Halitosis: Principios básicos sobre su origen y tratamiento Revisión narrativa / Halitosis: Basic Principles About its Origin and Treatment Narrative Review

RESUMEN Halitosis es la presencia de un olor desagradable que emana de la cavidad oral. La etiología de este mal olor es multifactorial, existiendo causas no orales, orales y extraorales. Los compuestos volátiles sulfurados (CVS): sulfuro de hidrógeno y metilmercaptano son los elementos prominentes del mal olor. Intraoralmente, existe una correlación significativa entre las concentraciones de CVS y bacterias periodontopatogénicas. En pacientes sin enfermedad periodontal el mal olor se origina principalmente de la cobertura del dorso de la lengua por lo que la limpieza o raspado de ésta es un método efectivo para prevenir o disminuir la halitosis. Existen múltiples opciones químicas para el abordaje del mal aliento que dependerán del origen y grado de severidad. Este artículo revisa el origen y los tratamientos tanto mecánicos como químicos que se tienen disponibles.

ABSTRACT Halitosis is the presence of an unpleasant smell that emanates from the oral cavity. The etiology of halitosis is multifactorial, existing non oral, oral and extraoral causes. The volatile sulphur compounds (VSC): hydrogen sulfide and methyl mercaptan are the prominent elements of malodour. Intraorally there is a significant correlation between VSC concentrations and periodontopathogenic bacteria. In patients with no gum disease the halitosis is originated mainly in the dorsal surface of the tongue, so cleaning or brushing it is an effective method to prevent or decrease halitosis. There are multiple chemical options for the treatment of the malodour that will depend on the origin and severity of it. This article reviews the origin and mechanical and chemical treatments that are available.

Instant and freshness effect of mouth rinses on type 1 (oral) halitosis / Efecto anti-halitosis instantáneo y efecto de frescura de los enjuagues bucales sobre la halitosis (oral) tipo I

Hygiene deficiency causes type 1 (oral) halitosis. There are short and long-term studies on the anti-halitosis effect of mouth rinses but less knowledge on their instant effects. The aim of this study was to compare instant and freshness effects of 8 mouth rinses on type 1 halitosis. Ninety self-reported halitosis patients (19-58 y.o., median 31) were randomly divided into 9 groups. Cysteine (20 mM) challenge test was applied to obtain maximum halitosis level in the mouth of each patient. Single use of 8 different mouth rinses (R1-R8) and tap water (R0) were tested on each group (n=10). Afterward, patients were requested to score oral freshness effect of the mouth rinse on a 5-point scale (0, bad; 5, fresh). Minimum halitosis level was obtained by rinsing with 20 mMol ZnCL2. In each step, oral gas (organic, NH3, SO2, H2S, H2) concentrations were quantified by using a portable multi-gas detector (MX6, IndSci, US). The ANOVA or Kruskal Wallis tests were used to compare the quantitative measurements. R3 (Halitosil Zn) mouth rinse was found to be have the highest instant anti-halitosis effect while the R2 (Colgate plax) had the lowest. The sensation of freshness was highest in R7 (Oxyfresh power mouth rinse lemon-mint) and lowest in R8 (Signal expert protection). The freshness effect was not associated with the anti-halitosis effect (r= 0.185, p=0.608). Mouth rinses containing ZnCl2 without alcohol are instantly effective on halitosis. Mouth rinses containing ethyl and other alcohols (including glycol, sorbitol, menthol, eucalyptol, thymol, xylitol and eugenol) were found to be less effective on halitosis.

La deficiencia de higiene causa halitosis tipo 1 (oral). Se han reportado efectos anti-halitosis a corto o largo plazo de los enjuagatorios bucales, pero se desconocen sus efectos instantáneos. El objetivo de este estudio fue comparar el efecto instantáneo y de frescura de 8 enjuagues bucales en la halitosis tipo 1. Noventa pacientes (19-58 años, mediana 31) que reportaron sufrir halitosis se dividieron aleatoriamente en 9 grupos. Se aplicó la prueba de provocación con cisterna (20 mM) para obtener el máximo nivel de halitosis en la boca de cada paciente. El uso individual de 8 enjuagues bucales diferentes (R1-R8) y agua del grifo (R0) se probó en cada grupo (n = 10). Posteriormente, se pidió a los pacientes que puntuaran el efecto de la frescura oral del enjuague bucal en una escala de 5puntos (0, malo; 5, fresco). El nivel mínimo de halitosis se obtuvo con 20 mMol de ZnCL2 enjuague. En cada paso, se cuantificaron las concentraciones de gases orales (orgánicos, NH3, SO2, H2S, H2) mediante el uso de un detector portátil de múltiples gases (MX6, IndSci, EE. UU.)Se encontró que el enjuague bucal R3 (Halitosil Zn) tiene un mayor efecto antihalitosis instantáneo, mientras que el R2 (Colgate plax) fue el más bajo. El sentido de frescura fue mayor en el enjuague bucal R7 (enjuague bucal Oxyfresh power lemon-mint) mientras que fue bajo en R8 (protección experta de Signal). El efecto de frescura no se asoció con el efecto anti-halitosis (r = 0.185, p=0.608). Los enjuagues bucales que contienen ZnCl2 sin alcohol son instantáneamente efectivos en la halitosis. Se encontró que los enjuagues bucales que contenían etil y otros alcoholes (incluidos glicol, sorbitol, mentol, eucaliptol, timol, xilitol y eugenol) son menos efectivos para el control de la halitosis.

Two mechanisms of oral malodor inhibition by zinc ions

Abstract Objectives The aim of this study was to reveal the mechanisms by which zinc ions inhibit oral malodor. Material and Methods The direct binding of zinc ions to gaseous hydrogen sulfide (H2S) was assessed in comparison with other metal ions. Nine metal chlorides and six metal acetates were examined. To understand the strength of H2S volatilization inhibition, the minimum concentration needed to inhibit H2S volatilization was determined using serial dilution methods. Subsequently, the inhibitory activities of zinc ions on the growth of six oral bacterial strains related to volatile sulfur compound (VSC) production and three strains not related to VSC production were evaluated. Results Aqueous solutions of ZnCl2, CdCl2, CuCl2, (CH3COO)2Zn, (CH3COO)2Cd, (CH3COO)2Cu, and CH3COOAg inhibited H2S volatilization almost entirely. The strengths of H2S volatilization inhibition were in the order Ag+ > Cd2+ > Cu2+ > Zn2+. The effect of zinc ions on the growth of oral bacteria was strain-dependent. Fusobacterium nucleatum ATCC 25586 was the most sensitive, as it was suppressed by medium containing 0.001% zinc ions. Conclusions Zinc ions have an inhibitory effect on oral malodor involving the two mechanisms of direct binding with gaseous H2S and suppressing the growth of VSC-producing oral bacteria.

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

OBJECTIVES: The aim of this work was to evaluate saliva and tongue coating pH in oral healthy patients with morning bad breath before and after use of different oral mouthrinses. MATERIAL AND METHODS: Saliva and tongue coating pH of 50 patients allocated in 5 groups were measured respectively by a digital pHmeter and color pH indicators, before, immediately after and 30 min after rinsing 5 different mouthrinses: cetilpiridine chloride associated with sodium chloride, triclosan, enzymatic solution, essential oil and distilled water. RESULTS: Only triclosan and essential oil increased salivary pH immediately after rising. The enzymatic solution decreased salivary and tongue coating pH immediately after rinsing. CONCLUSIONS: Salivary pH tended to be acidic while tongue coating pH tended to be alkaline, even after rising. Triclosan and essential oil mouthrinses increased salivary pH immediately after rinsing. Enzymatic solution decreased saliva and tongue coating pH immediately after rising.

Avaliação de um novo enxaguatório na formação de cáseos amigdalianos / Evaluation of a new mouthwash on caseous formation

Os cáseos amigdalianos afetam uma significativa porcentagem da população. As cirurgias, conservadoras ou não, têm sido as únicas alternativas viáveis de tratamento. Entretanto, ainda hoje não há um método econômico e não-invasivo de tratamento que apresente resultados satisfatórios. OBJETIVOS: Os objetivos deste estudo são avaliar a eficiência de um enxaguatório, cujos ingredientes ativos associam substâncias oxigenantes e antimicrobianas, na diminuição da formação dos cáseos amigdalianos e da saburra lingual, cuja etiologia é semelhante à dos cáseos, e avaliar a redução da concentração dos compostos sulfurados voláteis (CSVs). FORMA DE ESTUDO: Estudo clínico e experimental, randomizado, duplo-cego, placebo-controlado. MATERIAL E MÉTODO: Foi utilizada uma amostra de 50 voluntários, com queixa de tonsilite crônica caseosa há mais de um ano. A pesquisa foi realizada em 2005, nas cidades de São Paulo e Campinas. RESULTADOS: Para o grupo que utilizou a solução placebo, não houve correlação entre as variáveis nem significância estatística nos resultados. Para o grupo que utilizou o enxaguatório, os resultados foram significativos em todos os quesitos analisados. CONCLUSÕES: O novo enxaguatório demonstrou ser uma alternativa conservadora viável para o tratamento da tonsilite crônica caseosa, sendo eficiente também na redução da formação de saburra lingual e concentração dos CSVs.

Tonsil caseous affects a significant percentage of the population. Surgeries, conservative or not, have been the only viable alternatives of treatment. However, today there is still not, up to now, an economical and non-invasive treatment that presents satisfactory results. AIMS: The objectives of this study are to evaluate the efficiency of a mouthwash, with active ingredients that associate oxygenating and antimicrobial substances, in the reduction of caseous and tongue coating formation, whose etiology is similar to caseous, and to evaluate the reduction of the volatile sulfur compounds (VSCs) concentration. STUDY DESIGN: Double blind, placebo-controlled, randomized, clinical and experimental study. MATERIAL E METHODS: A sample of 50 volunteers with more than one year of chronic caseous tonsillitis complaint used it. The research was carried out in 2005, in the cities of São Paulo and Campinas. RESULTS: For the group that used the placebo solution, there was no correlation between the variables or statistical significance in the results. For the group that used the mouthwash, the results were significant in all analyzed questions. CONCLUSIONS: This new mouthwash proved to be a viable conservative alternative for the treatment of tonsil caseous, being also efficient in the reduction of tongue coating formation and VSCs concentration.

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

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

O objetivo do presente estudo foi avaliar o efeito inibitório do enxaguatório de dióxido de cloro a 0,1 por cento sobre a formação dos CSVs, quando comparados a um placebo. Um estudo randomizado, cruzado, duplo cego foi conduzido com 14 estudantes de odontologia apresentando saúde periodontal, os quais se abstiveram dos hábitos de escovação dentária e limpeza da língua durante dois períodos experimentais de 4 dias. Os voluntários foram orientados a utilizar o enxaguatório designado 3 vezes ao dia conforme indicado no rótulo. Um intervalo de 7 dias foi estabelecido entre os períodos experimentais. No início ("baseline") e no final de cada período experimental, os níveis de CSVs foram medidos com o uso do monitor de sulfetos. Análise estatística foi realizada utilizando-se os testes não-paramétricos de Wilcoxon e Mann-Whitney. No "baseline", uma análise intragrupo revelou que os níveis de CSVs não diferiram entre os grupos (p > 0.05); no dia 5, o uso do dióxido de cloro não promoveu mudanças significativas nos níveis de CSVs em relação ao "baseline" no grupo controle (p > 0,05), entretanto os níveis de CSVs duplicaram com a utilização enxaguatório placebo (p < 0,05). Uma análise entre os grupos teste e controle revelou diferença significante para os níveis de CSVs (40,2 ± 30,72 e 82,3 ± 75,63 ppb, p < 0,001) no dia 5. Dentro dos limites deste estudo, os achados sugerem que o uso de enxaguatórios contendo dióxido de cloro pode promover a manutenção de baixos níveis de CSVs no hálito matinal.