B) groups. Clinical parameters such as volatile sulphur compound concentration, organoleptic scores and TC were the outcome variables of interest. Study selection, quality assessment and data extraction were carried out by two independent reviewers.
RESULTS: After screening of the titles and abstracts and subsequent full text reading of the potential papers, we identified five publications that met the eligibility criteria and provided seven experiments. The five studies consisted of three RCTs and two CCTs. All experiments show a positive effect of mechanical tongue cleaning in addition to toothbrushing on various parameters of oral malodour.
CONCLUSIONS: This review demonstrated that mechanical approaches, such as tongue brushing or tongue scraping to clean the dorsum of the tongue, have the potential to successfully reduce breath odour and TC. However, data concerning the effect of mechanical tongue cleaning on chronic oral malodour (halitosis) are insufficient.

© 2010 John Wiley & Sons A/S.
PMID 20961381

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