RESEARCH PAPER Medical Science Volume : 3 | Issue : 12 | Dec 2013 | ISSN - 2249-555X

Comparative study of a stabilized 0.1 %chlorine

dioxide with 0.2% chlorhexidine mouthrinse
in inhibiting the formation of volatile sulphur
compounds (VSC)
KEYWORDS oral malodor, halimeter, VSCs, chlorine-di-oxide, chlorhexidine

Dr. Neetha J. Shetty Dr. David .K

Associate Professor, Dept. of Periodontology, Manipal
Reader, Dept. of Periodontology, Manipal College of
College of Dental Sciences, Manipal University
Dental Sciences, Manipal University , Mangalore
Mangalore

Dr. Kamala D. N Dr. Ramya Shenoy

Associate Professor, Department of Public Health
Research Co-ordinator, Group Pharmaceuticals Limited,
Dentistry, Manipal College of Dental Sciences,
Bangalore
Manipal University, Mangalore
ABSTRACT Background: Research has been done previously on the oxidizing property and the clinical efficacy of
chlorine dioxide (ClO2) on malodor. The aim of the present study was to compare the inhibitory effect of a
mouthwash
containing 0.1% ClO2 with 0.2% Chlorhexidine mouthwash.on morning oral malodor.
Materials and methods:
A randomized, double blind, crossover trial was conducted among18 healthy male volunteers, who were divided into 2
groups. Group-1 subjects were instructed to rinse with the experimental mouthwash containing 0.1% ClO2 and group-2
subjects were asked to rinse with 0.2% chlorhexidine, twice per day for 7 days. After a one week washout period, each
group then used the opposite mouthwash for 7 days. At baseline and after 7 days, oral malodor was evaluated with hal-
imeter which measures Volatile Sulphur Compounds (VSCs) in parts per billion. The clinical variables that were measured
included the plaque and gingival indices.
Results and conclusion:
A decrease in the amount of VSCs was noted after a 7 day use of ClO2 as well as with the use of chlorhexidine mouthwash,
which were statistically significant, with greater significance after the use of ClO2. Also, a significant reduction in plaque
scores was noted after the use of test mouthwash .The decrease in the amount of VSCs indicates a reduction in oral malo-
dor.
Future research is needed to examine the long-term effects, as well as effects of ClO2 on plaque accumulation and peri-
odontal diseases in a well-defined sample of oral malodor patients and broader population samples.

Introduction Since chlorine dioxide readily loses its activity, its stability
The etiology of halitosis is numerous, involving many intra-
and extra-oral factors such as gingivitis, periodontitis, nasal
inflammation, chronic sinusitis, diabetes mellitus, liver insuf-
ficiency, cirrhosis, ure mia, lung carcinoma,
trimethylaminuria and post 1 nasal drip . Epidemiological
researches have re-
ported that around 87% of the bad breath cases have oral
causes, whereas only 5-8% of the cases can be attributed to
ear, nose and throat causes. 2

Considering the relevance of the oral etiological aspects of

oral malodor, recent studies have been designed to verify
the real efficacy of some products such as toothpastes
and mouthrinses containing antimicrobial agents that are
claimed to produce a reduction on bad breath3, 4. Not only
have the antimicrobial capacity of these products, but also
the oxidative biochemical effect on volatile sulphur com-
pounds (VSCs) been investigated5.

The clinical use of mouthrinses containing chlorine dioxide

has been reported to reduce oral malodor by the control of
VSCs. Experimentally, the use of chlorine dioxide associated
with chlorite anion has been shown to result in oxidative con-
sumption of amino acids. like cysteine and methionine,
which
are precursors of VSCs6 Thus, clinical use of this mouthrinse
can be expected to reduce oral malodor by reducing
concentrations of VSCs. Chlorine dioxide, a strong oxidiz-
ing agent, consumes oral substrates containing cysteine
and methionine, thus preventing the production of VSCs.
168 X INDIAN JOURNAL OF APPLIED RESEARCH
has been prolonged through a stabilization process,
which converts chlorine dioxide to molecular chlorine
dioxide at a low pH7, 8, 9.

There is a lack, however, of controlled clinical trials conduct-

ed in order to prove the effectiveness of this formula. Thus,
the aim of this study was to evaluate the inhibiting effect of
a commercially available chlorine dioxide mouthwash (Fresh-
clor) in comparison with 0.2% chlorhexidine mouthwash on
VSC levels in a panel of healthy subjects.

Materials and methods

Patient Population:
Eighteen periodontally healthy male subjects between 18
35 years of age were included in the study. Females, subjects
with known medical disorders, smokers, subjects on antibi-
otic therapy and those who were on antimicrobial therapy
for the last 3 months, were excluded from the study. Fe-
males were excluded as menstrual cycle and the hormonal
changes that follow could affect oral malodor on the crosso-
ver design with one week washout. 10

The subjects received verbal and written information about

the study and signed consent forms to participate. An oral
examination was conducted to assess oral status of the sub-
jects prior to the study. At least 20 teeth that do not present
gingival probing depths greater than 3 mm and gingival
indices and plaque indices equal to 1 in more than 10% of
the sites (considering 0 = no plaque and 1 = plaque present).

169 X INDIAN JOURNAL OF APPLIED RESEARCH

 RESEARCH PAPER Volume : 3 | Issue : 12 | Dec 2013 | ISSN - 2249-555X

Subjects were asked to refrain from using commercial significant difference between the time intervals and exami-
mouthwash, antibacterial tooth paste, tongue brush and nation with the two mouthwashes. Twelve subjects reported
dental floss. a fresh breath feeling after rinsing with the experimental
mouthwash. On the other hand, only four subjects report-
All dental examinations were conducted by the one trained ed the same feeling with the control mouthwash. Thirteen
examiner for all subjects, both for baseline and for follow-up subjects perceived they had a reduced bad breath after
examinations. rinsing with the experimental mouthwash and three sub-
jects reported the same feeling with the control mouthwash.
Study design With the experimental mouthwash, three subjects reported
This study is a randomized, controlled clinical trial of 18 vol- problems such as does not foam and that of unpleasant
unteers divided into two crossover groups, performed in taste. With the control mouthwash, most of the subjects
two experimental periods of 7 days. A 7-day washout interval reported of having an unpleasant taste.
was established between the treatment periods.
Oral status evaluation
Test and control products The results of the PI, GI at baseline and after 7 days is
Test samples were commercial mouthrinse samples (Fresh- shown in the Table-1. With the test mouthwash used for 7
clor) containing stabilized chlorine dioxide 0.1 %. Control days, a statistically significant inhibition in plaque accumula-
samples consisted of 0.2 % chlorhexidine mouthrinse. tion was evident compared with before rinsing (p < 0.05).
With the control mouthwash used for 7 days on the other
Experimental phase hand, no statistically significant inhibition was observed
Baseline data on dental plaque (PI11) and gingival (GI11) compared with before rinsing. Further, the mean score of
indices were recorded in order to exclude volunteers the testgroup was significantly lower than the mean plaque
with periodontal disease, following the exclusion criteria. score of the control group after 7 days. Although the mean
Group-1 Subjects were instructed to rinse 10 ml of the ex- score of GI reduced with the experimental mouthwash used
perimental mouthwash containing 0.1% chlorine di oxide for 7 days, there was no statistically significant difference
for 30 seconds twice per day (after waking up and before compared with the GI value before rinsing.
sleeping) for 7 days and those in group-2, were asked to
rinse with 10 ml of 0.2% chlorhexidine. During the washout Oral malodor assessments
interval, a control dentifrice was used with a new toothbrush Oral malodor assessments using halimeter is listed in table-1
to avoid any carry-over effect. In the second phase, after a and also show the same general trends. There was no statis-
week washout period, each group then used the opposite tically significant difference between the test group and the
mouthwash for 7 days. control group at baseline. Statistically significant improve-
ments in reducing oral malodor occurred in the experimen-
Morning breath evaluation tal group with ClO2 mouthwash used for 7 days, compared
At the beginning and at the end of all experimental pe- with baseline scores (p < 0.01).The chlorhexidine mouthwash
riods, VSC concentrations was recorded using a portable used for 7 days, on the other hand, also showed statistically
industrial sulphide monitor (Halimeter), using the technique significant difference in oral malodor compared with base-
established by Rosenberg et al.12, 13 The data were recorded line scores, but when compared to the experimental group,
before rinsing at 9 a.m. (day 1), and twelve hours after the it was not statistically significant .
last rinse (day 7). The measurements were repeated three
times for each subject. Before the morning measurements DISCUSSION
(9 a.m.) on day 1 and 7, the volunteers were refrained from VSCs have been shown to result from the bacterial
toothbrushing, drinking, eating, gargling and using scented put1re5-. faction of proteins with sulfur- containing amino
cosmetic products.14 acids
Bacteria such as Porphyromonas gingivalis, Fusobacterium
Oral status assessments nucleatum, Tannerella forsythia, Treponema denticola,
Clinical assessments of Plaque Index and Gingival Index and several species of other oral bacteria associated with
were performed on four sites (Buccal ,lingual ,mesial ,distal) gingi- vitis or periodontitis are known to produce large
of the six key teeth (FDI tooth number 16 ,12 ,24 ,36 ,32 amounts of VSCs, which are malodorous. Periodontal
,44). Each of the sites was given a score from 0-3 depend- disease causes high concentrations of VSCs in mouth air.
ing on the severity of the gingival condition .All measure- The concentra- tions of methylmercaptan (CH3SH) are
ments were performed by the same examiner. significantly higher in patients with periodontal disease
than those in orally healthy individuals 16. Although the
RESULTS current study was con- ducted with orally healthy subjects,
Statistical analysis was performed using Statistical Package the results suggest that a mouthwash containing ClO2 might
for Social Sciences (SPSS16.5).Means and standard devia- reduce bacterial load and lower oral malodor in patients
tions of the clinical indices were calculated, following which with periodontal disease.
oral malodor scores between two mouthwashes were com-
pared by the studentt test. The difference between before In this randomized clinical trial, two mouthwashes were
and after rinsing scores at baseline and after 7 days were compared; one with ClO2 and one without ClO2, to inves-
analyzed by student pairedt test. tigate their effect on oral malodor. The results of this study
demonstrate that rinsing with a mouthwash containing
All 18 subjects completed the study. The oral status of sub- ClO2, used over a 7-day period, was effective in reducing
jects was as follows (mean S.D.): mean number of mean morning oral malodor and plaque scores in healthy subjects.
periodontal sulcus depth, 2.0 0.5 mm. There was no
statistically significant difference in the oral conditions of the Chlorine dioxide (ClO2) is a stable free radical which is
readily soluble in water and can remain intact for consider-
able periods of time17. Previous studies have suggested
 RESEARCH PAPER Volume : 3 | Issue : 12 | Dec 2013 | ISSN - 2249-555X

subjects in the two groups at the beginning of the study. that ClO2 and ClO2 are chemically reactive oxidants with
powerful reducing capacity on VSCs. Lynch et al.
Subjects perceptions of the mouthwashes reported
Over the 7-day period, either the test or control mouth- that reaction of L-cystein, a thiol compou, nd which
wash was used on 14 occasions. contrib- ute substantially towards oral malodor 18 with ClO2
, which contained 0.10% (w/v) ClO2, the same as the
The interval from last rinsing with the experimental mouth- experimental mouthwash used in this study.
wash and the control mouthwash to assessment on subjects
malodor was 9.00 2.00 hours .There was no statistically Fusobacterium nucleatum (Fn) is considered a bridge-
organism that facilitates colonization of other periodontal
 RESEARCH PAPER
Volume : 3 | Issue : 12 | Dec 2013 | ISSN - 2249-555X
malodorous bacteria. 19, 20. Moreover it is reported that Fn A substantial proportion of healthy people complain of
is an important in the development of complex morning bad breath .A proliferation of oral bacteria dur-
bacteriu2m1
dental plaque biofilms . Therefore the results of this study ing sleep is responsible for the release of offending gases,
suggested that the reducing effects on morning oral malodor most of which are VSCs. Healthy individuals who suffer
and plaque accumulation, was partially caused by reducing from bad breath most often use mouthwashes containing
the counts of F. n. In this study, we found a significant several masking or antimicrobial agents. Therefore, recent
effect on plaque accumulation using the ClO2 mouthwash papers have pointed out the relevance of comparative stud-
over a ies to verify the efficacy of the mouthwashes on morning
7-day period, but which did not translate into a significant bad breath in healthy subjects 28, 29. Most of the former
inhibitory effect on gingivitis. studies on mouthwash used healthy subjects who never
complained about oral malodor, often lacked an adequate
Frascella tested the effectiveness of a ClO2-containing control a.nd were known effective mouthwashes
mouthwash a1t 7different points of time for a total of 96 containing
hours
after rinsing . The results showed a significant improve- CHX 30, 31 Additional research should also be conducted in
ment in oral malodor scores when the tested mouthwash broader population samples, also including females. None-
was compared to a chlorhexidine control. The mean VSC theless, in this explorative study, the oral malodor score was
concentration in the test group maintained its effective lev- improved using the ClO2 mouthwash. Therefore, the mouth-
el at 9 hours after rinsing. In the present study, the interval wash clearly demonstrated an anti-malodor effect on morn-
from the last rinsing (before sleeping) with the experimental ing breath, potentially without any measurable side effects in
mouthwash to the assessment of subjects oral malodor was healthy subjects.
an average 9 (range 6.8 to 10) hours. We found that rinsing
with ClO2 dramatically reduced the halitosis on the morning CONCLUSION
of the assessment day. However after the one week washout In this study, the results showed that a mouthwash contain-
period, the VSCs level returned to those at the baseline. It ing ClO2 improved morning bad breath measured with the
is suggested that residual ClO2 remaining in the saliva or halimeter in healthy subjects. Also, ClO2 mouthwash used
oral cavity may have reduced VSC level for at least about over a 7- day period was effective in reducing plaque ac-
9 hours. Further research should define the maximum ef- cumulation. However, future studies are needed to examine
fective time on VSC reduction and that trials should be more long-term effects of the mouthwash in halitosis pa-
conducted over longer time periods, 2-4 weeks or longer. tients and broader population samples.
Recently, a number of over-the-counter mouthwashes have
been used in the treatment of oral malodor. Some of them Table 1 - Intergroup and Intragroup comparison of mean
merely mask malodor. The optimal mouthwash to treat oral value of Plaque Index, Gingival Index, VSCS
malodor would be an antiseptic agent with proven long-
lasting efficacy for reduction of oral malodor and VSC con- Group Baseline value 7 days after tvalue P
value
centrations, with no or few side effects. Plaque Group I 0.690.32
Index 0.320.21 5.24 0.000*
Chlorhexidine-containing mouthwashes inhibit formation of
VSCs and are effective oral antiseptics with antiplaque and Group II 0.530.28 0.450.29 1.08 0.295
antigingivitis effects 22. But in our study, there was not much
difference in the gingival index. Although CHX is considered P=0.13 P=0.04*
the most effective oral antiseptic agent, Grgan et al re- Gingival Group I 0.550.27
ported using 0.2% alcohol-free CHX mouthrinse for 1 week Index 0.550.27 0.53 0.601
caused more irritation to oral mucosa, greater burning sen-
sation, and increased altered taste perception compared to Group II 0.660.33 0.530.41 1.30 0.210
the placebo rinse [14]. Listerine (Johnson and Johnson,
P=0.28. P=0.35
New Jersey, USA), a mouthwash containing essential oils,
may also have antiplaque and antigingivitis activity 23 .How-
VSCs Group I 193.7285.76 138.7280.82 4.07 0.000*
ever, due to its high alcohol concentration taste sensation
is reduced and it can cause oral pain 24. Zinc ions are Group II 207.7896.71 141.8998.67 3.27 0.004*
kno2w5n.
to inhibit oral malodor but again, it had a taste problem P=0.64 P=0.05*
Triclosan and cetylpyridium chloride (CPC) are antimicrobial
agents widely used as antiseptic agents 26 However, their *p<0.001
clinical reduction of VSCs is still yet to be proved.
Conflict of interest: Nil
Sodium chlorite (NaClO2), equivalent to ClO2, is a non-toxic
substance approved by the U.S. Food and Drug Administra- Acknowledgement:
tion (FDA) as an antimicrobial agent 27. We found that ClO2 We acknowledge the support provided to us by Group Phar-
not only was effective at reducing oral malodor, but also maceuticals Limited, Bangalore in organizing the samples
none of the volunteers complained about tongue stimula- and the Halimeter for the study.
tion or discoloring with the 0.10% ClO2 (0.16% NaClO2)
mouthwash.

For some subjects, the taste and smell of this mouthwash

were disagreeable. This may be resolved in new formula-
tions which masks these problems.
RESEARCH PAPER Volume : 3 | Issue : 12 | Dec 2013 | ISSN - 2249-555X

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