A recent review by Silva et al (Dental Elf – 28th Aug 2017) suggested a prevalence of halitosis of 31.8% (95%CI; 24.6 – 39.0%) although other sources suggest a figure as high as 65%. The oral cavity is the source of majority of cases of halitosis with 3-10% of cases resulting from ear, nose and throat problems. Drugs, food, local, systemic and psychological factors contribute to its aetiology. A wide range of mechanical and chemical hygiene methods have been tested.
The aim of this Cochrane review was to assess interventions to control halitosis due to oral diseases only
Methods
Searches were conducted in the Cochrane Oral Health’s Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, LILACS, CINAHL, the National Database of Indian Medical Journals, OpenGrey (1992 to 19 April 2019), the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov , the World Health Organization International Clinical Trials Registry Platform, the ISRCTN Registry and the Clinical Trials Registry with no restrictions on language or date of publication. Randomised controlled trials (RCTs) in patients over the age of 16 of any intervention to manage halitosis compared to another intervention or placebo with a minimum follow up of 1 week were considered. The primary outcomes were self- expressed (perceived) and organoleptic test (OLT) (human nose) assessments of halitosis using any validated malodour intensity scale. Data collection and analysis followed standard Cochrane methods.
Results
- 44 RCTs (36 parallel; 8 cross-over) reported in 55 publications were included.
- 39 studies were published in English, 2 in Mandarin and one each in Portuguese, Spanish and one in Arabic. The studies took place in 17 different countries.
- 3 studies were considered to be at low risk of bias, 25 at unclear risk and 16 at high risk.
- The interventions were classified into a number of areas; mechanical debridement, chewing gums, systemic deodorising agents, topical agents, toothpastes, mouthrinse/mouthwash, tablets, and combination methods.
- Mechanical debridement: for mechanical tongue cleaning versus no tongue cleaning, the evidence was very uncertain for the outcome dentist-reported organoleptic test (OLT) scores (MD -0.20, 95% CI -0.34 to -0.07; 2 trials, 46 participants; very low-certainty evidence). No data were reported for patient-reported OLT score or adverse events.
- Chewing gums: for 0.6% eucalyptus chewing gum versus placebo chewing gum, the evidence was very uncertain for the outcome dentist- reported OLT scores (MD -0.10, 95% CI -0.31 to 0.11; 1 trial, 65 participants; very low-certainty evidence). No data were reported for patient- reported OLT score or adverse events.
- Systemic deodorising agents: for 1000mg champignon versus placebo, the evidence was very uncertain for the outcome patient-reported visual analogue scale (VAS) scores (MD -1.07, 95% CI -14.51 to 12.37; 1 trial, 40 participants; very low-certainty evidence). No data were reported for dentist-reported OLT score or adverse events.
- Topical agents: for hinokitiol gel versus placebo gel, the evidence was very uncertain for the outcome dentist-reported OLT scores (MD -0.27, 95% CI -1.26 to 0.72; 1 trial, 18 participants; very low-certainty evidence). No data were reported for patient-reported OLT score or adverse events.
- Toothpastes: for 0.3% triclosan toothpaste versus control toothpaste, the evidence was very uncertain for the outcome dentist-reported OLT scores (MD -3.48, 95% CI -3.77 to -3.19; 1 trial, 81 participants; very low-certainty evidence). No data were reported for patient-reported OLT score or adverse events.
- Mouthrinse/mouthwash: for mouthwash containing chlorhexidine and zinc acetate versus placebo mouthwash, the evidence was very uncertain for the outcome dentist-reported OLT scores (MD -0.20, 95% CI -0.58 to 0.18; 1 trial, 44 participants; very low-certainty evidence). No data were reported for patient-reported OLT score or adverse events.
- Tablets: no data were reported on key outcomes for this comparison.
- Combination methods: for brushing plus cetylpyridium mouthwash versus brushing, the evidence was uncertain for the outcome dentist- reported OLT scores (MD -0.48, 95% CI -0.72 to -0.24; 1 trial, 70 participants; low-certainty evidence). No data were reported for patient- reported OLT score or adverse events.
Conclusions
The authors concluded: –
We found low- to very low-certainty evidence to support the effectiveness of interventions for managing halitosis compared to placebo or control for the OLT and patient-reported outcomes tested. We were unable to draw any conclusions regarding the superiority of any intervention or concentration. Well-planned RCTs need to be conducted by standardising the interventions and concentrations.
Comments
This new Cochrane review incorporates earlier Cochrane review on tongue scraping and mouthrinses for halitosis. While the new review has undertaken an extensive search and identified a good number of studies only 3 out of 44 were considered to be at low risk of bias Most of the comparison were single trials so no meta-analyses could be conducted and the certainty of evidence for all 36 comparisons was low to very-low. In addition, follow up in most of the included studies was short-term (1-4 weeks) with only 1 study reporting a longer follow up of 3 months.
Additional high quality RCTs are needed to increase the evidence to support interventions for this common problem but it is important that there is a standardisation of the most important outcome measures as well the use of similar methodology and reporting standards to enable better comparisons of different interventions in the future.
Links
Primary Paper
Kumbargere Nagraj S, Eachempati P, Uma E, Singh VP, Ismail NM, Varghese E. Interventions for managing halitosis. Cochrane Database of Systematic Reviews 2019, Issue 12. Art. No.: CD012213. DOI: 10.1002/14651858.CD012213.pub2 .
Other references
Dental Elf – 28th Aug 2017
Cochrane Oral Health Group Blog: What is the best way to prevent and control bad breath?
