Few conditions are as embarrassing and socially frowned upon as halitosis, and it is a common patient complaint. Transitory causes may include the consumption of pungent food, or overnight "morning breath" resulting from reduced salivary flow. Chronic oral malodor can be induced by systemic disease, but is more typically generated by intraoral causes, e.g., smoking, mouth breathing due to sinus conditions, regular pungent food consumption, and suboptimal oral hygiene. When dental plaque and food debris are not completely cleared from the tongue and difficult-to-reach areas of the dentition on a regular basis, gram-negative bacteria proliferate and putrefactive processes occur, with the corresponding release of volatile sulfur compounds (VSC). VSCs are exhaled and produce foul odors. 132,133
The strategy for reducing oral malodor caused by insufficient oral hygiene includes more frequent and efficacious toothbrushing and interproximal cleaning, tongue brushing, and treatment for periodontal disease if appropriate.134 Research has shown many patients can additionally benefit from adding an antimicrobial product to their daily oral hygiene regimen. Mouthrinse antimicrobial agents like cetylpyridium chloride (CPC) have shown anti-malodor efficacy.135 However, many patients may lack motivation to utilize a mouthrinse faithfully together with toothbrushing.
Antimicrobial dentifrices can alternatively provide an effective malodor-fighting mechanism in one step (Figure 3). Of currently marketed dentifrice antimicrobial agents, 0.454% stannous fluoride (as found in multi-benefit dentifrices like Colgate® Total Deep Clean, Parodontax Complete Protection, Crest Pro-Health Bacteria Shield and Gum) has consistently demonstrated significantly superior malodor reduction (short-term and overnight) relative to negative controls with twice daily usage in controlled clinical investigations with stabilized SnF2.136-138 Notably, however, Zsiska and colleagues compared six different SnF2 dentifrices relative to controls in two randomized and controlled pilot clinical trials and determined that certain formulations performed better in reducing malodor. The authors concluded that “SnF2 dentifrices can provide significant oral malodor reductions, but the benefit is formulation dependent. The presence of SnF2 is not sufficient to ensure efficacy.”139
Flavoring agents in non-antimicrobial (NaF and MFP) toothpastes are another option for addressing oral malodor. Their breath-freshening effects, however, provide temporary masking of halitosis similar to the effect of breath mints, and do not treat the underlying etiology or provide the germ kill and more sustained breath protection benefits of antimicrobial dentifrices.