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Year : 2015  |  Volume : 33  |  Issue : 3  |  Page : 218-222

Effect of different oral hygiene measures on oral malodor in children aged 7-15 years

1 Department of Pedodontics, College of Dental Sciences, Davangere, Karnataka, India
2 Department of Pedodontics, Maratha Mandal's Dental College and Research Centre, Belgaum, Karnataka, India

Date of Web Publication9-Jul-2015

Correspondence Address:
Dr. Pallavi Pujar
Maratha Mandal's Dental College and Research Centre, Belgaum - 590 010, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-4388.160370

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Purpose: To evaluate the effect of various oral hygiene measures individually and in combination in reducing oral malodor. Materials and Methods: A total number of 120 children diagnosed as having oral malodor (oral malodor scores 2 and above) were included in the study. Children were then grouped under four oral hygiene categories (tooth brushing, tongue cleaning, mouth rinsing, and a combination group). There were 30 children in each group. The children were asked to perform oral hygiene methods individually and in combination. The children were then reassessed for oral malodor 2 h later. The results were analyzed and compared. Results: Both individual oral hygiene measure or in combination of tooth brushing, tongue cleaning, and mouth rinsing; all were effective in reducing oral malodor. Significant reduction (P < 0.05) in oral malodor was seen when all three oral hygiene measures performed together. Conclusion: Oral malodor was significantly reduced after performing oral hygiene measures individually, but reduced more when used in combination.

Keywords: Age, mouth breathing, oral malodor, oral hygiene measures, oral hygiene status, tongue coating

How to cite this article:
Patil PS, Pujar P, Subbareddy V V. Effect of different oral hygiene measures on oral malodor in children aged 7-15 years. J Indian Soc Pedod Prev Dent 2015;33:218-22

How to cite this URL:
Patil PS, Pujar P, Subbareddy V V. Effect of different oral hygiene measures on oral malodor in children aged 7-15 years. J Indian Soc Pedod Prev Dent [serial online] 2015 [cited 2023 Feb 1];33:218-22. Available from: http://www.jisppd.com/text.asp?2015/33/3/218/160370

   Introduction Top

Oral malodor can be an embarrassing problem for children, as well as parents. Bad breath, or halitosis, is any unpleasant odor emerging from the mouth, either caused by intra- and/or extraoral factors. [1] Although malodor is multifactorial in origin, 90% of it originates from the mouth itself. Certain chemical end products of bacterial putrefaction, known as volatile sulfur compounds (VSCs), smell foul and have been determined to be responsible for offensive odor. VSCs; such as hydrogen sulfide (H 2 S), methyl mercaptan (CH 3 SH), dimethyl sulfide ((CH 3 ) 2 S), dimethyl disulfide, and sulfur dioxide (SO 2 ); make up more than 90% of the putrid odors from the oral cavity. Nonsulfur containing compounds such as cadaverine, putrescine, indole, and skatole have also been implicated in oral malodor. [2],[3] Organoleptic measurement is a sensory test scored on the basis of the examiner's perception of a subject's oral malodor. [4],[5],[6],[7],[8],[9],[10],[11],[12] Thus, the most reliable and practical procedure for evaluating a patient's level of oral malodor is organoleptic measurement. [13] The main treatment goal is to reduce the microbial load in the mouth by both mechanical and chemical oral hygiene methods. Limited literature exists regarding oral malodor in children. The oral hygiene measures to reduce malodor in children have not yet been studied. Which oral hygiene measure would be superior in reducing oral malodor in children and at the same time be easy and practical to be performed in a child, needs to be evaluated. The purpose of this study was to evaluate the effect of three oral hygiene measures; tooth brushing, tongue scraping, and mouth rinsing on oral malodor in children. The combined effect of performing all three oral hygiene methods (i. e., combination of chemical and mechanical oral hygiene methods) together on malodor in children was also assessed.

   Materials and Methods Top

The present study was conducted in the Department of Pedodontics and Preventive Dentistry, College of Dental Sciences, Davangere, Karnataka. The research protocol of the study was reviewed and approved by the ethical committee of the institution.

A total number of 900 systemically healthy school children (463 males and 437 females) in the age range of 7-15 years were examined. The children were assessed for malodor. Out of which, 120 children with the malodor scores of 2 and above were diagnosed as having oral malodor were included in the study. The children were divided in to four groups of 30 children in each group.

The parents of the children were informed about the nature of the study and consent for participation of the children was obtained during the survey. The parents were given a questionnaire to fill about the medical history, habitual mouth breathing, and frequency of tooth brushing.

Inclusion criteria

Subjects should be aged between 7 and 15 years and have an oral malodor score of 2 and above.

Exclusion criteria

  • Subjects who had received antibiotic treatment within the past 3 weeks, who showed evidence of any systemic disease that could influence oral malodor.
  • Subjects who had an estimated organoleptic rating of 0-1(described below).

A survey proforma was created to gather data from the sample. The children were examined by the single examiner. The selected volunteers were assessed and recorded for the following clinical parameters from 10:30 am to 12:00 noon. Organoleptic measurement was carried out as recommended by a single calibrated examiner. It was done by sniffing the patient's breath and scoring the level of oral malodor. Children were instructed to abstain from taking antibiotics for 3 weeks before the assessment; to abstain from eating garlic, onion, and spicy foods for 48 h before the assessment; and to avoid using scented cosmetics for 24 h before the assessment. Patients were instructed to abstain from ingesting any food or drink, to omit their usual oral hygiene practices, and to abstain from using oral rinse and breath fresheners. [14]

A scale commonly used in breath malodor research is the 0-5 intensity scale. The scores being:

0-Absence of odor,

1-Questionable odor,

2-Slight malodor,

3-Moderate malodor,

4-Strong malodor, and

5-Severe malodor.

Score two and above were diagnosed as halitosis. [15]

The four groups of 30 children each were asked to perform oral hygiene measures as follows:

Group 1: Children were asked to brush their teeth with toothbrush (Colgate) using fluoridated toothpaste (Colgate Total - sodium fluoride-1,000 ppm of available fluoride) PVM/MA.

Group 2: Children were asked to rinse their mouth with a chlorhexidine mouth rinse (Rexidine-0.2% w/v chlorhexidine gluconate solution) for 30 s. Copolymer (Gantrez), silica, sorbitol, and triclosan (Colgate-Palmolive Co.).

Group 3: Children were asked to clean their tongue with tongue cleaner (Ajanta tongue cleaner). Group 4-Children were asked to perform all three oral hygiene measures, tongue cleaning followed by tooth brushing and mouth rinsing. Oral malodor scores were recorded again after 2 h of carrying out the oral hygiene measures.

Statistical analysis

All data were analyzed using the Statistical Package for Social Sciences (SPSS version 16.0). Results were compared as mean and standard deviations and number and percentages. Intragroup comparisons were made by paired t-test. One-way analysis of variance (ANOVA) was used for multiple group comparisons. Categorical data was analyzed by chi-square test. Multiple logistic regression was performed to assess the interaction effect of different parameters on malodor. α was set at 0.05, which means, a P - value of less than 0.05 was considered statistically significant.

   Results Top

Effect of various oral hygiene measures in reduction of oral malodor has been presented in [Table 1]. All the three oral hygiene measures were effective in reducing the oral malodor in children. Tongue cleaning yielded 72% reduction, all three combined oral hygiene measures together yielded 67% reduction in oral malodor, tooth brushing yielded 57% reduction, and mouth rinsing reduced 46% of oral malodor in children.
Table 1: Effect of various oral hygiene measures in reduction of oral malodor

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Intergroup comparisons of difference in malodor reduction after oral hygiene practices have been presented in [Table 2]. When each group was combined with each other, the difference between the tongue cleaning group and all three oral hygiene combination group was insignificant, that is, both the percentage reduction in the oral malodor for tongue cleaning and the 'combined group' was comparable (almost same). Mouth rinsing and the 'combination group' when compared, the P - value was significant, indicating that the combination group was effective and mouth rinsing can just be used as an adjunct. 'Combination group' was also effective as compared to 'tooth brushing group'.
Table 2: Intergroup comparisons of difference in malodor reduction after oral hygiene practices

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   Discussion Top

The aim of treatment of oral malodor is to reduce the overgrowth of microorganisms in the oral cavity, with concomitant reduction in the formation of volatile compounds. [16] This may be accomplished by mechanical or chemical methods. [17] Mechanical reduction [18] of microorganisms through improved oral hygiene procedures, both professional and personal, has been associated with reduced oral malodor. [19],[20],[21] The various oral hygiene measures used in the present study were tooth brushing; tongue cleaning; mouth rinsing; and combination of all three, tooth brushing followed by tongue cleaning and mouth rinsing. These methods were employed in the study as they are easy and more practical to be recommended in children as they have limited manual dexterity as compared to adults.

Colgate total dentifrice (Colgate Total - sodium fluoride (1,000 ppm of available fluoride), PVM/MA Copolymer (Gantrez), silica, sorbitol, and triclosan (Colgate-Palmolive Co.) was used along with soft and medium bristled toothbrush because it has shown effective control of oral malodor, 12 h after brushing the teeth. Sreenivasan using Colgate total dentifrice reported a significant decrease of all salivary bacteria and hydrogen sulfide producing odorigenic bacteria following use of this triclosan/copolymer dentifrice. These results may be attributed to the triclosan and sodium lauryl sulfate contained in the dentifrices as both have shown anti-VSC effect. In our study 57% reduction of malodor was seen with tooth brushing in children.

Various chemical plaque control agents have been used as an adjunct to combat oral malodor. Chlorhexidine is considered the golden standard for oral antiseptics. Chlorhexidine digluconate is useful in decreasing plaque and gingivitis, and therefore has shown significant improvement in reducing oral malodor. [22],[23],[24] The success of chlorhexidine, a cationic bisbiguanide, is based on its high intraoral substantivity, and its bactericidal and bacteriostatic activity. Studies have reported successful reduction of oral malodor using chlorhexidine. [25],[26] Chlorhexidine mouth wash (Rexidine-0.2% w/v chlorhexidine gluconate solution) was used in the present study. In our study, 46% reduction in oral malodor was seen in children. It is recommended that mouth rinsing can be used as an adjunct to mechanical oral hygiene in children to reduce oral malodor in children.

A manual tongue cleaner was used in the present study to clean the tongue. The dorsum of the tongue is a large surface for oral accumulation of microorganisms and debris. There is existence of an association between tongue microorganisms and those present in saliva. The anaerobic microbiota of the tongue biofilm is one of the main reasons for the release of sulfur compounds, which are directly involved in the occurrence of oral malodor. A study done to evaluate the effectiveness of new toothbrush design with tongue scrapper versus a conventional tongue scrapper in improving breath odor have shown equal effectiveness of both; and also, tongue cleaning reduced the facultative aerobic and anaerobic microbiota on the tongue surface. The dorsoposterior surface of the tongue has been identified as the principal location for the intraoral generation of VSCs. [13] Fissures and crypts of the tongue harbor large amounts of Porphyromonas gingivalis, Prevotella intermedia, spirochetes, etc. [28] These surface irregularities protect the bacteria from the flushing action of saliva and possess low oxygen levels, which facilitate their growth. [25] This is an excellent putrefactive habitat for gram-negative anaerobes that metabolize proteins as an energy source. The bacteria hydrolyze the proteins to amino acids containing sulfur functional groups, which are the precursors to VSCs. [26],[27],[28],[29],[30] Brushing the tongue significantly reduced concentrations of VSCs, such as methyl mercaptan; and to a lesser extent, hydrogen sulfide. Studies have shown that tongue brushing was very effective in reducing 70% of the volatile sulfides as compared with about 30% reduction that resulted from tooth brushing. In our study, 72% reduction of malodor was seen with tongue cleaning by tongue cleaner and 57% malodor reduction with tooth brushing. However, tongue cleaning by tongue cleaner is different from tongue cleaning by toothbrush.

The results of our study suggest that reduction in oral malodor was superior with tongue cleaning followed by tooth brushing and least being mouth rinsing when each oral hygiene measure was tested individually. However, the combination of all the three oral hygiene measures was most effective in reduction of malodor in children. This was because carrying out all oral hygiene measures had an additive effect as it acted on all the etiologic niches in the oral cavity from tooth surface to tongue to microbial load. A combination of mechanical and chemical methods is effective in reducing oral malodor in children. The treatment recommended in children for oral malodor would be a combination of tooth brushing, tongue cleaning, and mouth rinsing. All three oral hygiene habits have to be inculcated in the child's routine for the treatment of oral malodor. However, the long-term effects of performing these oral hygiene measures on oral malodor with the bigger sample size in children have to be studied.

Almost a billion per year is spent in developed and developing countries on mouth (oral) rinses, mints, and related over-the-counter products to manage bad breath. It would be preferable to spend this money on a proper diagnosis and etiologic care instead of short-term and even inefficient masking attempts. We cannot devise one effective measure of oral hygiene to combat oral malodor because of the multifactorial nature of oral malodor. In most cases, good professional oral care from childhood combined with a daily regimen of oral hygiene can lead to improvement. Although 90% of all oral malodors originate in the mouth, parents visiting the dentist complaining about oral malodor in children are few. Furthermore, the parents as well as children have to be made aware that oral problems and poor oral hygiene caused oral malodor. They have to be provided adequate education concerning the causes of oral malodor and motivated to visit the dentist and receive dental-oral treatment and oral hygiene instructions regularly. To improve the oral health, effective and pragmatic community-based oral diseases prevention programs should be implemented and instructions for the prevention of oral malodor should be included in oral health promotion activities. The parents and the children have to be made aware that oral malodor can be treated and prevented provided proper oral hygiene measures are implemented by them. The pedodontists also should address the problem seriously and tackle this socially embarrassing problem which might affect the social mingling of the child; and hence, the overall development of the personality of the child.

   Conclusions Top

Tongue cleaning is superior as compared to tooth brushing and mouth rinsing. Combination of the above oral hygiene measures yielded much more superior results in children. The present study supports the potential use of combination (mechanical and chemical) of oral hygiene measures for reduction of malodor in children. However, further studies evaluating the long-term effects of performing these oral hygiene methods on malodor in children must be carried out.

   References Top

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  [Table 1], [Table 2]

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