<div class="section">
<a class="named-anchor" id="CD012213-abs1-0001">
<!--
named anchor
-->
</a>
<h5 class="title" id="d375079e253">Background</h5>
<p id="d375079e255">Halitosis or bad breath is a symptom in which a noticeably unpleasant
breath odour
is present due to an underlying oral or systemic disease. 50% to 60% of the world
population has experienced this problem which can lead to social stigma and loss of
self‐confidence. Multiple interventions have been tried to control halitosis ranging
from mouthwashes and toothpastes to lasers. This new Cochrane Review incorporates
Cochrane Reviews previously published on tongue scraping and mouthrinses for halitosis.
</p>
</div><div class="section">
<a class="named-anchor" id="CD012213-abs1-0002">
<!--
named anchor
-->
</a>
<h5 class="title" id="d375079e258">Objectives</h5>
<p id="d375079e260">The objectives of this review were to assess the effects of various
interventions
used to control halitosis due to oral diseases only. We excluded studies including
patients with halitosis secondary to systemic disease and halitosis‐masking interventions.
</p>
</div><div class="section">
<a class="named-anchor" id="CD012213-abs1-0003">
<!--
named anchor
-->
</a>
<h5 class="title" id="d375079e263">Search methods</h5>
<p id="d375079e265">Cochrane Oral Health's Information Specialist searched the following
databases: Cochrane
Oral Health's Trials Register (to 8 April 2019), the Cochrane Central Register of
Controlled Trials (CENTRAL; 2019, Issue 3) in the Cochrane Library (searched 8 April
2019), MEDLINE Ovid (1946 to 8 April 2019), and Embase Ovid (1980 to 8 April 2019).
We also searched LILACS BIREME (1982 to 19 April 2019), the National Database of Indian
Medical Journals (1985 to 19 April 2019), OpenGrey (1992 to 19 April 2019), and CINAHL
EBSCO (1937 to 19 April 2019). The US National Institutes of Health Ongoing Trials
Register ClinicalTrials.gov (8 April 2019), the World Health Organization International
Clinical Trials Registry Platform (8 April 2019), the ISRCTN Registry (19 April 2019),
the Clinical Trials Registry ‐ India (19 April 2019), were searched for ongoing trials.
We also searched the cross‐references of included studies and systematic reviews published
on the topic. No restrictions were placed on the language or date of publication when
searching the electronic databases.
</p>
</div><div class="section">
<a class="named-anchor" id="CD012213-abs1-0004">
<!--
named anchor
-->
</a>
<h5 class="title" id="d375079e268">Selection criteria</h5>
<p id="d375079e270">We included randomised controlled trials (RCTs) which involved
adults over the age
of 16, and any intervention for managing halitosis compared to another or placebo,
or no intervention. The active interventions or controls were administered over a
minimum of one week and with no upper time limit. We excluded quasi‐randomised trials,
trials comparing the results for less than one week follow‐up, and studies including
advanced periodontitis.
</p>
</div><div class="section">
<a class="named-anchor" id="CD012213-abs1-0005">
<!--
named anchor
-->
</a>
<h5 class="title" id="d375079e273">Data collection and analysis</h5>
<p id="d375079e275">Two pairs of review authors independently selected trials, extracted
data, and assessed
risk of bias. We estimated mean differences (MDs) for continuous data, with 95% confidence
intervals (CIs). We assessed the certainty of the evidence using the GRADE approach.
</p>
</div><div class="section">
<a class="named-anchor" id="CD012213-abs1-0006">
<!--
named anchor
-->
</a>
<h5 class="title" id="d375079e278">Main results</h5>
<p id="d375079e280">We included 44 trials in the review with 1809 participants comparing
an intervention
with a placebo or a control. The age of participants ranged from 17 to 77 years. Most
of the trials reported on short‐term follow‐up (ranging from one week to four weeks).
Only one trial reported long‐term follow‐up (three months).
</p>
<p id="d375079e282">Three studies were at low overall risk of bias, 16 at high overall
risk of bias, and
the remaining 25 at unclear overall risk of bias.
</p>
<p id="d375079e284">We compared different types of interventions which were categorised
as mechanical
debridement, chewing gums, systemic deodorising agents, topical agents, toothpastes,
mouthrinse/mouthwash, tablets, and combination methods.
</p>
<p id="d375079e286">
<b>Mechanical debridement:</b> 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.
</p>
<p id="d375079e291">
<b>Chewing gums:</b> 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.
</p>
<p id="d375079e296">
<b>Systemic deodorising agents:</b> for 1000 mg 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.
</p>
<p id="d375079e301">
<b>Topical agents:</b> 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.
</p>
<p id="d375079e306">
<b>Toothpastes:</b> 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.
</p>
<p id="d375079e311">
<b>Mouthrinse/mouthwash:</b> 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.
</p>
<p id="d375079e316">
<b>Tablets:</b> no data were reported on key outcomes for this comparison.
</p>
<p id="d375079e322">
<b>Combination methods:</b> 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.
</p>
</div><div class="section">
<a class="named-anchor" id="CD012213-abs1-0007">
<!--
named anchor
-->
</a>
<h5 class="title" id="d375079e328">Authors' conclusions</h5>
<p id="d375079e330">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.
</p>
</div><p id="d375079e335">
<b>Interventions for managing bad breath</b>
</p><p id="d375079e340">
<b>Review question</b>
</p><p id="d375079e345">With this Cochrane Review we tried to find out the best way
to control bad breath,
also called halitosis, due to a disease within the mouth in adults.
</p><p id="d375079e347">
<b>Background</b>
</p><p id="d375079e352">Bad breath or halitosis is caused by too much bacteria or
small food parts left inside
the mouth, most commonly at the back of the tongue. It can be a sign of a disease
within the mouth or other body diseases. People with bad breath can have low self‐esteem
and feel embarrassed. It can affect their personal relationships and work. In this
review, we looked at treatments for bad breath due to a disease within the mouth and
at treatments that aim to control not just mask bad breath.
</p><p id="d375079e354">
<b>Study characteristics</b>
</p><p id="d375079e359">This review is up‐to‐date as of 8 April 2019. The review includes
44 studies involving
1809 people who were 17 to 77 years old. The review compared an intervention with
another intervention, a placebo or a control. It looked at eight different ways to
control bad breath: mechanical cleaning (e.g. tongue cleaners and toothbrushes), chewing
gums, systemic deodorising agents (e.g. mushroom extract that you eat), topical agents
(e.g. gel that you apply), toothpastes, mouthrinse/mouthwash, tablets, and combination
of different treatments.
</p><p id="d375079e361">
<b>Key results</b>
</p><p id="d375079e366">The evidence was very uncertain for mechanical tongue cleaning
versus no tongue cleaning,
0.6% eucalyptus chewing gum versus placebo chewing gum, 1000 mg mushroom extract versus
placebo, hinokitiol gel versus placebo gel, 0.3% triclosan toothpaste versus control
toothpaste, mouthwash containing chlorhexidine and zinc acetate versus placebo mouthwash,
and brushing plus cetylpyridium mouthwash versus brushing.
</p><p id="d375079e368">Harmful effects of the different interventions were not reported
or were not important.</p><p id="d375079e371">
<b>Certainty of the evidence</b>
</p><p id="d375079e376">The level of certainty we have in these findings is low to
very low. This was due
mainly to risk of bias and the small number of people studied in the included trials.
</p><p id="d375079e378">
<b>Conclusion</b>
</p><p id="d375079e383">We do not have enough evidence to say which intervention works
better to control bad
breath.
</p>