Vol. 26, no. 3, 691-697 (2013)

INTERNATIONAL JOURNAL OF IMMUNOPATHOLOGY AND PHARMACOLOGY

USE OF ORAL CHROMATM IN THE ASSESSMENT OF VOLATILE SULFUR COMPOUNDS IN PATIENTS WITH FIXED PROSTHESES B. SINJARI, G. MURMURA, S. CAPUTI, L. RICCI, G. VARVARAandA. SCARANO

Department ofMedical, Oral and Biotechnological Sciences, University ofChieti-Pescara, Italy Received July 19, 2012 - Accepted May 20, 2013 Prosthetic rehabilitation improves the patient's quality of life and oral health. The purpose of the present study was to assess the production of volatile sulfur compounds (VSCs) using Oral Chroma" in patients wearing provisional and permanent fixed prosthesis, who were treated or not, with supportive non-surgical periodontal therapy. A total of 10 healthy patients not affected by periodontal disease and who needed the restoration of at least two edentulous single sites were included in the present study. Registrations of VSCs were carried out with a Gas Chromatograph OrabChrema" (Oral Chromat'", Abimedical, Abilit Corp., Osaka, Japan) one month after placement of the provisional restoration (group 1) and one month after placement of the final restoration (group 3). After each measurement, professional oral hygiene was carried out both on patients with provisional (group 2) and permanent prostheses (group 4) and VSC values were registered. The results showed that there were no statistical significant differences in the VSC quantity between groups with temporary or permanent prostheses. Meanwhile, statistically significant differences were found in VCS values between groups before and after the professional health care session (p < 0.05). Also it was observed that dimethyl sulphide (CH3)2S was present in all the study groups. The present preliminary study suggests that Oral'Chroma" produce a comprehensive assessment ofVSC in the clinical diagnosis of halitosis and that professional oral hygiene seems to influence VSC production. However, further clinical long-term studies with a larger sample size are necessary for a better understanding of halitosis manifestation in patients wearing provisional and permanent fixed prosthesis. (VSCs) are the most extensively studied (4). Among the VSCs the most important components in the development of halitosis are hydrogen sulphide (HzS), methyl mercaptan (CH 3SH), and dimethyl sulphide (CH 3)zS) (2). The main methods of analyzing oral malodour are organoleptic measurement, gas chromatography (GC) and sulphide monitoring (e.g. Halimeter). Organoleptic measurement is a sensory test scored on the basis of the examiner's perception of a subject's oral malodour; the most widely used scoring system

Halitosis is a common disorder affecting 1030% of the population (1). Notwithstanding its multifactorial etiology, it is widely accepted that oral malodor originates from the oral cavity in approximately 80-90% of all cases (2, 3). Oral malodour is produced by the degradation of organic substrates (i.e. sulfur-containing peptides, amino acids in saliva, gingival crevicular fluid, blood and desquamated epithelial cells) by anaerobic bacteria, producing a range ofmalodorous molecular components ofwhich the volatile sulphur compounds

Key words: halitosis, oral croma, oral hygiene, prostheses restoration, volatile sulphur compounds Mailing address: Dr. Bruna Sinjari D.D.S., PhD Dept. Medical, Oral and Biotechnological Sciences, University "G. d' Annunzio" Chieti-Pescara, Via dei Vestini, 31 66100 Chieti, Italy Tel.: +39 08713554125 Fax: +39 0871 3554070 e-mail: [email protected]

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Copyright © by BIOLlFE, s.a.s, This publication andlor article is for individual use only and may not be further reproduced without written permission from the copyright holder. Unauthorized reproduction may result in financial and other penalties DISCLOSURE: ALL AUTHORS REPORT NO CONFLICTS OF INTEREST RELEVANT TO THIS ARTICLE.

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for ranking halitosis is the Organoleptic Score popularized by Rosenberg and McCulloch (5). Currently, Gas Chromatography (GC) is considered to be highly objective, reproducible, and reliable for measuring oral malodour (6); it is considered the gold standard because it specifically determines the concentrations of VSC, the main cause of oral malodour (7). However, GC is not easily implemented in dental practice due to its relatively high cost, the requirement of highly trained persons, extensive procedures and its cumbersome equipment (3); therefore, portable gas-chromatograph (Oral Chroma''Y, Abimedical, Abilit Corp., Osaka, Japan) was developed to measure sulphur-containing compound levels inside the mouth (8). Compared to a standard gas chromatograph it is highly sensitive, low cost and uses air instead of a special gas carrier (9). A recent study showed that the Oral Chroma" may produce a more comprehensive assessment of VSC produced by oral microflora than the Halimeter (10). Intraoral conditions, such as poor oral hygiene, tongue coating, extraction sites, necrotic tissues, deep carious lesions, mucosal ulcerations, healing oral mucosa wounds, impacted food or debris, prosthetic appliances, imperfect dental restorations, oral carcinoma, pericoronitis, peri-implant disease, gingivitis and periodontitis, contribute to oral malodors (11-15). In fact, fixed prostheses may cause halitosis due to food retention, plaque formation and periodontal tissue inflammation. In addition, faulty restorations, particularly if ill-fitted or decemented, may even intensify the problem by allowing bacterial accumulation and proliferation in the inner gaps between the prepared tooth and the restoration, forming a reservoir of anaerobic bacteria (16). In particular, the porous nature of acrylic appliances, such as fixed temporary prostheses, may increase the tendency to adsorb salivary proteins, resulting in bacterial adhesion and major plaque accumulation (17). Therefore, prosthetic rehabilitation is very important to oral health, but in literature there is a lack of information on its role in halitosis development. Therefore, the aim of the present study was to evaluate the effects ofprofessional hygiene in patients with no periodontal disease, wearing provisional or permanent fixed prosthesis, assessing the production of VSC using Oral Chroma TM.

MATERIALS AND METHODS Study design Twenty subjects (10 males and 10 females, age ranging from 18 to 60 years, mean age 31 years), who needed fixed prosthetic rehabilitation, were visited at the Department of Periodontics of University "G. d' Annunzio" ChietiPescara, Italy, and were selected for this study. The inclusion criteria were: healthy patients with no periodontal disease, in need of prosthetic rehabilitation in at least two single sites. In order to evaluate the tissue clinical conditions a single calibrated periodontist (GV) evaluated the following clinical information: probing depth (PD) in millimeters (mm), presence or absence of bleeding on probing (BOP) and plaque index (PI). The site was considered clinically healthy when the probing depth was ::;3 mm, plaque index score was = I and there was no presence of bleeding upon probing. Exclusion criteria were: severe systemic diseases (diabetes mellitus, gastrointestinal disorders, respiratory dysfunction, neoplasia, various carcinomas, etc.), smoking more than 10 cigarettes a day, pregnancy or lactating, history of antibiotics or non-steroidal anti-inflammatory drugs for the previous 3 months. Patients who had less than 20 teeth, or untreated teeth and caries, orthodontic appliances and deep-fissured tongue were also excluded. The purpose and procedures of the study were explained to all potential study volunteers and written informed consent was obtained from all 20 study participants. Treatment procedure The oral malodor measurements of all patients were carried out one month after placement of the provisional restoration and one month after delivery of the final restoration. To reduce confounding problems, after each measurement, professional oral hygiene was carried out by a dental hygienist eliminating only the plaque, without polishing the teeth. In total, each patient received 4 measurements; therefore, the patients were divided as follows: Group I: patients with temporary prosthesis, without professional hygiene Group 2: patients with temporary prosthesis after professional hygiene Group 3: patients with final prosthesis without professional hygiene Group 4: patients after final prosthesis after professional hygiene All patients were given oral hygiene instructions on tooth and interdental brushing, including tongue cleansing. Instructions consisted of cleaning their tongue from the terminal sulcus to the front using a soft, smallheaded toothbrush with gentle force and strokes before

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tooth brushing (18). The Simplified Gas chromatography (GC) method was used for the oral malodor measurement. YSC measurements were taken between 9 and II a.m. because morning breath odor has been used as a standard mouth breath for oral malodor (19). The patients were advised to abstain from food or drink on the morning ofthe assessment day and to refrain from their usual oral hygiene practice the morning of the day of the measurements. Subjects were also instructed to refrain from eating strong smelling foods for at least 48 h, using strong perfumes for 24 h, and drinking alcohol for 12 h prior to the measurements. VSC measurement A portable gas chromatograph device (OralChromaw, Abimedical, Abilit Corporation, Osaka City, Japan) was used to measure YSC quantity. Sample collection was taken using a disposable syringe (all-plastic syringes, 1 ml), which was inserted into the oral cavity of the patient. The subjects was invited to nose breathe while keeping the oral cavity sealed and unventilated for at least 1 minute. After one minute the piston was pulled to the very end of the syringe, and the syringe was filled again with a breath sample. The process of pulling the piston twice is necessary to eliminate the unwanted air in the syringe. Then the breath sample (0.5 ml) was injected into the measuring device and the measurement was started. The measurement process was completed in 8 minutes. Upon completion a graph was shown on the PC monitor (Samsung N 150, Samsung Town, Seoul, South Korea) and then the values of concentration of the three gases (H2S, CH 3SH and (CH3)2S) were displayed in either ng/lO ml or ppbv (nmol/mol).

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1 presented higher VSC values (0.778±0.8207) than group 2 (0. 142±0.2422), with statistically significant differences (p < 0.05) (Table II). The total mean concentration of (CH 3)zS was higher than HzS and CH3SH values in the two groups, with statistically significant differences (p < 0.05) . VSCs values in patients with final restoration before (group 3) and after (group 4) professional oral hygiene In group 3, VSC values were prevalent (0.728±1.191) with statistically significant differences compared to group 4 (0.145±0.283) (p < 0.05) (Table III). The (CH 3)zS mean values were higher than HzS and CH 3SH values in the two groups, with statistically significant differences (p < 0.05) The total mean concentration of CH 3SH was statistically (p < 0.05) lower than HzS and (CH 3)zS values in the two groups. In particular, in group 4 the CH 3SH values were O. Comparison VSC values between all groups Bonferroni's test for multiple simultaneous comparisons showed a statistical significance (p < 0.05) between groups 1 and 2, and between groups 3 and 4 (Table IV). There were no statistically significant differences in the VSC quantity between patients with temporary (group 1) or permanent (group 3) prostheses.

DISCUSSION Statistical analysis Statistical analysis of the values obtained was carried out using analysis of variance (ANaYA) and significant differences were accepted as p < 0.05. The results are presented as mean (M) ± standard deviations (SD) and standard error of the mean (SEM). Bonferroni's test for multiple simultaneous comparisons was also performed and significant differences were accepted as p < 0.05. The results are presented as mean ± standard deviations and error.

RESULTS VSC values in patients with provisional restoration before (group J) and after (group 2) professional oral hygiene The total VSC value expressions were different between the two examined groups (Table I). Group

In literature, the aSSOCIatIOn between manifestation or intensity of oral malodor and dental prosthetic restorations has been evaluated by only a few studies especially regarding the patients wearing complete and removable dentures (17, 20, 21). It was shown that types of malodor-producing bacteria, not normally considered important members of the oral microbiota (i.e., Enterobacteriaceae), severely increased in the case of denture wearers (17). In addition, oral malodor levels among complete removable denture wearers can be reduced by the maintenance of good oral and denture hygiene as well as the removal of dentures overnight (20, 21). Only one study conducted by Zigurs et al. (2005) evaluated the relationship between construction of fixed bridge dentures and the intensity of halitosis

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Table I. VSC values (ng/10ml) in patients with fixed provisional prosthesis before (Group 1) and after (Group 2) oral professional hygiene.

Group I VSC ngilOml

I VSC

I CH3SH

HzS 0.62±1.20

I M±SD

I 1.81±2.62

Group 2 VSC ngilOml

I (CH3)zS 12.58±2.72

HzS 0.14±0.28

I CH3SH

I (C H3)ZS

10.06±0.45

10.80±1.06

M: Mean; SD: Standard Deviation

Table II. Mean values ± standard deviations of VSC values in groups, the statistical analysis by the means ofanalysis of variance (ANOVA) test.

Group

NPt

I 2 3 4

M±SD 0.778±0.8207 0.142±0.2422 0.728±1.191 O.145±O.283

20 20 20 20

SEM 0.2595 0.07658 0.3766 0.08948

N Pt: Patients number; M: Mean; SD: Standard Deviation; SEM: Standard Error ofthe Mean

Table III. VSC values (ng/10ml) in patients with fixed definitive prosthesis before (Group 3) and after (Group 4) oral professional hygiene.

Group 3 VSC ngilOml

I VSC I M±SD

I CH3SH 10.27±0.31

HzS 0.77±0.87

Group 4 VSC ng/IOml

I (CH3hS 10.92±1.48

HzS 0.11±0.23

I CH3SH

I (CH3)ZS

lo±o

10.32±0.56

M: Mean; SD: Standard Deviation

Table IV. Comparison of VSC values between all groups.

Groups I vs 4 I vs 2 I vs 3

Difference of means 102.7 - 0.329 = 102.4 102.7 - 0.806 = 101.9 102.7 - 0.92 = 101.8

Test 4.444 4.423 4.418

P values < 0.05< 0.05> 0.05°S

*significance; "' not significant Significance ofdifference between groups was measured using Testfor multiple simultaneous comparisons by Bonferroni showed a statistically significance (p < 0.05)

manifestations. These Authors investigated the basic hygiene requirements for construction of fixed dentures in order to exclude retention of food particles and avoid bad breath in patients wearing dental prostheses; they concluded that the type and form of fixed bridge denture intermediate parts and relations with gums are determinant criteria of oral

health, hygiene and fresh breath (12). Indeed, to the best of our knowledge, this is the first study to investigate the influence of both temporary and permanent fixed prostheses on halitosis, assessing the VSCs. The present data demonstrated that there were no statistically different values in production of VSCs between groups with

Int. J. Immunopathol. Pharmacol.

temporary and permanent prostheses, when the measurements were carried out both before and after professional oral hygiene. This study investigated only the short-term effects of professional oral hygiene on oral malodor treatment in the presence of temporary and permanent prostheses. The evaluation of VSC may be influenced by the multifactorial etiology of oral malodor, tongue coating, plaque accumulation, plaque retention factors, gingivitis and periodontitis (22). In particular, the tongue coating is also an important factor for oral malodor production in both periodontally compromised and healthy individuals (14). A study demonstrated that tongue coating was associated with halitosis in more than 60% of 2,000 patients of a breath clinic, alone or associated with periodontal inflammation (23). Therefore, in the present study the patients were instructed to correctly clean the tongue, avoiding the alterations of VSC values by the presence of plaque on the tongue. In view of this clinical background, oral hygiene instructions were given to all the study subjects. Indeed, in addition to mechanical treatment of tongue coating, handling strategies to control oral malodor are primarily directed at reducing total bacterial amounts in the oral cavity and are focused on improving the sufferer's oral hygiene (7, 24). For patients with complicating factors, such as fixed and! or removable prosthesis or for elderly people, more advanced hygiene methods should be employed, including oral irrigation and sonic or ultrasonic toothbrush (12). In the present study the reduction was evaluated ofbacterial counts by mean of professional oral hygiene, demonstrating a statistically significant reduction of the VSC values, both in patients with temporary and permanent prostheses. Recently, Zigurus et al. showed that hygienic measures (intensified cleansing of teeth, visits to hygienist) would not cause substantial changes in oral cavity until the etiological factor, such as the existing low quality denture, was eliminated (16). In addition to cleansing techniques, antimicrobial components such as chlorhexidine, cetylpyridinium chloride, triclosan, essential oils, chlorine dioxide, zinc salts, benzalkonium chloride, hydrogen peroxide and sodium bicarbonate have been used to control the oral bacteria involved in the breakdown of salivary proteins and food debris (25). It has been demonstrated that the intensity of

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clinical bad breath is significantly associated with intra-oral VSC levels (26, 27). In the present study, an evaluation of hydrogen sulfide (HzS), methyl mercaptan (CH3SH), and dimethyl sulfide [(CH3)zS] by mean Oral Chroma™ was performed. The main advantage of the OralChroma™ is that it can make a distinction between different sulphur gases, which can be helpful for a differential diagnosis (3). The presence of HzS and CH3SH mainly contribute to intra oral halitosis; in particular, methyl mercaptan is the major oral malodour component associated with periodontal disease (28), while (CH3)zS is a compound more associated with extra-oral causes of halitosis (29, 30). In the present study, the VSC mostly expressed in all groups was (CH)zS, confirming its limited role in intra-oral malodour, as suggested in a previous investigation (3). Despite the limited sample size, the present clinical investigation showed that, in clinical practice, the VCS assessment by portable gaschromatograph OralChroma™ should be an efficient strategy in the diagnosis of halitosis. Furthermore, the lack of scientific literature regarding the evaluation of halitosis in prosthetic patients did not allow an optimal comparison with the data observed. However, the results of this preliminary study showed a possible influence of professional oral hygiene in oral halitosis, confirming also the importance of hygiene motivation in patients with fixed prosthesis. Further long-term clinical studies are needed to confirm these results and to better understand the possible relationship between oral malodour and the presence of provisional or permanent fixed prostheses in healthy patients. REFERENCES 1. 2. 3.

4.

Meskin LH. A breath of fresh air. J Am Dental Ass 1996; 127:1282-6. Porter SR, Scully C. Oral malodour (halitosis). BMJ 2006; 333:632-5. vanden BroekAM, FeenstraL, de Baat C. A review of the current literature on aetiology and measurement methods of halitosis. J Dent 2007; 35:627-35. Vandekerckhove B, Van den Velde S, De Smit M, Dadamio J, Teughels W, Van Tomout M, Quirynen

696

B. SINJARI ET AL.

M. Clinical reliability of non-organoleptic oral malodour measurements. J Clin Periodontol 2009; 36:964-9.

Rosenberg M. Isolation of Enterobacteriaceae from the mouth and potential association with malodor. J

5.

Rosenberg M, McCulloch CA. Measurement of oral

Dent Res 1997; 76: 1770-75. 18. Fukui Y, Yaegaki K, Murata T, Sato T, Tanaka T,

6.

malodor: current methods and future prospects. J Periodontol 1992; 63:776-82. Murata T, Yamaga T, Iida T, Miyazaki H, Yaegaki

Imai T, Kamoda T, Herai M. Diurnal changes in oral malodour among dental-office workers. Int Dent J 2008; 58: 159-66.

K. Classification and examination of halitosis. Int Dental J 2002; 52:181-6.

19. van Steenberghe D, Avontroodt P, Peeters W,

7.

Yaegaki K, Coil JM. Examination, classification, and

Pauwels M, Coucke W, Lijnen A, Quirynen M. Effect of different mouthrinses on morning breath. J

8.

treatment of halitosis; clinical perspectives. J Can Dent Assoc 2000 66:257-61. Ongole R, Shenoy N. Halitosis: much beyond oral

Periodontol 2001; 72: 1183-91. 20. Baran I, Nalcaci R. Self-reported denture hygiene habits and oral tissue conditions of complete denture

9.

malodor. Kathmandu Univ Med J 2010; 8:269-75. Tanaka M, Anguri H, Nishida N, Ojima M, Nagata

wearers. Arch Gerontol Geriatr 2009; 49:237-41. 21. Nalcaci R, Baran I. Oral malodor and removable

H, Shizukuishi S. Reliability of clinical parameters

complete dentures in the elderly. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008; 105:e5-e9.

for predicting the outcome of oral malodor treatment. J Dent Res 2003; 82:518-22. 10. Salako NO, Philip L. Comparison of the use of the Halimeter and the Oral Chroma™ in the assessment of the ability of common cultivable oral anaerobic bacteria to produce malodorous volatile sulfur compounds from cysteine and methionine. Med Prine Pract 2011; 20:75-79. II. Tangerman A, Winkel EG. The portable gas chromatograph Oralf.hroma'>': a method of choice to detect oral and extra-oral halitosis. J Breath Res 2008; 2( I ):0 170 I O. 12. Klokkevold

PRo

Oral

malodor:

a periodontal

perspective. J Calif Dent Assoc 1997; 25: 153-9. 13. Eldarrat A, Alkhabuli J, Malik A. The prevalence of self-reported halitosis and oral hygiene practices among Libyan students and office workers. Libyan J Med 2008; I: 170-76. 14. Pham TAV, Ueno M, Zaitsu T, Takehara S, Shinada K, Lam PH, Kawaguchi Y. Clinical trial of oral malodor treatment in patients with periodontal diseases. J Periodont Res 2011; 46:722-27. 15. Aizawa F, Kishi M, Moriya T, Takahashi M, Inaba D, Yonemitsu M. The analysis of characteristics of elderly people with high VSC level. Oral Dis 2005;

22. Bornstein MM, Kislig K, Hoti BB, Seemann R, Lussi A. Prevalence of halitosis in the population of the city of Bern, Switzerland: a study comparing self-reported and clinical data Eur J Oral Sci 2009; 117:261-67. 23. Quirynen M, Dadamio J, Van den Velde S, De Smit M, Dekeyser C, Van Tornout M, et al. Characteristics of 2000 patients who visited a halitosis clinic. J Clin Periodontol 2009; 36:970-75. 24. Association Report: ADA Council on Scientific Affairs. Oral Malodor. J Am Dent Assoc 2003; 134:209-14. 25. Payne D, Gordon JJ, Nisbet S, Karwal R, Bosma ML. A randomised clinical trial to assess control of oral malodour by a novel dentifrice containing 0.1%w/w o-cymen-5-ol, 0.6%w/w zinc chloride. Int DentJ 2011; 3:60-66. 26. Rosenberg M, Kulkarni GV, Bosy A, McCulloch CAG. Reproducibility and sensitivity oforal malodor measurements with a portable sulfide monitor. J Dental Res 1991; 70:1436-40. 27. Rosenberg M, Septon I, Eli I, Bar-Ness R, Gelernter I, Brenner S, Gabbay J. Halitosis measurement by an industrial sulfide monitor. J Periodontol 1991; 62:487-89.

11:1:80-2. Halitosis

28. Nakano Y, Yoshimura M, Koga T. Methylmercaptan

manifestation and prevention means for patients with

production by periodontal bacteria. Int Dental J

16. Zigurs G, Vidzis A, Brinkmane A.

fixed teeth dentures. Stomatologija 2005; 7:3-6. 17. Goldberg S, Cardash H, Browning 3rd H, Sahly H,

2002; 52:217-20. 29. Suarez FL, Fume, JK, Springfield J, Levitt MD.

Int. J. Immunopathol. Pharmacol.

Morning breath odor: influence of treatments on sulfur gases. J Dent Res 2000; 79:1773-77. 30. Tangerman A, Winkel EG. Intra- and extra-oral

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halitosis: finding of a new form of extra-oral bloodborne halitosis caused by dimethyl sulphide. J Clin Periodontol 2007; 34:748-55.