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2015 Eur J Oral Sci

Eur J Oral Sci 2015; 123: 7279


DOI: 10.1111/eos.12169
Printed in Singapore. All rights reserved

European Journal of
Oral Sciences

Short-term effect of strontium- and


zinc-containing toothpastes and
mouthrinses on volatile sulphur
compounds in morning breath: a
randomized, double-blind, cross-over
clinical study

o G. Soares1, Grazyna Jonski2,


Le
Eduardo M. B. Tinoco1, Alix Young3
1

Department of Periodontology, Universidade


Estadual do Rio, Rio de Janeiro-RJ, Brazil;
Clinical Research Laboratory, Faculty of
Dentistry, University of Oslo, Oslo, Norway;
3
Department of Cariology and Gerodontology,
Institute of Clinical Dentistry, Faculty of
Dentistry, University of Oslo, Oslo, Norway
2

Soares LG, Jonski G, Tinoco EMB, Young A. Short-term eect of strontium- and
zinc-containing toothpastes and mouthrinses on volatile sulphur compounds in morning
breath: a randomized, double-blind, cross-over clinical study.
Eur J Oral Sci 2015; 123: 7279. 2015 Eur J Oral Sci
Zinc (Zn) reduces the formation of volatile sulphur compounds (VSCs) associated
with oral malodour. Although strontium (Sr) is included in some products for
reducing dental hypersensitivity, it may also have anti-halitosis properties. This randomized, double-blind, cross-over clinical study compared the anti-VSC eect of
brushing with commercial toothpastes and rinses containing Zn and Sr. The volunteers (n = 30) either brushed/rinsed with/without tongue brushing using Zn-containing toothpaste/rinse, Sr-containing toothpaste/rinse, or placebo (control). Volatile
sulphur compounds [hydrogen sulphide (H2S) and methyl mercaptan (CH3SH)]
were measured, in morning breath, using gas chromatography. The anti-VSC eects
of the test toothpastes and test rinses were signicantly better than the anti-VSC
eects of the respective controls. Toothbrushing with test toothpastes gave median
reductions, compared with the control, of 70% for H2S and 5557% for CH3SH.
Rinsing with the Sr- and Zn-containing solutions had the same anti-VSC eect as
toothbrushing and tooth- and tongue brushing with the Sr- and Zn-containing
toothpastes. Zinc-containing rinse resulted in a signicantly higher median salivary
level of Zn compared with brushing with Zn-containing toothpaste, although this
eect did not correlate with the anti-VSC eect. It can be concluded that the
Sr- and Zn-containing toothpastes and the Zn- and Sr-containing rinses, when used
in the evening, are equally eective in reducing morning-breath VSCs the following
day.

Oral malodour, or bad breath, is a common problem


that aects individuals of dierent ages, and it has
become a topic of increasing interest in the scientic
community (1). A recent study reported that among
patients attending a halitosis clinic, 83% were diagnosed with true halitosis, of which 96% had an oral
cause (2). For most people it is not uncommon to experience some degree of bad breath (also called morningbreath odour) upon awakening after a nights sleep.
This is caused, in part, by a physiological reduction in
saliva secretion during sleep (3) that results in the build
up of sulphur-containing gasses in the oral cavity (4).
Oral malodour is usually a symptom of local oral conditions or infections, whereby accumulations of oral
bacteria, often associated with gingivitis, tongue

o G. Soares, Rua Alfredo da Costa Mattos


Le
Jr, 75/2 - Paraba do Sul, RJ RJ, CEP
25850-000, Brazil.
E-mail: dr_leog@hotmail.com
Key words: gas chromatography; halitosis;
strontium; volatile sulphur compound; zinc
Accepted for publication December 2014

coating, and periodontal disease, are the main oral


sources of malodour (47). When oral bacteria catabolize available sulphur-containing substrates in the oral
cavity, many species produce volatile sulphur compounds (VSCs) (4).
Hydrogen sulphide (H2S), methyl mercaptan (MM;
CH3SH), and dimethyl sulphide [DMS; (CH3SH)2S] are
the main oral VSCs (8, 9). These compounds have
unpleasant odours, even when present at very low levels,
and the concentration of compound is strongly correlated to the degree of oral malodour (7, 10). In addition
to using organoleptic methods for detection and diagnosis of oral malodour, several portable devices are
available for analysis and quantication of VSCs. However, for research purposes, gas chromatography (GC)

Eect of zinc and strontium on oral VSCs

provides the most objective and accurate quantication


of the dierent VSC components (9, 11).
In many cases the treatment of oral malodour will
involve physical measures to resolve gingivitis and/or
systematic treatment of periodontal disease (5, 12, 13).
Removal of the tongue coating is also considered to be
an important measure (10, 14, 15). In some cases, a
chemical approach may also be appropriate for short
periods of time, and various oral hygiene products
(such as mouthrinses or toothpastes containing metal
salts and various antibacterial substances) are targeted
for reducing oral malodour (1618). The anti-VSC ecacy of metal ions relates to a combination of their
antibacterial activity and their anity for sulphur (S)
(8, 1821). Zinc (Zn) has known antibacterial eects as
well as good anity for S ions. When Zn ions bind to
S ions, the resulting ZnS compounds have low solubility, and the odiferous gases are, in this way, eliminated
from the oral cavity, thus explaining the well-documented anti-VSC eects of ZnS (22, 23).
In vitro studies have shown that other metals, such
as tin and copper, are also eective in inhibiting VSCs
(24). Strontium (Sr) is an alkaline, soft, highly reactive
metal that forms neutral aqueous salt solutions. Strontium chloride (SrCl) is used in cosmetics (skin conditioning and soothing) and is considered to have
relatively low toxicity (25). Strontium has been shown
to adsorb strongly to calcied tissues, including dentine. It has been widely tested for its eect in reducing
dentine hypersensitivity, where the benecial eects
have been attributed to blockage of the organic matrix
on tooth root surfaces (26, 27). Strontium salts are
included in several commercially available toothpastes
developed for patients suering from dentine hypersensitivity (26, 28, 29).
Dentine hypersensitivity is often a problem in
patients with periodontal disease. Following mechanical-debridement procedures, tooth-root surfaces often
become exposed and patients can experience sensitivity.
Although Sr is expected to have S-binding properties,
no studies have been reported on the anti-VSC eect of
Sr-containing toothpaste. It was therefore of interest to
examine whether a commercial Sr-containing toothpaste for reducing dentine hypersensitivity can also
reduce the levels of VSCs in morning breath.
The aim of the present study was to test the 12-h
anti-VSC eects of toothbrushing (with and without
tongue brushing) with two commercial toothpastes
one containing Sr and one containing Zn. Aqueous
solutions of Zn and Sr were also tested in order to
compare the anti-VSC eects of these metal ions when
present in mouthwashes. The null hypothesis tested was
that there is no dierence between the anti-VSC eect
of the Sr- and Zn-containing toothpastes and rinses,
using morning breath as a study model system.

73

study protocol was approved by the Committee for Medical


Research Ethics (REK sr-st: 2012/548D). The experiment
was performed at the Clinical Research Laboratory, Faculty
of Dentistry, University of Oslo (Oslo, Norway) from June
2012 to November 2012.
Study participants
The number of participants recruited to the study was
determined using a standardized sample size calculation
(SigmaPlot statistical software; Systat Software, San Jose,
CA, USA). The calculation was based on the number of
treatment groups, the cross-over study design, a statistical
power of 80%, and a signicance level of 5%. A true difference in the percentage reduction of VSCs between test
treatments and controls was suggested to be 2.4%, with a
common standard deviation of the error of 2%. The estimated number of individuals needed for the chosen study
design was therefore 28 (2). Interested persons responded
to an advertisement mounted on information boards at
university student accommodation. In order to allow
for some dropout, the rst 30 persons who fullled the
inclusion criteria were recruited and received written information about the study. Respondents recruited were
non-smokers, 1850 yr of age, with no self-reported history of systemic diseases or periodontal disease, no
complaints of xerostomia, and no regular use of medicines.
Before starting the study, informed written consent
was obtained from all participants: 17 male subjects and
13 female subjects, with a mean  SD (range) age of
28  7 (2045) yr. In a short prestudy questionnaire,
participants were asked about their current oral-hygiene
routines for brushing, as well as interdental and tonguehygiene measures and their usual diet.
Test toothpastes and solutions
Details of the Zn- and Sr-containing toothpastes and solutions tested in the study are given in Table 1. When preparing the rinsing solutions, the concentration of Zn and
Sr was calculated to match the concentration of the metal
salts in the respective toothpastes. The preparation and
coding of the test agents was performed by a dierent
researcher from the one in contact with the participants
and who also performed the VSC analyses.
Experimental phase
The participants received standard uoride toothpaste for
use in a 7- to 10-d washout period before starting the
study. The same toothpaste was used during the study period, except on evenings before test days. Based on the
results of pilot studies, a washout period of a minimum of
3 d between dierent treatments was used in order to
avoid any carry-over/interference between the test treatments. The participants were randomly assigned to test the
dierent treatments in dierent orders, and were blinded
to the treatments.
Test toothpastes

Material and methods


This study had a randomized, double-blind, cross-over
design and tested 12-h morning breath in volunteers. The

Participants were instructed to brush their teeth for 2 min


with 1 g of preweighed samples of the test and control
toothpastes in the evening before their allocated test days.
They were provided with new disposable toothbrushes for

74

Soares et al.
Table 1
Details of the test methods and test agents

Code

Method

Test agent

Fluoride (p.p.m. F as NaF)

C-t
C-tt

2 min of toothbrushing
2 min of toothbrushing + tongue
brushing
2 min of toothbrushing
2 min of toothbrushing + tongue
brushing
2 min of toothbrushing
2 min of toothbrushing + tongue
brushing
1 min of mouth rinsing
1 min of mouth rinsing
1 min of mouth rinsing

Control toothpaste containing no Zn or Sr

1500

Toothpaste containing 0.003 g of Zn/g of toothpaste

1450

Toothpaste containing 0.08 g of Sr/g of toothpaste

1040

Deionized water control no Zn or Sr


Aqueous solution containing 0.003 g of Zn/10 ml solution
Aqueous solution containing 0.08 g of Sr/10 ml solution

Zn-t
Zn-tt
Sr-t
Sr-tt
C-r
Zn-r
Sr-r

F, uorine; NaF, sodium uoride; Sr, strontium; Zn, zinc.

each toothpaste test and were instructed to use their usual


brushing method. It was emphasized to the volunteers that
they must use the same technique for each of the test days
involving toothbrushing. When the test involved both
tooth- and tongue brushing, participants were instructed
to brush their tongue using three strokes over the dorsum
of the tongue after they had brushed their teeth.
Test solutions
Participants were instructed to rinse with 10 ml of the test/
control solution for 1 min in the evening before each allocated rinse test day. No toothbrushing or dental ossing
was performed on the evenings when the participants rinsed
with the test or control solutions. The participants were
instructed to refrain from eating/drinking and from other
oral hygiene practices following the evening treatments and
until after they were tested, 12 h later. Test participants
met up at the research laboratory in the morning of their
allocated test days and times, and single morning-breath
samples were immediately collected and analysed for VSCs.
VSC measurements
Morning breath levels of H2S and MM were measured
using a gas chromatograph specically calibrated for sulphur detection (Shimadzu, Kyoto, Japan). The volunteers
were instructed to keep their mouth closed for 90 s, before
samples of mouth air were aspirated using a mouthpiece
and a 10-ml syringe. Samples were injected into a 6-ml
sample loop connected to the auto injector of the gas
chromatograph. Analysis was performed directly by separation using a Teon column (3.66 m 9 0.32 cm, temperature 70C, nitrogen gas ow 32 ml min 1, hydrogen gas
ow rate 125 ml min 1 and airow rate 43 ml min 1)
packed with polyphenol ether (5%) and phosphoric acid
(0.05%) on 40/60 mesh Chromosorb T and a ame photometric detector.

were sealed, coded, and immediately frozen until required


for analysis. Saliva samples collected on test days when
the participants had brushed with the toothpaste without
Zn or Sr, and when they had rinsed with water, functioned
as the controls for metal concentrations in the saliva for
each participant.
Before analysis, the saliva was thawed at room temperature and centrifuged at 3619 g for 20 s at 20C. Three-millilitre aliquots of the saliva samples were mixed with 1 ml
of 65% nitric acid (HNO3) and 0.5 ml of 5% lanthanum
oxide (La2O3). The samples were analysed blind for either
Zn or Sr ions using atomic absorption spectrometry
(AAS) (Model 3300; Perkin Elmer Analytical Instrument,
Norwalk, CT, USA) with a wavelength of 422.7 nm and
an air-acetylene ame. Solutions containing 5 p.p.m. Sr
and Zn and 0.5 ml of 5% La2O3 were used as the standards for calibration.
Statistical analysis
For the GC analysis of VSCs, the raw data consisted of
the area under the chromatogram curve (AUC) measurements for each VSC in each breath analysis. The data
were not normally distributed according to the Shapiro
Wilk test, and the Friedman test and post hoc Tukey test
were performed to detect dierences between treatments
for both H2S and CH3SH. The eects of each treatment
method were also calculated as a percentage of the control. These data were also not normally distributed and
the Wilcoxon test was performed to test for dierences
between the treatment eects for the dierent VSCs.
For the salivary metal analysis, the raw data consisted
of metal ion concentrations (p.p.m.) in the saliva samples,
as measured by AAS. These data were not normally distributed and the same statistical analyses were performed
as for the VSC data.
Statistical analyses were performed using SIGMAPLOT
statistical software. All dierences were considered signicant at P < 0.05.

Saliva collection and analysis


Unstimulated whole saliva samples were collected from the
participants immediately after collection of breath samples.
Participants were instructed to spit into a 15-ml test tube
until at least 3 ml of saliva had been collected. Samples

Results
All participants completed all stages of the study and
there were no complaints or reactions associated with

Eect of zinc and strontium on oral VSCs

brushing with the toothpastes or rinsing with the


solutions. The entire study was performed over a period of 18 wk. The results of the prestudy questionnaire
showed that 15 (50%) volunteers reported using dental
oss at least four times per week and 17 (56%) volunteers brushed their tongue regularly.
GC analyses of VSCs

Hydrogen sulphide: The area under the chromatogram


curve (AUC) for H2S for each treatment method is
shown in Fig. 1. Toothbrushing with the Zn- and Srcontaining toothpastes (with and without additional
tongue brushing), and rinsing with the Zn- and Sr-acetate-containing solutions were all signicantly more
eective against H2S than their respective controls
(P < 0.001). Toothbrushing alone gave a median reduction in H2S of about 70% compared with the control
toothpaste (Table 2). Although there were no signicant dierences in anti-VSC eects between tooth- and
tongue brushing and toothbrushing alone, the Zn-containing toothpaste tended to have a better anti-H2S
eect (median 85% reduction) when the tongue was
also brushed. Rinsing with the test solutions resulted in
median H2S reductions, compared with the control
rinse, of 82% for Zn and 77% for Sr (Table 2).
Although this was slightly higher than for toothbrushing alone for Zn, this dierence was not signicant.
Methyl mercaptan: The area under the chromatogram
curve for MM for each treatment method is shown in
Fig. 2. Toothbrushing with the Zn- and Sr-containing
toothpastes (with and without tongue brushing), and
rinsing with the Zn- and Sr-acetate-containing solutions

Fig. 1. Box plots of hydrogen sulphide levels (H2S,


AUC = area under the chromatogram curve) recorded in
morning breath of test participants, 12 h after brushing with
the toothpastes or rinsing with the solutions (n = 30 test subjects). See Table 1 for an explanation of the codes. The box
plots show the median and upper/lower quartiles. The whiskers represent the upper 90th and lower 10th percentiles. Outliers are shown as separate points. (Friedman test, P < 0.05,
, , #, *: groups with the same signs are not statistically signicantly dierent from each other).

75

were all signicantly more eective against MM than


were their respective controls (P < 0.001). Toothbrushing alone gave a median reduction in MM of 5557%
for the test toothpastes compared with the control
toothpaste (Table 2). The results for tooth- and tongue
brushing were not signicantly dierent from the
results for tongue brushing only, although the Sr-containing toothpaste tended to have a lower anti-MM
eect (median 34% reduction) when the tongue was
also brushed. Rinsing with the test solutions resulted in
a median MM reduction, compared with the rinse control, of 55% for Zn and 65% for Sr (Table 2). This difference was not signicant, and the anti-MM eect of
the test rinses was not signicantly dierent from that
of the test toothpastes.
Analyses of salivary Zn and Sr

The results of the salivary analyses are shown in Fig. 3.


There was a signicantly higher median 12-h salivary
metal concentration (Zn) after rinsing with the Zn-acetate-containing solution than after the other treatments.
Statistical analyses did not reveal any signicant relationships between the salivary Zn or Sr levels and the
respective VSC levels for the dierent treatment
methods.

Discussion
The results of this double-blind, cross-over clinical
study on morning breath showed that there was no signicant dierence between the anti-VSC eect of the
Zn- and Sr-containing toothpastes tested. Furthermore,
when solutions containing the same concentration of
metal ions as in the respective toothpastes were tested
for their anti-VSC eect, no dierence could be seen
between the anti-VSC eects of rinsing with the Znand Sr-acetate solutions. The null hypothesis was therefore proven to be correct. Furthermore, the study also
showed that brief tongue brushing in addition to toothbrushing had no additional anti-VSC eect.
The protocol for the present study was in accordance
with Standardization of clinical protocols in oral malodour research, including a cross-over study design to
avoid the eects of individual variations, and the use of
GC (11). The randomized cross-over design reduces
variability and enables dierent products to be tested
on the same subjects, and GC is the preferred method
used at halitosis centres to measure the dierent VSC
components.
Oral hygiene products contain various active ingredients aimed at consumers looking for specic needs.
Zinc is one agent that has commonly been included in
products for oral malodour, and the ecacy of Zn-containing agents against oral malodour has been conrmed. Several studies that have tested the eect of
toothpaste formulations containing various Zn salts
(Zn-chloride, -sulphate, -citrate, and -gluconate) have
demonstrated good ecacy against oral malodour (22,
23). Zinc salts are also demonstrated as ecacious in

76

Soares et al.
Table 2

Percentage reductions, compared with controls, in morning-breath volatile sulphur compounds (VSCs) [hydrogen sulphide (H2S) and
methyl mercaptan (CH3SH)]
Method
Toothbrushing
H2S

CH3SH

Tooth- and tongue brushing

Mouth rinsing

H2S

H2S

CH3SH

CH3SH

Test person

Sr-t

Zn-t

Sr-t

Zn-t

Sr-tt

Zn-tt

Sr-tt

Zn-tt

Sr-r

Zn-r

Sr-r

Zn-r

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Median

97.58
99.90
98.61
63.93
99.55
57.67
54.75
5.06
65.93
72.74
100
43.86
43.39
81.36
0
57.30
43.42
54.48
68.46
95.43
93.59
97.45
96.10
77.59
85.24
6.56
76.78
46.36
0
98.08
70.60

55.93
94.57
97.36
67.81
0
0
86.28
63.54
22.33
72.21
88.05
0
0
79.58
0
96.58
82.17
8.99
11.68
97.81
99.60
97.33
100
7.91
99.67
31.65
99.65
0
56.28
90.02
70.01

52.82
99.36
96.41
46.07
85.89
36.01
52.20
43.46
14.08
84.65
81.36
58.80
21.78
76.53
0
14.83
30.70
0
35.64
77.89
85.26
89.52
81.49
84.41
0
57.24
70.52
19.83
0
85.59
55.03

59.52
97.94
92.83
92.56
0
21.27
74.01
93.09
23.49
33.59
82.35
50.03
0
17.64
0
82.27
54.25
14.42
0
98.22
95.46
83.11
88.11
0
78.07
26.88
90.01
15.60
50.47
82.44
56.88

79.72
81.64
97.96
94.07
93.59
0
67.82
26.18
0
32.17
55.02
99.48
97.72
66.24
43.92
37.61
91.95
56.77
45.61
82.12
43.37
73.68
92.19
62.21
97.53
81.66
6.92
82.12
69.97
92.51
71.82

58.52
33.12
96.83
81.75
0
0
0
27.30
0
63.22
97.70
0
0
53.81
0
96.25
96.01
86.57
84.40
93.48
94.21
96.15
93.23
99.25
86.77
93.63
94.50
74.83
98.24
99.44
85.48

38.19
0
90.10
94.66
21.40
0
0
43.49
59.47
14.31
11.65
86.89
77.54
30.96
15.09
0
37.08
62.63
0
95.63
0
0
40.91
12.70
79.45
86.12
0
51.55
0
60.06
34.02

66.53
0
85.51
94.21
63.04
0
0
28.00
0
54.78
88.42
0
0
0
0
86.28
68.44
84.65
47.38
81.33
0
0
26.62
89.07
98.08
91.00
79.39
50.66
89.00
90.97
58.91

0
0
55.19
89.54
0
0
39.62
91.63
0
95.97
66.38
90.66
76.85
99.96
48.17
10.20
87.71
72.17
80.85
98.58
99.79
77.72
77.16
26.58
89.57
74.76
95.10
80.90
97.38
99.42
77.44

53.28
38.89
70.41
0
0
0
27.95
87.92
0
98.00
59.92
92.86
95.11
96.79
0
87.26
94.11
64.66
65.92
98.26
99.53
77.15
96.76
68.91
97.78
0
97.16
99.99
97.87
97.87
82.21

0
0
84.63
70.53
0
0
49.41
62.51
0
88.98
72.14
69.92
82.93
89.08
53.87
36.18
66.49
8.54
69.14
96.81
16.85
68.34
42.37
0
63.63
54.92
84.94
99.69
94.99
72.58
65.06

0
12.80
52.13
0
0
0
52.11
58.15
0
70.90
71.35
51.03
97.67
51.80
0
73.25
85.65
73.49
16.62
86.46
0
100
81.02
32.29
79.64
74.62
93.57
99.92
84.13
45.09
55.14

Values are given as percentage reductions in morning-breath VSCs. The median percentage reduction in morning-breath VSCs, following
application of the dierent test methods, is given for all test participants at the foot of the table.
0, no reduction in VSCs, compared with controls, in morning breath following the treatments.
See Table 1 for details of treatment codes.

mouthrinse formulations (17, 20, 30, 31, 32). The


present study conrmed the good ecacy of Zn in both
toothpaste and as a rinse against morning-breath odour.
The other metal tested, Sr, has not been commonly
included in oral hygiene products. Strontium has a documented eect in reducing dental hypersensitivity and
has been included in toothpastes for this reason (28).
Like Zn ions, divalent Sr ions could also be expected to
bind S ions and to have some anti-VSC eect. However, there are no other studies reporting on the eect
of Sr-containing products for oral malodour, and the
Sr-containing toothpaste tested in the present study is
not marketed as having an anti-VSC eect. The results
of the present study indicate, for the rst time, that Srcontaining toothpaste and solutions have an anti-VSC
eect in morning breath.
In the present study, it may be worth noting that
although not statistically signicant, the Zn-containing
toothpaste tended to have a better eect against H2S

when both the teeth and the tongue were brushed,


compared with when only the teeth were brushed. Furthermore, the Sr-containing toothpaste tended to have
a poorer eect on MM when both the teeth and the
tongue were brushed, compared with when only the
teeth were brushed. It would be interesting to perform
further studies in a more homogeneous test population
to determine whether these trends indicate true eects.
Such a population could be a group of patients with
periodontitis who have higher background levels of
VSCs in morning breath.
The levels of Zn and Sr in saliva were measured, 12 h
after brushing/rinsing with the test toothpastes/solutions,
in order to examine the possible relationship between
them and their anti-VSC eects. Elevated salivary levels
of Zn, 34 h after brushing with a Zn-citrate dentifrice,
has been reported previously (33). Oral retention of Zn
following rinsing with aqueous Zn salts has been measured previously, and the salivary concentration of Zn

Eect of zinc and strontium on oral VSCs

Fig. 2. Box plots of methyl mercaptan levels (MM,


AUC = area under the chromatogram curve) recorded in
morning breath of test participants, 12 h after brushing with
the toothpastes or rinsing with the solutions (n = 30 test subjects). See Table 1 for an explanation of the codes. The box
plots show the median and the upper/lower quartiles. The whiskers represent the upper 90th and lower 10th percentiles. Outliers are shown as separate points. (Friedman test, P < 0.05; ,
, #, *: groups with the same signs are not statistically signicantly dierent from each other).

was shown to decrease rapidly to about 15% of the rinse


concentration during the rst 4 h (34). Normal mean
whole salivary Zn concentrations have previously been
reported in the range of 0.4600.478 p.p.m. (35, 36). In
the present study, the mean salivary Zn concentration,
12 h after rinsing with Zn-acetate, was about three times
that level (1.32 mg l 1), clearly suggesting the oral retention of Zn ions.
Regarding Sr, there are few studies reporting normal
salivary Sr concentrations. In a study on 14-yr-old subjects, a mean salivary Sr concentration of 0.035 mg l 1
(range 0.022.93 mg l 1) was reported (37). In the present study, 12 h after rinsing with Sr-acetate, the mean
salivary Sr concentration was 3.89 mg l 1, indicating
retention of Sr. The median retention of metal ions
was, however, signicantly greater following rinsing
with the Zn-acetate solution than for the other treatments. This nding may indicate an important dierence in oral substantivity between Zn and Sr ions, at
least for these metals in aqueous form, although this
dierence was not seen with the two metals in the
toothpastes.
Toothpastes include many dierent components, and
the rationale for including rinsing with the Zn- and Sracetate solutions in the present study was to evaluate
the eect of the metal ion alone. However, the present
study design and protocol could not demonstrate that
rinsing with the Zn- and Sr-containing solutions was
more ecacious than brushing with Zn- and Sr-containing toothpastes. Furthermore, no signicant correlations were observed between the salivary metal
concentrations and the anti-VSC eect, 12 h after the
dierent treatments. The latter nding may be a function of the long time between the evening treatment
regimes and the time of saliva collection the next day.

77

Fig. 3. Box plots showing the salivary concentration (p.p.m.)


of zinc (Zn) or strontium (Sr), 12 h after using the toothpastes and solutions (n = 30 test subjects). See Table 1 for an
explanation of the codes. The box plots show the median and
the upper/lower quartiles. The whiskers represent the upper
90th and lower 10th percentiles. Outliers are shown as separate points. (Friedman test, P < 0.05; #, *: groups with the
same signs are not statistically signicantly dierent from each
other). NB: Zn and Sr were not detectable in the saliva after
brushing/rinsing with control toothpaste and solutions.

Physiological inter- and intra-individual variations in


VSC levels are reported (38, 39) and provide a challenge for experimental protocols. In the present study,
the large variation in VSC levels (both control levels
and treatment response levels) may partly be a result of
the heterogeneous nature of the group of volunteers.
Approximately half of the test participants reported
using dental oss four times per week, suggesting a relatively high level of oral hygiene. Although it has been
demonstrated that the low frequency of toothbrushing
is correlated with halitosis, one study found that there
was no association between the reported use of dental
oss and halitosis (40). Furthermore, somewhat more
than half of the test participants in the present study
brushed their tongue regularly.
Two clinical epidemiological studies found that tongue
coating was the main factor associated with high VSC
levels (41, 42). In a group of periodontally healthy dental
students, tongue scraping appeared to be the most
important hygiene procedure for reducing morning halitosis (43). For patients with periodontitis, periodontal
treatment was shown to play an important role in reducing halitosis, while tongue cleaning contributed to a lesser extent; in the same study, tongue cleaning alone was
also shown to be the best approach to reduce halitosis in
patients with gingivitis (44). A systematic review on the
eectiveness of mechanical tongue cleaning and tongue
coating concluded that tongue cleaning has the potential
to reduce both tongue coating and breath odour (15).
Despite this, the authors concluded that the evidence was
not yet convincing regarding the eectiveness of tongue
cleaning on halitosis. In the present study, no signicant
dierence in the eect on VSCs could be shown when
tooth- and tongue brushing were compared with toothbrushing only. This result may be partly explained by the
fact that half of the volunteers may not have had much

78

Soares et al.

tongue coating to remove and therefore received no additional eect of tongue brushing in this study.
It can be concluded, from this study, that there was
no signicant dierence between the Sr- and Zn-containing toothpastes tested, and their anti-VSC eect on
morning breath. Furthermore, a similar anti-VSC eect
was achieved by rinsing with aqueous solutions of Sr
and Zn as for toothbrushing with the test toothpastes.
The null hypothesis was therefore proven to be correct.
The fact that toothpastes containing Sr, which are
aimed at reducing dentine sensitivity, may also have a
clinical anti-VSC eect, can be important for some
patients. Patients with periodontitis usually undergo
systematic mechanical debridement of their teeth and
this often results in exposed tooth-root surfaces. Periodontitis is also very often associated with halitosis.
Periodontal patients will, in many cases, experience
dental hypersensitivity following treatment, and toothpaste that helps with this problem, and at the same
time reduces VSCs, may therefore be very useful.
Interestingly, although a signicantly higher median
salivary metal ion level was observed 12 h following
rinsing with the Zn-containing rinse compared with the
other treatments, this was not signicantly correlated
with the respective anti-VSC eect of the toothpastes
and solutions. Furthermore, as noted by other
researchers, no additional eect of tongue brushing
was seen in the volunteers in the study, who generally
had a good level of tongue hygiene before starting the
study.
Acknowledgements The authors would like to thank our volunteers, the foreign students in Oslo, Norway, for their excellent
cooperation in this study. No external funding was used for this
research apart from the support of the authors institution. Leo
G. Soares had a scholarship from CAPES/Brazil Process no.
2438-11-9.
Conicts of interest The authors declare that there are no conicts of interest for this study.

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