Italian pharmacy online: cialis senza ricetta medica in farmacia.
A review of the current literature on management of halitosis
Oral Diseases (2008) 14, 30–39. doi:10.1111/j.1601-0825.2006.01350.x
Ó 2007 The Authors. Journal compilation Ó 2007 Blackwell Munksgaard
A review of the current literature on management ofhalitosis
AMWT van den Broek1, L Feenstra2, C de Baat1
Departments of 1Oral and Maxillofacial Surgery and Special Dental Care and 2Otorhinolaryngology, Erasmus University MedicalCenter, Rotterdam, the Netherlands
Halitosis is an unpleasant or offensive odour, emanating
social embarrassment. In approximately 80% of all
from the oral cavity. In approximately 80% of all cases,
cases, halitosis is caused by oral conditions, deﬁned as
halitosis is caused by microbial degradation of oral organic
oral malodour (Miyazaki et al, 1995; Delanghe et al,
substrates. Major degradation products are volatile sul-
1997). There seems consensus that oral malodour results
phur-containing compounds. In this review, the available
from tongue coating, periodontal disease, periimplant
management methods of halitosis and their effective-
disease, deep carious lesions, exposed necrotic tooth
ness and significance are presented and discussed.
Undoubtedly, the basic management is mechanically
wounds, impacted food or debris, imperfect dental
reducing the amount of micro-organisms and substrates
restorations, unclean dentures and factors causing
in the oral cavity. Masking products are not, and anti-
decreased salivary ﬂow rate (Yaegaki and Sanada,
microbial ingredients in oral healthcare products are only
1992a,b; Morita and Wang, 2001a,b; Morita et al,
temporary effective in reducing micro-organisms or their
2001; Kleinberg et al, 2002; Hinode et al, 2003; van
substrates. Good short-term results were reported with
Steenberghe, 2004; Verran, 2005; Liu et al, 2006).
chlorhexidine. Triclosan seems less effective, essential oils
Undoubtedly, the tongue is a major site of oral
and cetylpyridinium chloride are only effective up to 2 or
malodour production, whereas periodontal disease and
3 h. Metal ions and oxidizing agents, such as hydrogen
other factors seem only a fraction of the overall problem
peroxide, chlorine dioxide and iminium are active in
(Bosy et al, 1994; Stamou et al, 2005; Rosenberg, 2006).
neutralizing volatile sulphur-containing compounds. Zinc
The oral malodour arises from microbial degradation
seems to be an effective safe metal at concentrations of at
of organic substrates present in saliva, crevicular ﬂuid,
least 1%. The effectiveness of active ingredients in oral
oral soft tissues and retained debris. Major microbial
healthcare products is dependent on their concentration
degradation products are volatile sulphur-containing
and above a certain concentration the ingredients can
compounds (Tonzetich, 1977). Non-oral aetiologies of
have unpleasant side effects. Tonsillectomy might be
halitosis include disturbances of the upper and lower
indicated if (i) all other causes of halitosis are managed
respiratory tract, some systemic diseases, metabolic
properly; (ii) halitosis still persists and (iii) crypts in tonsils
disorders, medications and carcinomas (Tangerman,
are found to contain malodorous substrates.
2002). The three primary methods for measuring hali-
tosis are organoleptic measurement, gas chromatogra-phy and sulphide monitoring.
Before halitosis may be managed eﬀectively, an
accurate diagnosis must be achieved. An accuratediagnosis depends on analysis of data collected frompatient history and physical examination. The patient
history should contain main complaint, medical, dental
Halitosis is an unpleasant or oﬀensive odour emanating
and halitosis history, information about diet and habits,
from the oral cavity, leading to discomfort and psycho-
and third part conﬁrmation conﬁrming an objectivebasis to the complaint. Parts of the physical examinationare extraoral examination, intraoral examination with
Correspondence: Ms AMWT van den Broek, Department of Oral and
special attention paid to the tongue and the periodontal
Maxillofacial Surgery and Special Dental Care, Erasmus University
tissues, and upper respiratory tract examination. After
Medical Centre, PO Box 2040, 3000 CA Rotterdam, the Netherlands.
taking history and proper physical examination, halito-
Tel: +31 (0) 10 4633955, Fax: +31 (0) 10 4633098,
sis can be classiﬁed into categories of genuine (oral or
E-mail: email@example.comReceived 17 May 2006; revised 30 August 2006; accepted 1 October 2006
extraoral) halitosis, pseudo-halitosis and halitophobia
Management of halitosisAMWT van den Broek et al
(Murata et al, 2002). Pseudo-halitosis is obviously not
sulphur-containing compounds in morning breath after
perceived by others, although the patient stubbornly
consumption of a hard, dry bread roll, without any oral
complains of its existence. Halitophobia is diagnosed if
cleaning procedures (Suarez et al, 2000).
no physical or social evidence exists suggesting that
Extreme hyposalivation increased the production of
halitosis is present, whereas the patient persists in
volatile sulphur-containing compounds (Kleinberg et al,
believing that he or she has halitosis. Pseudo-halitosis
2002; Koshimune et al, 2003). However, between a
and halitophobia are further left out of consideration.
group of healthy patients with, and a control group
In this review, the available management methods of
without halitosis, no diﬀerences in salivary ﬂow rate
genuine halitosis, their eﬀectiveness and signiﬁcance for
were found (Oho et al, 2001). In an earlier study,
both clinicians and patients are presented and discussed.
variations in the level of unstimulated saliva could not
The available methods leading to lowering of oral
explain the variance in volatile sulphur-containing
malodour level can be divided into: usage of masking
compounds in a group of subjects with bad breath
products, mechanical reduction of micro-organisms and
(Rosenberg et al, 1991). A lower level of saliva during
their substrates, chemical reduction of micro-organisms,
the night is physiological. The level of saliva may be
and chemical neutralization of odorous compounds,
lowered as well by mouth breathing or snoring. The
eﬀect, bad morning breath, may be quite easily treated
Patients diagnosed as suﬀering from non-oral halitosis
by salivary stimulation. Salivary stimulation by eating
should be referred to a clinic for otorhinolaryngology or
breakfast, chewing or consuming acid food and saliva
internal medicine for appropriate treatment.
substitutes diminished the eﬀect of hyposalivation(Norris et al, 1984; Mackie and Pangborn, 1990; Klein-berg and Westbay, 1992; Edgar et al, 1994; Bots et al,
Usage of masking products only is never a real
Chewing gum may have a mechanical role in stimu-
management of halitosis. Nevertheless, some commer-
lating the salivary ﬂow and thus cleaning surfaces of
cially available products, such as mints, toothpastes,
teeth (Edgar et al, 1994; Reingewirtz et al, 1999; Bots
mouthrinses, sprays and chewing gums, attempt to
et al, 2004). However, by cysteine challenge testing was
control halitosis with pleasant ﬂavours and fragrances.
demonstrated that chewing of a gum without any active
Mints and chewing gum without active ingredients had
ingredient reduced halitosis only modestly (Wa˚ler,
no signiﬁcant eﬀect on tongue dorsum malodour 3 h
1997a). The basis of cysteine challenge testing is rooted
after use (Greenstein et al, 1997; Yaegaki et al, 2002).
in two fundamental aspects of the halitosis process.
After 3 h, similar organoleptic and sulphide monitor
When broken down by oral bacteria, cysteine produces
scores were observed for subjects who chewed either a
hydrogen sulphide. This volatile product, when ionized,
menthol-containing gum or a neutral unsweetened gum
contributes to the lowering of the oxidation–reduction
or no gum. A short masking eﬀect appeared only with
potential, which is the primary physico-chemical factor
the menthol-containing gum and may be the result of
favouring growth of Gram-negative oral anaerobes
the menthol (Reingewirtz et al, 1999).
(Kleinberg and Codipilly, 2002). Sugarless chewinggum had no eﬀect on volatile sulphur-containingcompounds concentrations (Yaegaki et al, 2002).
Mechanical reduction of micro-organismsand their substrates
Brushing the teeth, ﬂossing, using toothpicks
Mechanical reduction of micro-organisms and their
Mechanical cleaning of teeth, such as brushing the teeth,
substrates can be achieved by taking a solid breakfast,
ﬂossing and using toothpicks reduced the amount of
improving hyposalivation, using chewing gum, brushing
oral bacteria and substrates, thereby presumably redu-
the teeth, ﬂossing, using toothpicks, tongue cleaning and
cing oral malodour (Coil et al, 2002; Tanaka et al,
2003). However, clinical studies revealed that brushingthe teeth exclusively was not very eﬀective in reducing
Breakfast, improving hyposalivation and chewing gum
oral malodour scores (Yaegaki and Sanada, 1992c;
Fasting, during longer periods or during the night, was
Kleinberg and Codipilly, 2002). Furthermore, in sub-
suggested as being a physiological cause of temporary
jects free of caries, periodontal disease and tongue
halitosis, so-called bad morning breath, resulting from
coating, exclusively brushing the teeth had no appreci-
stagnation of epithelial and food debris on the soft oral
able inﬂuence on the concentration of volatile sulphur-
tissues. Passage of solid food over the surface of the
tongue could remove the tongue coating (Kleinberg and
compared with no brushing and rinsing the mouth with
Westbay, 1992). Subjects who exhibited early morning
halitosis, showed signiﬁcant reductions of hydrogensulphide by 60% and methyl mercaptan concentrations
by 83% 1 h after breakfast, without any oral cleaning
Various instruments can be applied to the tongue and by
procedures (Tonzetich and Ng, 1976). Subjects who
gentle pressure the majority of the tongue coating can be
were free of caries, periodontal disease and visible
scraped oﬀ (Yaegaki et al, 2002). Brushing the dorsum
of the tongue with a toothpaste was more eﬀective than
cally substantially reduced concentrations of volatile
brushing the teeth. Levels of volatile sulphur-containing
compounds could be reduced for at least 1 h by
mouthrinse produced signiﬁcant reductions in volatile
brushing the teeth and the tongue, and then rinsing
sulphur-containing compounds levels and in organolep-
the mouth with water (Tonzetich, 1971, 1978; Tonzetich
tic scores (Rosenberg et al, 1991; van Steenberghe et al,
and Ng, 1976). Other studies found a relationship
2001; Carvalho et al, 2004). Similar results with 0.12%
between tongue cleaning and the reduction of both
chlorhexidine-(di)gluconate were reported in combina-
organoleptic scores and levels of volatile sulphur-
tion with teeth and tongue brushing (Bosy et al, 1994;
containing compounds (Bosy et al, 1994; Suarez et al,
De Boever and Loesche, 1995). A mouthrinse containing
2000; Seemann et al, 2001). In patients with high levels
0.025% chlorhexidine was only moderate eﬀective,
of oral malodour, a regular toothbrush was statistically
whereas a concentration of 0.2% was much more
signiﬁcantly less eﬀective in tongue cleaning than a
eﬀective and even showed a tendency to improved eﬀect
device that brushed and scraped, or a scraper. Because
during 3 h (Young et al, 2003a). In adolescents with
of the limited duration of the eﬀect, the eﬃcacy
halitosis, organoleptic scores were signiﬁcantly reduced
remained questionable (Seemann et al, 2001). Scraping
after tongue cleaning with a hard toothbrush, wetted
the tongue after cysteine challenge testing reduced
with 0.12% chlorhexidine gluconate. It was not possible
halitosis only modestly, but brushing the tongue dorsum
to discriminate between the inﬂuence of the mechanical
was remarkably eﬀective (Kleinberg and Codipilly,
cleaning and the chlorhexidine (Cicek et al, 2003).
2002). Two weeks of tongue brushing or scraping by a
Therefore, it is uncertain if the results were due to
group of patients free of periodontitis resulted in
chlorhexidine, to cleaning of the teeth and the tongue, or
negligible reductions in bacteria on the tongue, whereas
to both. Chlorhexidine has the side eﬀects of tooth
the amount of tongue coating decreased signiﬁcantly.
staining and an unpleasant taste at concentrations from
Therefore, tongue cleaning seems to reduce the sub-
at least 0.2% (Jones, 1997; Young et al, 2003a). Tooth
strates for putrefaction, rather than the bacterial load
staining seems to be the result of a local precipitation
chromogens found within foodstuﬀs and drinks. Fur-
thermore, the activity of chlorhexidine is reduced in the
Professional oral health care was delivered by dental
presence of anionic agents, found in certain types of
hygienists once a week to a group of elderly patients,
toothpaste (Jones, 1997). Chlorhexidine concentrations
needing daily nursing care. The dental hygienists cleaned
in mouthrinses till 0.12% and mucosa exposure not
the teeth, the dentures, the buccal mucosa and the
exceeding 1 min twice a day, seem the best procedure to
tongue. They used hand scalers, an electric toothbrush,
protect tastes in clinical practice (Marinone and Savoldi,
an interdental brush and a sponge brush. A control
group received only denture cleaning and swabbing theoral cavity with a sponge brush. The professional care
reduced the levels of methyl mercaptan signiﬁcantly
(Adachi et al, 2002). Patients with periodontitis under-
phenylether, is the most widely used antibacterial and
went a one-stage full-mouth disinfection, combining
antiplaque agent in oral care products. It is insoluble in
scaling and root planing of teeth with the application of
water and has to be solubilized in organic solvents or
chlorhexidine, or consecutive root planings per quad-
detergents. Triclosan has a broad spectrum of antimi-
rant at a 1- to 2-week interval. The full-mouth disinfec-
crobial activity against bacteria, especially the Gram-
tion resulted in a faster and additional reduction
negative anaerobic species (Brading et al, 2004). The
in organoleptic scores, even after 2 months. However,
antimalodour eﬀect was not maintained when oils, oily
the levels of volatile sulphur-containing compounds
substances and uncharged detergents were used as
remained unchanged in both groups (Quirynen et al,
solubilizers (Young et al, 2002). A toothpaste contain-
ing 0.3% triclosan, 2.0% of a copolymer of polyvinylmethyl ether maleic acid and 0.243% sodium ﬂuoridehas been shown in double-blind clinical trials to be
signiﬁcantly better than a placebo toothpaste in redu-
Toothpastes and mouthrinses with antimicrobial prop-
cing organoleptic scores up to 12 h. However, the
erties can reduce oral malodour by reducing the number
beneﬁt of triclosan was relatively small, when compared
of micro-organisms chemically (Brading and Marsh,
with the placebo toothpaste. The copolymer is claimed
2003). Often used active ingredients in these products
to improve the retention of the triclosan within the oral
are chlorhexidine, triclosan, essential oils and cetylpy-
cavity (Niles et al, 1999; Sharma et al, 1999). Addition
ridinium chloride. Other eﬀective chemical agents are
of a special grade of silica did not further improve the
allylpyrocatechol, L-triﬂuoromethionine and dehydro-
eﬃcacy of the toothpaste in reducing organoleptic scores
(Sharma et al, 2002). The same toothpaste was associ-ated with a signiﬁcant decrease of hydrogen sulphide-
producing bacteria (Sreenivasan, 2003; Vazquez et al,
Chlorhexidine has a bactericidal and bacteriostatic
2003). An increase of volatile sulphur-containing com-
antiplaque eﬀect as a result of the dicationic nature of
pounds, occurring during the development of experi-
the chlorhexidine molecule (Addy and Moran, 1997;
mental gingivitis, was reduced by toothpastes containing
Jones, 1997). In several studies, a 0.2% chlorhexidine
0.3% triclosan (Nogueira-Filho et al, 2002). Raising the
Management of halitosisAMWT van den Broek et al
level of triclosan from 0.2% to 0.3% in a calcium
closely related to some oral mucosal lesions, such as oral
carbonate-based system, was suggested enhancing its
submucous ﬁbrosis, oral leukoplakia and oral cancer
(Jeng et al, 2001; Avon, 2004). Arecoline and safrole arethought to be the major toxic ingredients in betel quid
(Shieh et al, 2003). Study results exhibited marked
In the history of mankind, the Egyptians made exten-
depression of the volatility of methyl mercaptan by
sively use of essential oils for cosmetics as well as
betel quid and by a mixture of areca fruit and slaked
medicinal purposes. Among others the products were
lime paste. The depression was more marked when
used in the embalming process. During the following
increasing amounts of slaked lime paste were added or
periods, the medicinal properties of essential oils were
when the slaked lime paste was replaced with alkaline
applied for several health problems. Essential oils are
salts (Wang et al, 2001). A bioassay-guided fraction-
odorous, volatile products of plant secondary metabo-
ation yielded allylpyrocatechol as the major active
lism, many of them possessing strong antimicrobial
principle. This non-toxic product showed promising
properties (Kalemba and Kunicka, 2003). The short-
antimicrobial activity against obligate anaerobes (Ramji
term eﬀect of a mouthrinse containing essential oils and
menthol was evaluated in comparison with a placebo.
Based on its masking eﬀect, the experimental mouth-
rinse was more eﬀective against oral malodour than the
Methyl mercaptan arises from the bacterial metabolism
placebo during 0.5 h. At 1 h and up to 3 h, the greater
of methionine. It was shown with an in vitro study that
eﬀectiveness was maintained by a sustained reduction in
the growth of Porphyromonas gingivalis, a periodontal
the levels of odorigenic bacteria (Pitts et al, 1981, 1983).
micro-organism that produces large amounts of mer-
In clinical trials, an essential oil-containing toothpaste
captan, was strongly inhibited by L-triﬂuoromethionine,
as well as an essential oil-containing toothpaste with
a ﬂuorinated derivative of methionine (Yoshimura et al,
addition of 1% zinc citrate, were signiﬁcantly and
equally more eﬀective than a control toothpaste inreducing oral malodour from 1.5 to 2 h (Olshan et al,
Full-strength oxidizing lozenges were eﬀective in redu-cing tongue malodour over a period of 3 h (Greenstein
et al, 1997). The eﬀect may be due to the activity of
Quaternary ammonium compounds, such as benzalko-
dehydroascorbic acid, generated by peroxide-mediated
nium chloride and cetylpyridinium chloride, inhibit
oxidation of ascorbate present in the lozenges.
bacterial growth (Xiong et al, 1998). A chromatograph-ically determined signiﬁcant reduction in both the
hydrogen sulphide and methyl mercaptan levels of
subjects with good oral health was reached with amouthrinse, containing a quaternary ammonium com-
Toothpastes, mouthrinses, lozenges and other products
pound and alcohol (Solis-Gaﬀar et al, 1975). Daily
can reduce halitosis by chemically neutralizing odorous
usage of a two-phase oil–water mouthrinse containing
compounds, including volatile sulphur-containing com-
cetylpyridinium chloride reduced oral malodour over a
pounds. Often used active ingredients of these products
6-week period, when compared with a similar mouth-
are metal ions and oxidizing agents. Metals, such as
rinse without cetylpyridinium chloride (Kozlovsky et al,
zinc, sodium, stannous and magnesium are thought to
1996). A similar cetylpyridinium containing mouthrinse
interact with sulphur. The interaction forms insoluble
was eﬀective with an 80% reduction of volatile sulphur-
sulphides. The mechanism proposed is that metal ions
containing compounds during 3.5 h (Yaegaki and
oxidize the thiol groups in the precursors of volatile
Sanada, 1992c). Using cysteine challenge testing, a
sulphur-containing compounds (Tonzetich, 1978; Ng
mouthrinse containing cetylpyridinium plus domiphen
and Tonzetich, 1984). However, no positive correlation
bromide was minimally eﬀective in reducing halitosis
was found between metal ions aﬃnity for sulphur and
(Kleinberg and Codipilly, 2002). Also using cysteine
their inhibiting eﬀect on volatile sulphur-containing
challenge testing, a mouthrinse containing 0.025%
compounds (Wa˚ler, 1997b). Oxidizing agents might
cetylpyridinium was not more eﬀective than water,
reduce halitosis by reducing conditions necessary for
whereas a concentration of 0.2% was only moderately
metabolizing sulphur-containing amino acids to volatile
Betel quid, composed of Piper betel leaves or inﬂores-
Mouthrinses containing zinc were eﬀective in reducing
cences, fresh areca fruit and slaked lime paste, is a
oral malodour, as registered by the usual measurement
natural masticator in many countries. Tobacco can be
methods (Schmidt and Tarbet, 1978; Tonzetich, 1978).
added to the mixture, but betel leaves are also chewed
Zinc has to be present in a speciﬁc quantity. The
exclusively. Among others, it is used to remove halitosis
addition of 0.5 mg zinc acetate to a mouthrinse and a
(Wang et al, 2001; Ramji et al, 2002). However, epide-
chewing gum showed no signiﬁcant eﬀect, but the
miological studies showed that betel quid chewing is
addition of 2 mg resulted in signiﬁcant reductions of
45% of volatile sulphur-containing compounds levels
was reported of severe hypermagnesaemia, following
(Wa˚ler, 1997a). Using cysteine challenge testing, a
chronic gargling with Epsom SaltÒ, which resulted in
mouthrinse containing zinc chloride was eﬀective in
coma, cardiopulmonary arrest, and ﬁnally the death of
reducing halitosis, depending on the concentration. At a
concentration of 12 mM zinc, the eﬀectiveness was morepronounced and prolonged than at a concentration of
3 mM (Kleinberg and Codipilly, 2002). A mouthrinse
The potential of hydrogen peroxide for reducing the
containing 1% zinc was most eﬀective 1 h after use, but
levels of salivary thiol precursors of oral malodour was
was still very eﬀective after 3 h. The mouthrinse had a
investigated in 10 volunteers. The mean reduction by
somewhat unpleasant taste, whereas a 0.1% concentra-
1-min tooth brushing with a toothpaste containing
tion was found acceptable, but had only a minor eﬀect.
0.67% hydrogen peroxide and 5.48% sodium bicar-
The unpleasant taste may be overcome in commercial
bonate was 59% 0.5 h after application. However, it
products by masking with other ingredients (Young
was not possible to discriminate between the inﬂuence
of hydrogen peroxide and of sodium bicarbonate.
Other studies revealed that sodium bicarbonate is not
or only minimally active at concentrations below 20%
There is a long tradition of using sodium bicarbonate in
(Grigor and Roberts, 1992; Brunette et al, 1998). In
oral cleaning in Japan. Also in North America, many
subjects free of caries, periodontal disease and visible
people like to use sodium bicarbonate to clean their
tongue coating, mouth rinsing with 3% hydrogen
teeth. The popular name of this product is baking soda.
peroxide produced reductions of up to 90% of oral
The eﬀectiveness of toothpastes containing sodium
volatile sulphur-containing compounds in morning
bicarbonate in reducing oral malodour was indicated
breath for 8 h, measured chromatographically (Suarez
subjectively and also organoleptically and chromato-
graphically in reducing the amounts of volatile sulphur-containing compounds (Brunette, 1996). Toothpastes
containing 20% or more sodium bicarbonate had a
Chlorine dioxide (ClO2) has the power to oxidize the
signiﬁcant malodour-reducing eﬀect for time periods up
amino acids methionine and cysteine, both precursors of
to 3 h (Brunette et al, 1998). Additional studies are
volatile sulphur-containing compounds (Lynch et al,
needed to determine how sodium bicarbonate might be
1997). Using a liquid-air spray device, halitosis patients
applied most eﬀectively, for instance in toothpaste or
were treated with professional cleaning and irrigation of
mouthrinse. Furthermore, studies are needed to ﬁnd out
all soft tissues in the mouth with aqueous ClO2. The
the working mechanism of sodium bicarbonate. As yet,
clinical results were very good, but it was impossible to
it is not clariﬁed if the eﬀect is real bactericidal or
discriminate between the eﬀect of professional cleaning
a transformation of volatile sulphur-containing compo-
and the ClO2 (Richter, 1996). One double-blind, cross-
over study demonstrated that a single use of a ClO2-containing mouthrinse slightly reduced oral malodour in
patients with slightly unpleasant organoleptic scores
A toothpaste-containing stannous ﬂuoride was more
eﬀective than water, 8 h after tooth brushing, but the
double-blind, parallel group study in similar patients
patients still suﬀered from halitosis (Gerlach et al,
revealed that the same mouthrinse signiﬁcantly reduced
1998). Toothpaste containing stannous ﬂuoride and
volatile sulphur-containing compounds concentrations
amine ﬂuoride showed only minor changes in volatile
in mouth air for at least 8 h post rinsing (Frascella et al,
sulphur-containing compounds in morning breath of
2000). Using cysteine challenge testing, the eﬀectiveness
students who refrained from oral hygiene procedures
of a mouthrinse containing 1.0% sodium chlorite
(NaClO2) was more pronounced and prolonged thanat a concentration of 0.1% (Kleinberg and Codipilly,
Epsom SaltÒ, an agent originally developed in 1695 andderived from a well in Epsom, England, is used as a
cathartic in patients with impaired renal function or
Sanguinarine has been demonstrated to be eﬀective in
treating eclampsia of pregnancy (Morris et al, 1987;
chemically neutralizing volatile sulphur-containing com-
Nordt et al, 1996). It contains almost 100% magnesium
pounds, based on its unique chemical iminium structure.
sulphate. Toxicity is uncommon in healthy subjects at
Iminium is a non-metal oxidation catalyst, which, at
doses of around 10 g day)1. Minor elevation of serum
physiological acidity levels, is able to neutralize cysteine
magnesium, is characterized by nausea, headache,
as well as hydrogen sulphide and methyl mercaptan
ﬂushing, warmth and lightheadedness. At higher doses
the cardiovascular, respiratory and neuromuscular sys-tems are aﬀected. Magnesium in serum has the risk of
hypermagnesaemia. In large doses, magnesium acts like
If diﬀerent halitosis-reducing agents and ingredients
curare (Ferdinandus et al, 1981). In rare cases, people
operate by diﬀerent mechanisms, it is conceivable that
are using Epsom SaltÒ as a gargle for halitosis. A case
combinations may provide an enhanced or synergistic
Management of halitosisAMWT van den Broek et al
eﬀect. Some combinations have demonstrated enhanced
Table 1 Results of ten relevant studies comparing the effect of several
or synergistic eﬀectiveness in clinical trials.
A chlorhexidine and zinc mouthrinse had a strong eﬀect
on volatile sulphur-containing compounds and was
eﬀective for at least 9 h. Control rinses with chlorhex-
idine or zinc alone had a respectively moderate and
strong eﬀect for 1 h, but these eﬀects diminished with
time, respectively, fast and slightly (Young et al, 2003b).
Zn2+ > triclosanZn2+ > Na+/triclosan
A cetylpyridinium chloride and zinc mouthrinse had a
good synergistic eﬀect on volatile sulphur-containing
compounds levels after 1 h, but minimal above the eﬀect
Chlorhexidine, cetylpyridinium chloride and zinc
A solution containing chlorhexidine, cetylpyridium
chloride and zinc lactate, was more eﬃcient in reducing
organoleptic scores and levels of volatile sulphur-
containing compounds than a placebo mouthrinse (vanSteenberghe et al, 2001; Quirynen et al, 2002; Rolda´n
CHX, chlorhexidine; CPC, cetylpyridinium chloride; EO, essential oils;ClO
et al, 2003). The eﬀectiveness of this solution was
2, chlorine dioxide; Alc, alcohol; Sn2+, stannous; Na+, sodium;
Zn2+, zinc; Cu2+, cupric; Am+, amine; /, in combination with; >,
conﬁrmed in a double-blind placebo-controlled study
eﬀect signiﬁcantly better than …; ¼, eﬀect not statistically signiﬁcant
managing halitosis, though there are no clinical studies
The addition of 2% zinc to sodium bicarbonate con-
supporting this treatment. Only if other causes of
taining toothpastes diminished chromatographic meas-
halitosis are managed properly and halitosis still per-
urements signiﬁcantly after 3 h (Brunette et al, 1998).
sists, and if crypts in tonsils are found to contain
Using cysteine challenge testing, a mouthrinse freshly
malodorous substrates, tonsillectomy may be indicated
combining 0.1% NaClO2 and 6 nM zinc chloride, was
(Darrow and Siemens, 2002). Clinical studies are exclu-
much more eﬀective when compared to separate mouth-
sively reported on Helicobacter pylori infection, the
rinses with 0.1% NaClO2 or 6 nM zinc chloride. If the
main factor of inﬂammatory and ulcerative changes in
agents were combined and left for 4 days, the eﬀective-
the gastric mucosa (Hoshi et al, 2002). One report is
ness was drastically reduced and further deterioration
presented on management of malodorous intestinal
continued with time (Kleinberg and Codipilly, 2002).
gases by Escherichia coli (Henker et al, 2001).
Sanguinarine, containing iminium, in combination with
If clinical examination in 260 halitosis patients did not
zinc was 67% more eﬀective in reducing volatile
reveal any cause, a C13-urea test for detecting H. pylori
sulphur-containing compounds from incubated saliva
was carried out. Twenty-one tests were performed and
than zinc alone (Boulware and Southard, 1984).
seven (33.3%) were positive. This percentage was similarto the percentage of positive tests, found in the Ônormal’
Comparison of different (combinations of) agents
European population. Three patients started a therapy
The results of studies on the eﬀectiveness of oral
of amoxicillin, metronidazole and omeprazole. How-
healthcare products containing ingredients against hali-
ever, none of them noticed a decrease of halitosis
tosis are controversial and sometimes contradictory.
Ten relevant studies have been carried out to compare
Omeprazole and amoxicillin signiﬁcantly reduced
the eﬀect of several products (Rosenberg et al, 1992;
sulphide monitor and organoleptic scores in about
Kozlovsky et al, 1996; Gerlach et al, 1998; van Stee-
80% of H. pylori-positive dyspeptic patients, whereas
nberghe et al, 2001; Young et al, 2001; Borden et al,
mouth rinsing with chlorhexidine failed. The remaining
2002; Quirynen et al, 2002; Ro¨sing et al, 2002; Carvalho
20% of patients were positively treated by omeprazole,
et al, 2004; Rolda´n et al, 2004). The results of these
amoxicillin and clarithromycin. Unfortunately, these
patients were not examined for intraoral causes ofhalitosis (Ierardi et al, 1998).
In children with H. pylori infection, symptoms of
halitosis were assessed by a questionnaire. After 6 weeks
Reports on management of non-oral aetiologies are very
therapy by lansoprazole, amoxicillin and clarithromy-
scarce. Tonsillectomy is often cited as in indication for
cin, the halitosis scores were improved signiﬁcantly.
Eradication of bacteria was achieved in only 56% of
• oral malodour measurements at a minimum of
two appropriate time periods after baseline during
Helicobacter pylori-positive patients, who showed no
organic lesions on endoscopic examination and no
• organoleptic examination by two trained and calib-
atrophy of the gastric mucosa histopathologically,
rated odour judges or measurement of volatile
received omeprazole, amoxicillin and clarithromycin.
sulphur-containing compounds using gas chroma-
Endoscopic examination was carried out before and
4–6 weeks after therapy, and halitosis was investigated
• evidence of signiﬁcant reductions in oral malodour
by a questionnaire. Patients and their relatives were
questioned. The patients with conﬁrmed H. pylori
• evidence that at least 80% of the subjects demon-
eradication (74%), reported halitosis reduced from
strate a reduction to questionable or no oral
61% to 3%. Again, patients were not examined for
malodour at some time during the management
intraoral causes of halitosis (Serin et al, 2003).
• evidence that microbial resistance does not occur.
None of the studies mentioned in this review meet all
A girl with increased formation of malodorous intestinal
ADA-guidelines. Any future study should meet these
gases was successfully treated with a suspension of living
requirements in order to provide evidence-based results.
non-pathogenic bacteria E. coli. The concept of this
Nevertheless, within the limitations of the studies
treatment is to re-colonize the intestinal tract with
reviewed, some careful conclusions can be drawn.
normal or other intestinal bacteria and therefore
Undoubtedly, the basic management of halitosis is
suppress those contributing to the formation of
mechanically reducing the amount of micro-organisms
malodorous gases (Henker et al, 2001).
and substrates in the oral cavity, with a special attentionto the tongue. For subjects with healthy oral conditions
and only early morning halitosis, taking a solid break-fast is an eﬀective natural mechanical method.
The American Dental Association has established
Masking products are not eﬀective in reducing micro-
Acceptance Program Guidelines applying to products
organisms or their substrates and in neutralizing odor-
designed for managing oral malodour of non-systemic
ous compounds. With some masking products, such as
origin (American Dental Association, 2003; Wozniak,
menthol and mint, only a short-term masking eﬀect of
2005). Products considered are active chemical agents as
<2 h of halitosis can be expected.
well as mechanical means. Regarding safety and eﬃcacy
Chemical reduction of micro-organisms by antimi-
crobial ingredients in oral healthcare products is only
• clinical study of oral soft tissues and teeth;
temporary eﬀective. The eﬀectiveness of the ingredients
• monitoring oral ﬂora for the development of
is dependent on their concentration and above a certain
opportunistic and pathogenic organisms during a
concentration the ingredients may have unpleasant side
eﬀects. Good short-term results were reported with
3 weeks and 6 months, unless the product has
chlorhexidine. Triclosan seems less eﬀective. Essential
already been used for plaque and gingivitis control
oils and cetylpyridinium chloride are only eﬀective for
or whose active ingredient is generally recognized
short-time periods of up to 2 or 3 h. Allylpyrocatechol,
L-triﬂuoromethionine and dehydroascorbic acid could
• assessment of gingival inﬂammation with an appro-
be promising antibacterial agents. No clinical trials were
found comparing the eﬀect of antimicrobial ingredients
• examination of pathological conditions, such as
in oral healthcare products with the eﬀect of mechan-
allergic reaction, oral ulceration, candidiasis and
ically reducing bacteria and substrates. Chemical ingre-
dients of oral healthcare products seem most eﬀective
• examination of effect on hard tooth tissues and
when applied in addition to instructions in oral hygiene
restorative materials, such as staining, shade alter-
and professional mechanical cleaning (Quirynen et al,
• assessment of possible toxic or adverse effects;
Metal ions and oxidizing agents are active ingredients
• patient reports of any changes in taste, saliva ﬂow,
of oral healthcare products for chemically neutralizing
burning sensation, xerostomia or other characteris-
volatile sulphur-containing compounds. Again, the
eﬀectiveness of the active ingredients is dependent on
• two independent 3-week clinical studies utilizing an
their concentration and above a certain concentration the
ingredients can have unpleasant side eﬀects. Zinc seems
• crossover or parallel group study design;
to be an eﬀective safe metal at concentrations of at least
1%. Oxidizing agents, such as hydrogen peroxide, ClO2
• study population of individuals from 21 to 65 years
and iminium are reported to be eﬀective for longer
of age with intrinsic oral malodour of oral origin;
periods of time in patients with slightly unpleasant
• exclusion of subjects with advanced periodontitis
halitosis. These agents could be used in addition to daily
and subjects who smoke or wear oral appliances;
mechanical cleaning in order to reach a day-long eﬀect.
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D I A G N O S I S O F F E L I N E L O W E R U R I N A R Y T R A C T D I S E A S E ( F L U T D ) DIAGNOSTICS: ■ Obtain history■ Perform physical exam, complete urinalysis1 and serum chemistry panel■ If UTI, obtain urine culture and sensitivity (MIC if possible)■ Perform radiography2 and contrast studies Urolith(s)/crystalluria detected? Unknown or mixed composition Calciu
Konkurransen Unge Forskere Climate Change Coverage in British Newspapers Kjersti Skaaraaen Herberg Gjøvik videregående skole Abstract This essay is an investigation of how conservative British tabloid and qualitynewspapers skew the issue climate change. Through media analysis it discusses the researchquestion “ to what extent do the British newspapers The Daily Mail a