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Usefulness of a new malodour-compound detection portable device in oral malodour diagnosis

This content has been downloaded from IOPscience. Please scroll down to see the full text. 2013 J. Breath Res. 7 046005 (http://iopscience.iop.org/1752-7163/7/4/046005) View the table of contents for this issue, or go to the journal homepage for more Download details: IP Address: 207.162.240.147 This content was downloaded on 04/07/2017 at 07:33 Please note that terms and conditions apply.

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IOP PUBLISHING

JOURNAL OF BREATH RESEARCH

doi:10.1088/1752-7155/7/4/046005

J. Breath Res. 7 (2013) 046005 (5pp)

Usefulness of a new malodour-compound detection portable device in oral malodour diagnosis Jesica Dadamio 1,2 , Isabelle Laleman 1 , Sophie De Geest 1 , Frederique Vancauwenberghe 1 , Christel Dekeyser 1 , Wim Coucke 3 and Marc Quirynen 1,2,4 1

Department of Oral Health Sciences, KU Leuven & Dentistry, University Hospitals Leuven, Catholic University Leuven, Research Group Periodontology, Kapucijnenvoer 33, B-3000 Leuven, Belgium 2 Catholic University Leuven, Department of Oral Health Sciences, KU Leuven & Dentistry, University Hospitals Leuven, Catholic University Leuven, Research Group for Microbial Adhesion, Kapucijnenvoer 33, B-3000 Leuven, Belgium 3 Scientific Institute of Public Health, Department of Clinical Biology, Brussels, Belgium E-mail: [email protected]

Received 3 September 2013 Accepted for publication 2 October 2013 Published 1 November 2013 Online at stacks.iop.org/JBR/7/046005 Abstract R ) able to detect malodour compounds has recently been made A new device (BB Checker available. This retrospective analysis aimed at evaluating the usefulness of this device as adjunct tool for the diagnosis of oral malodour. Data from 100 consecutive volunteers with bad breath complaints attending their first consultation at a halitosis clinic were analysed. In addition to the standard protocol (organoleptic ratings from mouth and nose air, and from R measurements from mouth air; tongue coating when present; OralChromaTM and Halimeter and intra-oral examinations), oral, exhaled and nasal air samples were examined with the BB R R . We could not establish a correlation between the BB Checker values and the Checker organoleptic scores, or the sulfur-compound levels determined by the OralChromaTM or the R (R < 0.3, p > 0.05). The overall sensitivity and specificity of the new device did Halimeter not exceed the 50%. The correlations between the organoleptic scores and the R measurements were good and in line with previous reports OralChromaTM and the Halimeter R as adjunct (R between 0.56 and 0.73). Our results do not favour the use of the BB Checker tool in the diagnosis of oral malodour.

1. Introduction

this particular situation that the term ‘oral malodour’ correctly applies. The microbial activity produces a wide range of volatile compounds out of which sulfur-containing gases are the most extensively studied. Hydrogen sulphide (H2S) and methyl mercaptan (CH3SH) have been proposed as the main contributors to the unpleasant smell [3, 4]. Nowadays, the diagnosis of bad breath involves the subjective detection of the unpleasant smell (organoleptic rating), along with an objective recording of the odours compounds whenever possible. Despite its subjective nature, the organoleptic rating is still the diagnostic ‘gold standard’.

‘Bad breath’, ‘malodour’ and ‘halitosis’ are synonym terms used to describe the unpleasant smell in a person’s breath. In 2003, the American Dental Association (ADA) concluded that up to 25% of the population suffers from chronic bad breath [1]. In most of the cases (90%), this unpleasant smell originates within the oral cavity as the result of the degradation of organic substrates by anaerobic bacteria [2]. It is only in 4

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J. Breath Res. 7 (2013) 046005

J Dadamio et al

Table 1. Main characteristics of patients with and without obvious oral malodour. Since data were not normally distributed, median, upper and lower quartiles are presented (median, UQ, LQ) for some variables.

Age (years) Gender (female:male) Smokers (n) PPD (mm)∗ OHI∗ TCI∗ R (ppb)∗ Halimeter tVSC(OralChromaTM ) (ppbv)∗ H2 S(OralChromaTM ) (ppbv)∗ CH3 SH(OralChromaTM ) (ppbv)∗ R BB Checker oral (BBV) R BB Checker exhaled (BBV) R BB Checker nasal (BBV))

No oral malodour (n = 35; OLS  1)

Obvious oral malodour (n = 61; OLS  2)

32 (28–47) 19:16 8 3 (3–3) 1 (0–1) 1 (1–1) 76 (64–90) 15 (0–85) 4 (0–62) 0 (0–2) 13 (0–40) 35 (10–56) 30 (0–66)

42 (27–53) 28:33 6 4 (3–6) 2 (1–2) 2 (1–3) 150 (100–287) 412 (78–925) 257 (75–742) 57 (0–200) 14 (0–44) 35 (7–71) 30 (4–69)

(∗ ) p < 0.01 after Bonferroni’s correction for multiple comparisons; PPD: pocket probing depth; OHI: oral hygiene index; TCI: tongue coating index; tVSC: total VSC; BBV: BB value.

The human nose is the only ‘sensor’ able to detect 10 000 different odours [5]. Moreover, this method of evaluation is immediate, and reflects best how the patients’ breath is perceived by others in their environments. Gas chromatography is probably the most objective and repeatable method for the measurement of many volatile compounds [4, 6]. Unfortunately, however, its complexity and high cost make it unsuitable for routine analyses. R and Several ‘sulphide monitors’, such as the Halimeter TM and even a portable gas chromatograph, the Breathtron the OralChromaTM , have been developed over the years. These devices allow the volatile sulfur compounds (VSCs) in breath samples to be quantified with more or less specificity. R has A new portable gas detector called BB Checker recently been made available. This thin-coat tin dioxide semiconductor gas sensor is said to be capable of detecting several volatile compounds such as VSCs, hydrogen, ethanol, acetone, butyrate and ammonia. This device has been specially designed to make independent measurements of oral, exhaled and nasal air samples [7]. Our aim was to evaluate the usefulness of this new portable device in the diagnosis of oral malodour. To this end, the BB R (Oral/Breath Gas Detector mBA-21) was compared Checker with standard diagnostic tools in the examination of patients with bad breath complaints who attended a special halitosis consultation.

and to refrain from using chewing gum, mints, drops, scents or mouth rinses on the morning of the appointment. Tooth brushing with water and having breakfast were allowed in order to avoid confusion between breath malodour and morning bad breath. Upon arrival, patients were informed about the new device to be used in the study, and they were asked for their consent to doing so. All measurements were recorded between 8:30 and 11:30 in the morning, and at least 2 h after eating or drinking, and after oral hygiene. All patients were examined by the same breath specialist [2]. 2.2. Diagnostic tools Briefly, the breath samples were evaluated organoleptically R and and by means of two portable devices (Halimeter OralChromaTM ). The organoleptic evaluation preceded all other measurements, and was performed by a trained and calibrated judge, who assessed the samples using the 0–5 Rosenberg scale [8]. The evaluation included mouth and nose air samples, as well as tongue coating samples when present. The intra-oral examination included the assessment of the tongue coating’s presence and extent [6], the level of oral hygiene according to Silness and Lo¨e (1964) [9], and the pocket probing depth [2]. The full protocol has been described R was added to the in detail before [2]. In time, the BB Checker above routine clinical examination at the halitosis consultation. All devices were used according to the manufacturers’ instructions, and data were electronically stored by means of dedicated software whenever possible. R was used to analyse three sample types. The BB Checker On the one hand, oral and exhaled air samples were measured while keeping the sensor probe inside the patient’s oral cavity for 15 s while he either held his breath or exhaled after a deep inhalation. Nasal air samples, on the other hand, were measured with the help of a nose adaptor placed in one of the patient’s nostrils while he pressed his other nostril shut using one of his fingers. The sensor probe was covered with a disposable cardboard piece, which allowed us to directly insert the probe into the mouth of the different volunteers.

2. Materials and methods 2.1. Population Data from 100 consecutive patients attending their first consultation at the halitosis clinic (University Hospitals KU Leuven) were considered for analysis (Approval Ethical Committee ML9381). Prior to the examination, patients received a letter including the following instructions: to refrain from eating garlic, onion or spicy food for two days before the appointment; to refrain from drinking alcohol or coffee, and from smoking during the 12 h period before the appointment; 2

J. Breath Res. 7 (2013) 046005

J Dadamio et al

R Table 2. Spearman’s correlation between the OLS (gold standard) and the BB Checker (new device) with other breath parameters. R BB Checker

OralChromaTM

OLSbreath OLStongue coating R BB Checker oral R BB Checker exhaled R BB Checker nasal

R Halimeter

tVSC

H2S

CH3SH

Oral

Exhaled

Nasal

0.63∗ 0.73∗ 0.28 0.14 0.11

0.68∗ 0.68∗ 0.14 0.09 0.02

0.66∗ 0.68∗ 0.15 0.11 0.04

0.61∗ 0.56∗ −0.04 −0.13 −0.17

0.13 0.28

0.09 0.08 0.59∗

0.05 0.08 0.49∗ 0.93∗

tVSC: total VSC; (∗ ) p < 0.001 after Bonferroni’s correction for multiple comparisons. Table 3. Sensitivity, specificity, positive, and negative predictive values for the three devices when an OLS  2 was considered to be ‘obvious halitosis’. Device

Threshold

Sensitivity (%)

Specificity (%)

PPV (%)

NPV (%)

160 ppb 107 ppb

45.9 73.8

97.1 88.6

96.6 91.8

50.7 66.0

H2S  112 ppbv or CH3SH  26 ppbv

75.9

88.6

91.7

68.9

R BB Checker oral R BB Checker exhaled R BB Checker nasal

60 BBV

16.4 34.4 36.1

91.4 80.0 71.4

76.9 75.0 68.8

38.6 41.2 39.1

R BB Checker oral R BB Checker exhaled R BB Checkernasal

14 BBV 37 BBV 32 BBV

50.8 49.2 47.5

51.4 57.1 54.3

64.6 66.7 64.4

37.5 39.2 37.3

R Halimeter

OralChromaTM

PPV: positive predictive value; NPV: negative predictive value; BBV: BB value.

While the data from the other two portable devices were R delivers reported in parts per billion (ppb), the BB Checker arbitrary data called ‘BB values’ (BBVs) in a 0–100 range. According to the manufacturing company, this arbitrary scale follows the Weber–Fechner law, which states that ‘the magnitude of a subjective sensation increases proportional to the log of the stimulus intensity’ [7]. Even though values above 100 were recorded—as in 8/96 nasal air measurements—, these values were considered as ‘100’ for the statistics. A zero calibration was always performed at the beginning of the day before using the device.

of malodour with suspected extra-oral origin were excluded from the analysis. A total of 14 subjects were smokers, and 25 were diagnosed with gingivitis or periodontitis. ‘Obvious malodour’ (OLS  2) was diagnosed in 61 patients (64%). The presence of tongue coating alone (37/61) or in combination with periodontal disease (16/61) was the major cause of oral malodour (86.9%). Gingivitis and/or periodontitis were detected without the concomitant presence of tongue coating in seven patients (11.5%). One patient suffered from oral malodour as the result of extremely poor oral hygiene. The main characteristics of both groups are shown in table 1. Although no effort was made to keep any balances, no statistically significant differences were observed for the age, gender or number of smokers in each group. The correlations between the OLS and the data from the three devices are shown in table 2. Whereas the OLS R correlated well (p < 0.001) with the Halimeter and the TM OralChroma (H2S, CH3SH, tVSC) data, the correlation R with the BB Checker values was extremely weak and R statistically not significant. Within the BB Checker data, a good correlation was observed between the exhaled and the nasal air samples. Table 3 shows the compatibility between the three devices and the gold standard when using the manufacturers’ thresholds. Both the OralChromaTM and R the Halimeter showed a very good sensitivity ( ± 74%) R and a very good specificity (>88%). For the BB Checker , the sensitivity for all the measurements was below 40%, while the specificity varied between 71 and 91%. Even when considering an OLS  3 to be ‘obvious malodour’ as in a previous report (see discussion), no improvements were observed in the outcomes. Neither the exclusion of the smoker

2.3. Data analysis The Spearman’s rank correlation was used to assess the agreement of the different devices with respect to the organoleptic score (OLS), considered to be the gold standard. The Mann–Whitney U test was used to assess the differences between the groups. Correction for simultaneous hypothesis testing (Bonferroni’s correction) was applied when needed. The sensitivity, specificity, positive and negative predictive values for each device were calculated using the manufacturers’ thresholds. Additionally, a 107 ppb threshold previously established by our group was used R [10]. A receiver-operating characteristics for the Halimeter (ROC) curve was built to establish the optimal sensitivity and specificity combination value for each of the three R . measurements recorded with the BB Checker

3. Results Our final data base consisted of 96 patients (47 female; mean age 40.1 years) in general good health (table 1). Four cases 3

J. Breath Res. 7 (2013) 046005

J Dadamio et al R and the OralChromaTM data, both for the the Halimeter mouth air and tongue coating samples (correlation coefficient between 0.60 and 0.66), which is in line with previous reports [6, 10, 11]. R In this study, while the BB Checker showed a good specificity (>70%), the sensitivity observed turned out to be extremely low (

Usefulness of a new malodour-compound detection portable device in oral malodour diagnosis.

A new device (BB Checker) able to detect malodour compounds has recently been made available. This retrospective analysis aimed at evaluating the usef...
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