Antimicrobial Effectiveness of Cetylpyridinium Chloride

and Zinc Chloride–Containing Mouthrinses on

Bacteria of Halitosis and Peri-implant Disease
Jeong Hyun Kang, DDS, MSD1/Yun Ji Jang, MSD2/Dae Jeong Kim, DDS, PhD3/Ji Woon Park, DDS, PhD4

Purpose: To clarify the antimicrobial efficacy of zinc chloride (ZnCl2) and cetylpyridinium chloride (CPC) by
testing their impact on the growth of seven bacterial strains known to be involved in the pathophysiology of
both peri-implant disease and halitosis—Staphylococcus aureus, Streptococcus mutans, Porphyromonas
gingivalis, Prevotella intermedia, Fusobacterium nucleatum, Treponema denticola, and Tannerella forsythia.
Materials and Methods: A time-response growth curve was obtained. Commercial mouthrinses with CPC,
ZnCl2, or both were added to the media in a final concentration of 0.25% CPC, 2.5% ZnCl2, and 2.5% ZnCl2 with
0.25% CPC. Results: Both CPC and ZnCl2 effectively inhibited the growth of almost all bacterial strains tested
except T denticola. ZnCl2 was generally more effective in suppressing bacterial growth than CPC. ZnCl2 with
CPC showed the greatest inhibitory activities on almost all strains of bacterial growth except for P gingivalis
and T denticola, followed by ZnCl2, then CPC, thus suggesting the possibility of a synergistic effect of the two
agents. P gingivalis exhibited a different pattern because ZnCl2 showed the most significant inhibitory effect.
CPC did not show growth inhibitory effects on T denticola, but ZnCl2 did. Conclusion: Zinc and CPC effectively
inhibit bacterial growth that causes both halitosis and peri-implant disease. The effect is even more powerful
when applied in combination. Int J Oral Maxillofac Implants 2015;30:1341–1347. doi: 10.11607/jomi.3824

Key words: bacterial growth, cetylpyridinium chloride, halitosis, peri-implant disease, zinc chloride

I n the past 10 years, dental implants have become

one of the most frequently discussed themes in den-
tistry. The use of dental implants is widely accepted
and is considered a highly successful and predictable
treatment modality.1–3 The number of patients who
receive implant placements is increasing yearly, and
millions of dental implants are placed every year.4 In
addition, the survival of dental implants is increasing
because of technical advancements in implant design
1Resident
and Graduate Student, Department of Oral Medicine
and Oral Diagnosis, School of Dentistry and Dental Research
Institute, Seoul National University, Seoul, Korea.
2Researcher, Department of Oral Microbiology and
Immunology, School of Dentistry, Seoul National University,
Seoul, Korea.
3Adjunct Professor, Department of Oral Medicine and Oral
Diagnosis, School of Dentistry and Dental Research Institute,
Seoul National University, Seoul, Korea.
4 Assistant Professor, Department of Oral Medicine and Oral
Diagnosis, School of Dentistry and Dental Research Institute,
Seoul National University, Seoul, Korea.
Correspondence to: Dr Ji Woon Park, Orofacial Pain Clinic,
Department of Oral Medicine and Oral Diagnosis, School
of Dentistry and Dental Research Institute, Seoul National
University, 28 Yunkeun-Dong, Chongro-Ku, Seoul 110-749,
Korea. Fax: +82-2-744-9135. Email: ankara01@snu.ac.kr
©2015 by Quintessence Publishing Co Inc.
and surgical procedures, with 10-year survival rates as
high as 97% being reported.5 So dentists may encoun-
ter more complications resulting from the combined
effect of increased placement and longer survival of
dental implants.6
The true prevalence of peri-implant disease still re-
mains a controversy. However, the number of patients
with peri-implant disease is growing.7 A recent study
reported peri-implant mucositis in 63.4% and peri-im-
plantitis in 18.8% of the studied subjects.8 Peri-implan-
titis was first described by Mombelli and coworkers7
in 1987 as an infectious disease that shared features
with periodontitis, including progressive bone loss
and inflammation. Such inflammatory processes are
known to be caused by microflora characterized by a
large proportion of anaerobic gram-negative red (Por-
phyromonas gingivalis, Treponema denticola, and Tan-
nerella forsythia) and orange (Prevotella intermedia,
Fusobacterium nucleatum, and Aggregatibacter actino-
mycetemcomitans) microbiota.9 Previous studies have
shown discrepancies in defining causative microor-
ganisms of peri-implant disease. One study doubted
the relationship between A actinomycetemcomitans
and peri-implantitis because they failed to isolate it
from any implant pockets.10 Microorganisms such as
Staphylococcus aureus and Streptococcus mutans have
also been associated with peri-implantitis.11,12

The International Journal of Oral & Maxillofacial Implants 1341

© 2015 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Kang et al
Table 1  Antimicrobial Effects of ZnCl2 and
CPC on the Seven Bacterial Strains*
Intergroup
Bacterial strain significance F P
Staphylococcus (I,II), (I,III), (I,IV) 51.007
aureus
Streptococcus mutans NS 7.980
Porphyromonas NS 7.228
gingivalis
Prevotella intermedia (I,II), (I,III), (I,IV) 15.110
Fusobacterium NS 2.973
nucleatum
Treponema denticola NS 3.074
Tannerella forsythia (I,II), (I,III), (I,IV) 64.752
ZnCl2 = zinc chloride; CPC = cetylpyridinium chloride; I = control
group; II = 0.25% CPC group; III = 2.5% ZnCl2 group; IV = 2.5% ZnCl2
with 0.25% CPC group. NS = no significant difference.
*Data were obtained through repeated measures analysis of
variance. Post hoc analysis was conducted using the Bonferroni test.
**Differences were significant at P < .05.
Halitosis is an unpleasant odor arising from the oral
cavity that causes embarrassment and affects social
communication. The overall result is a reduction of
one’s quality of life.13 Halitosis is generally known to
be caused by volatile sulphur compounds (VSCs) pro-
duced by gram-negative anaerobic bacteria through
proteolytic catabolization of organic substances
originating from periodontal pockets and the tongue
dorsum.14,15 A study based on polymerase chain re-
action analysis of the tongue and subgingival plaque
of patients with halitosis identified six periodonto-
pathic bacteria, including A actinomycetemcomitans,
F nucleatum, P gingivalis, P intermedia, T forsythia, and
T denticola.16
A large portion of the microbiota that contribute
to peri-implant disease overlaps with the microbiota
known to cause halitosis. So it would be natural to infer
that those who have peri-implant disease would also
have a substantial amount of halitosis. In spite of the
common causative factor in their pathophysiology, few
studies have reported on issues concerning halitosis in
patients with peri-implant disease. The relationship be-
tween halitosis and peri-implant disease is still elusive
both clinically and theoretically. Halitosis is not a life-
threatening ailment, but the amount of psychologic
distress experienced by the patient is noteworthy.
Considering the clinical importance of halitosis and
its impact on one’s quality of life, the current lack of
any clinical and microbiologic data is problematic.
To assess the possibility of clinically applying che-
motherapeutic agents to reduce halitosis in patients
with peri-implant disease, we studied the antimicrobi-
al efficacy of zinc and cetylpyridinium chloride (CPC),
which are both known to effectively reduce halitosis-
producing bacteria.17–20 We tested the impact of zinc
1342 Volume 30, Number 6, 2015
© 2015 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
and CPC on seven bacterial strains reported to play a
role in the pathophysiology of both peri-implant dis-
ease and halitosis.
.000**
MATERIALS AND METHODS
.025**
.026** Chemicals and Microbiologic Media
Chemicals were all analytic grade or better and were
.000** obtained from Sigma Chemical unless otherwise indi-
.132 cated. Microbiologic media, including supplements,
were obtained from Becton Dickinson (B-D) and pre-
.153
pared according to the manufacturer’s instructions.
.000**
Preparation of Bacteria
The seven laboratory strains of bacteria used were
obtained from the Department of Microbiology and
Immunology of the School of Dentistry at Seoul Na-
tional University. The seven strains included F nu-
cleatum (ATCC 25586), P gingivalis (ATCC 33277),
P intermedia (ATCC 25611), T denticola (ATCC 33521),
T forsythia (ATCC 43037), S aureus (ATCC 29213), and
S mutans (ATCC 25175). All bacteria were stored
in a sterile vial at –70.0°C. Growth of F nucleatum,
P gingivalis, and P intermedia was carried out in brain heart
infusion broth (Difco Laboratories) containing hemin
(10.0 μL/mL) and vitamin K (1.0 μL/mL) (Sigma-Aldrich).
T denticola and T forsythia were grown in modified new
oral spirochete medium (12.5 g/L of brain heart infu-
sion broth; 10 g/L of trypticase; 2.5 g/L of yeast extract;
0.5 g/L of sodium thioglycolate; 1 g/L of L-cystein;
0.25 g/L of L-asparagine; 0.2% sodium bicarbon-
ate; 50.0 mL of heat-inactivated fetal bovine serum;
0.0006% thiamine pyrophosphate; pH 7.4) (Sigma-
Aldrich).21 S aureus and S mutans were grown in tryp-
tic soy broth (Sigma-Aldrich). All bacteria suspensions
were incubated at 37.0°C under anaerobic conditions
for 24 hours before adding mouthrinse solution con-
taining zinc and/or CPC.
Antimicrobial Agents
Mouthrinses with CPC, zinc chloride (ZnCl2), or both
(Hambakwooseum Bio) were commercially obtained.
This specific mouthrinse was selected because it did
not have any additives, including alcohol and pre-
servatives, which could substantially affect microbial
activities. The three different agents were added to
the media at a final concentration of 0.25% CPC, 2.5%
ZnCl2, and 2.5% ZnCl2 with 0.25% CPC. Each agent also
contained sorbitol, glycerine, propylene glycol, mono-
sodium phosphate, flavor, and purified water.
Direct Exposure Test
To monitor the antimicrobial effects of the agents, a
time-response growth curve was obtained. The agents

1.4 
1.2  1.2
1.0  1.0  CPC + ZnCI2
OD (600 nm)
0.8  Control
CPC
0.6  0.6
ZnCI2
0.4  CPC + ZnCI2
0.2  0.2
0 
0 2 4 6 8 10 12
Time (h)
Fig 1   The antimicrobial effects of CPC and ZnCl2 on Staphylo-
coccus aureus (ATCC 29213) at concentrations of 0.25% CPC,
2.5% ZnCl2, and 2.5% ZnCl2 with 0.25% CPC.
were added to the broth containing each bacterial
strain and then incubated under anaerobic conditions
at 37.0°C. The growth phase was determined by mea-
suring the optical density (OD) of the cultures at 600 nm
at 1- or 2-hour intervals using a spectrophotometer and
analysis software (SoftMax). The initial OD was set to
approximately 0.2. The experiments were performed in
triplicate. Media without any antimicrobial agent served
as a negative control in each experimental condition.
The whole experiment was performed three times.
Statistical Analysis
The statistical differences among initial ODs of the dif-
ferent groups were analyzed using the Kruskal-Wallis
one-way analysis of variance (ANOVA). The statistical
differences among the inhibitory effects of each agent
were analyzed with repeated measures ANOVA fol-
lowed by post hoc analysis with the Bonferroni test.
Differences with the respective controls were con-
sidered to be statistically significant at P < .05.
RESULTS
The initial ODs of all seven bacterial strains did not
show any statistically significant differences among
groups (data not shown). Both CPC and ZnCl2 ef-
fectively inhibited the growth of almost all bacterial
strains tested except T denticola. The normal growth
pattern was interrupted after approximately 3 hours
following exposure to the test agent. ZnCl2 was gen-
erally more effective than CPC in suppressing bacte-
rial growth, but the difference was not statistically
significant. ZnCl2 with CPC showed the greatest inhibi-
tory activity on bacterial growth, followed by ZnCl2
and then CPC, and this pattern was most evident in F
© 2015 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Kang et al
1.4  Control
CPC
 
ZnCI2
OD (600 nm)
0.8 
 
0.4 
 
0 
0 2 4 6 8 10 12
Time (h)
Fig 2   The antimicrobial effects of CPC and ZnCl2 on Strepto-
coccus mutans (ATCC 25175) at concentrations of 0.25% CPC,
2.5% ZnCl2,and 2.5% ZnCl2 with 0.25% CPC.
1.4  Control
CPC
1.2 
ZnCI2
1.0 
CPC + ZnCI2
OD (600 nm)
0.8 
0.6 
0.4 
0.2 
0 
0 4 8 12 16 20
Time (h)
Fig 3  The antimicrobial effects of CPC and ZnCl2 on Porphy-
romonas gingivalis (ATCC 33277) at concentrations of 0.25%
CPC, 2.5% ZnCl2, and 2.5% ZnCl2 with 0.25% CPC.
nucleatum. CPC and ZnCl2 showed potential synergism
in inhibiting bacterial growth. ZnCl2 and CPC showed
statistically significant inhibitory effects on the
growth of S aureus, S mutans, P gingivalis, P intermedia,
and T forsythia compared with the control group
(Table 1). Five bacterial strains showed similar pat-
terns of growth inhibition: P intermedia, F nucleatum,
S aureus, S mutans, and T forsythia. On the other hand,
P gingivalis exhibited a different pattern with ZnCl2
showing the most significant inhibitory effect, but the
difference between CPC and ZnCl2 with CPC was not
statistically significant. CPC did not show growth in-
hibitory effects on T denticola, whereas ZnCl2 did show
some inhibitory effects. The antimicrobial effects of
each agent on the bacterial growth curves are shown
in Figs 1 to 7, and the inhibitory effect expressed in
percentage of OD values is given in Table 2.
The International Journal of Oral & Maxillofacial Implants 1343
Kang et al

Control 1.4  Control

1.4 
CPC 1.2  CPC
1.2 
ZnCI2 ZnCI2
1.0  1.0 
CPC + ZnCI2 CPC + ZnCI2
0.8 
OD (600 nm)

OD (600 nm)
0.8 
0.6  0.6 
0.4  0.4 
0.2  0.2 
0  0 
0 4 8 12 16 20
0 4 8 12 16 20
Time (h) Time (h)

Fig 4   The antimicrobial effects of CPC and ZnCl2 on Prevotella Fig 5   The antimicrobial effects of CPC and ZnCl2 on Fusobacte-
intermedia (ATCC 25611) at concentrations of 0.25% CPC, 2.5% rium nucleatum (ATCC 25586) at concentrations of 0.25% CPC,
ZnCl2, and 2.5% ZnCl2 with 0.25% CPC. 2.5% ZnCl2, and 2.5% ZnCl2 with 0.25% CPC.

Control
1.4 
CPC
1.4  Control
1.2  ZnCI2
1.2  CPC
1.0  CPC + ZnCI2
ZnCI2
1.0 
CPC + ZnCI2 0.8 
OD (600 nm)

OD (600 nm)
0.8 
0.6  0.6 

0.4  0.4 
0.2  0.2 
0  0 
0 8 16 24 32 40 48 56 64 72 0 4 8 12 16 20 24 28 32 36 40
Time (h) Time (h)

Fig 6   The antimicrobial effects of CPC and ZnCl2 on Treponema Fig 7   The antimicrobial effects of CPC and ZnCl2 on Tannerella
denticola (ATCC 33521) at concentrations of 0.25% CPC, 2.5% forsythia (ATCC 43037) at concentrations of 0.25% CPC, 2.5%
ZnCl2, and 2.5% ZnCl2 with 0.25% CPC. ZnCl2, and 2.5% ZnCl2 with 0.25% CPC.

Table 2 Inhibition Level of Bacterial Growth DISCUSSION

with ZnCl2 and CPC*
CPC + ZnCl2 The results of the present study show that both CPC
Bacteria strain CPC (%) ZnCl2 (%) (%) and zinc effectively suppress the growth of bacteria
Staphylococcus 80.37 89.13 90.76 involved in the pathophysiology of halitosis and peri-
aureus implant disease, whereas zinc more efficiently inhibits
Streptococcus 73.43 55.24 82.09 bacterial growth than CPC under given concentrations.
mutans The market of mouthrinses for controlling halitosis
Porphyromonas 83.27 88.83 81.88 has quickly grown and has become the most easily
gingivalis selected treatment for halitosis by the general popu-
Prevotella 87.29 87.01 87.94 lation.22 In spite of the increasing number of formula-
intermedia tions in the market, the scientific evidence supporting
Fusobacterium 70.70 78.95 97.31 their efficacy is inconclusive.17 Mouthrinses are less
nucleatum limited in reaching and removing VSC-producing bac-
Treponema NS 55.56 23.59 teria from intraoral areas with restricted accessibility
denticola compared to mechanical methods. Controversy still ex-
Tannerella 64.09 83.70 85.93 ists as to which is the most effective agent for halitosis
forsythia control, its ability to reach deep pockets, and its phar-
ZnCl2 = zinc chloride; CPC = cetylpyridinium chloride; NS = not macologic characteristics, such as substantivity and
significant.
*Inhibition levels are expressed in percentage of final optical density minimum inhibitory concentrations. A recent system-
compared with control values. atic review showed that CPC-containing mouthrinses

1344 Volume 30, Number 6, 2015

© 2015 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

may have an important role in reducing halitosis-pro-
ducing bacteria from the tongue, and zinc-containing
mouthrinses can effectively neutralize VSCs.17
CPC is a positively charged amphiphilic compound
that binds to negatively charged bacterial cell walls
and consequently breaks down the bacterial wall while
also inhibiting insoluble glucan synthesis.23–25 CPC has
been used safely and effectively as a component of oral
hygiene products for a long time. Studies indicate that
CPC reduces dental plaque and gingivitis.26 A study
evaluating two over-the-counter CPC mouthrinses
demonstrated broad-spectrum antimicrobial activity
against laboratory strains and plaque bacteria.20 Zinc,
another longstanding anti-halitosis substance, has also
been mixed into numerous oral hygiene products, and
its efficacy in reducing VSCs has been proven.27–29 Un-
like CPC, the antibacterial mechanism of zinc has not
been clearly identified yet. Zinc has a known effect on
glycolysis in oral bacteria and inhibits thiol proteinase
activity related to VSC production.30,31 In addition to its
antimicrobial effects, cationic free zinc ions show strong
binding affinity with anionic sulphide ions and oxidize
the sulphydryl group to form an insoluble nonvolatile
complex that can be easily removed.32 In a study using
gas chromatography to compare the concentration-
dependent effect of zinc, CPC, and chlorhexidine on VSC
levels, zinc significantly lowered VSC levels, whereas CPC
was no better than distilled water at a concentration of
0.025%.33 The results of the present study corroborate
such reports by providing microbiological data show-
ing that zinc suppresses bacterial growth more effi-
ciently than CPC. Interestingly, the results of the present
study show that though less than zinc, 0.25% CPC also
inhibits bacterial growth. This fact necessitates further
verification because this may reflect an enhanced anti-
microbial effect of CPC at a higher concentration. Few
studies evaluated the combined effect of zinc and CPC
on halitosis. A previous study showed that zinc and
CPC had a synergistic inhibitory effect on VSC levels
with gas chromatography.34 Another study reported on
the reduction of bacteria from tongue coating, saliva,
and subgingival areas with a commercial mouthrinse
containing chlorhexidine, CPC, and zinc lactate.19 Even
though the synergism between CPC and zinc in reduc-
ing VSC production has been inferred, microbiologic
data supporting such findings have not been available
until now. The results of the present study show that
the two substances synergistically suppress bacterial
growth in certain bacterial strains, hence suggesting
that together these two substances can reduce VSCs
more effectively than when applied separately. Such
findings suggest a different operation mechanism of
the two agents and should be considered when devel-
oping anti-halitosis mouthrinses for patients with peri-
implant disease.
© 2015 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Kang et al
Although the precise microbial mechanism and
relationship between halitosis and peri-implant dis-
ease remains obscure, the bacterial species tested in
this study were selected based on their mutual role
in both peri-implant disease35 and halitosis.16,36,37 Ac-
cording to the present results, the antibacterial ac-
tivity of each sample showed a similar pattern in five
bacterial strains (P intermedia, F nucleatum, S aureus, S
mutans, and T forsythia), whereas P gingivalis differed
from the other species in that zinc showed better
bactericidal activity than CPC and the combination
of zinc and CPC. The sensitivity of P gingivalis to zinc
has been reported previously. However, other results
are contradictory. A study on the antimicrobial activity
of metal ions reported that zinc salts failed to exhibit
strong activity against periodontal pathogens includ-
ing P gingivalis.38 However, the results of the present
study showed that zinc efficiently suppressed bacterial
growth and P gingivalis also showed the same effect.
Previous microbiologic studies showed that sensitiv-
ity to antibacterial agents varies according to different
bacterial strains.38 The antimicrobial activity of CPC
on T denticola was questionable in the study, but few
studies exist to provide the rationale for such lack of
activity. Such diversity in the effect of chemotherapeu-
tic agents on different bacterial strains indicates the
need to develop and apply different combinations of
antihalitosis agents according to individual microflora
rather than treating different patients en bloc. The first
step to such customized treatment would be addi-
tional microbial studies with a wider range of bacte-
rial strains involved in both halitosis and peri-implant
disease. Diverse antimicrobial agents should be tested
in this process in both single and combination therapy.
Also, the fact that distributions of bacteria vary accord-
ing to different sites of the oral cavity suggests that
the use of mouthrinses should be further subdivided
based on the bacterial cause of halitosis and its site of
origin. In patients with peri-implant disease who have
deep pockets around implant fixtures, F nucleatum
would be the major residing bacteria, so this should be
considered in the selection of mouthrinse.19 The need
for individualized halitosis treatment could be further
supported by the fact that different bacteria produce
different VSCs.39,40 Therefore, a patient with halitosis
should be differentiated not only based on the total
level of measured VSCs as is currently practiced, but
also according to the dominant type of oral micro-
flora and VSCs through microbiologic analysis and gas
chromatography.
In addition to the psychologic distress caused by
halitosis, VSCs may further aggravate the inflammation
of peri-implant disease, causing accelerated alveolar
bone loss and final implant failure. VSCs exhibit toxic-
ity to human gingival fibroblasts and epithelial cells.
The International Journal of Oral & Maxillofacial Implants 1345
Kang et al
Their penetration into the gingival pocket epithelium
may lead to collagen, bone degradation, and delayed
wound healing.41 So halitosis should be actively and
early treated not only for social reasons but also to
suppress inflammation and increase the implant’s lon-
gevity. Such facts increasingly magnify the need for
studies concerning halitosis and peri-implant disease.
One limitation of the current study is that there
were no attempts to study the interaction among bac-
teria as occurs in a natural oral environment. It is also
necessary to point out that this was an in vitro study.
To overcome such limitations, future studies should
be conducted as both ex vivo and in vivo evalua-
tions. The need to use oral bacteria directly from the
oral cavity and also with a biofilm model is support-
ed by the fact that a biofilm model of growth affects
the antimicrobial susceptibility of microorganisms.42
Although the growth of almost all bacterial strains
tested in this study was efficiently inhibited, this was
not always reflected in results of statistical analyses be-
cause of the sample size, though the number of tests
conducted was sufficient from a microbiologic aspect.
Future studies should include a larger sample size to
overcome such technical problems. The results of this
study remain incomplete with regard to direct applica-
tion in a clinical setting. However, the results do show
the possibility of patients with peri-implant disease us-
ing mouthrinses for controlling periodontal infection
and resulting halitosis because of the shared microbial
pathophysiology of these two conditions. Considering
the lack of even the most basic level of data, the first
approach to halitosis in the peri-implant disease popu-
lation would be to gain objective clinical data on the
incidence, level, and characteristics of halitosis in this
patient group with measurements using a portable
VSC measurement device, gas chromatography, and
organoleptic methods. Also, other possible causes of
halitosis in peri-implant disease, such as concomitant
periodontitis or systemic conditions, should be inves-
tigated with well-defined patient groups. Following
that step, oral bacteria could be harvested and evalu-
ated on culture to gain insight into the microbiologic
cause of halitosis in this specific disease population.
Mouthrinses containing agents previously known to
be effective against halitosis also should be studied
both clinically and microbiologically to help develop
effective treatment tools for halitosis in patients with
peri-implant disease.
CONCLUSIONS
The problem of halitosis in the peri-implant disease
group is likely to occur considering their common
microbiologic pathophysiology. Currently, the data
1346 Volume 30, Number 6, 2015
© 2015 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
supporting this concept are lacking. This study showed
that a combination of CPC and zinc effectively inhib-
its problematic bacteria for both halitosis and peri-
implant disease; these results would be a meaningful
start to further research. Such results could be applied
in the development of mouthrinses that are specifi-
cally effective for the peri-implant disease group.
ACKNOWLEDGMENTS
The authors reported no conflicts of interest related to this study.
REFERENCES
  1. Aglietta M, Siciliano VI, Zwahlen M, et al. A systematic review of the
survival and complication rates of implant supported fixed dental
prostheses with cantilever extensions after an observation period
of at least 5 years. Clin Oral Implants Res 2009;20:441–451.
  2. Jung RE, Pjetursson BE, Glauser R, Zembic A, Zwahlen M, Lang
NP. A systematic review of the 5-year survival and complication
rates of implant-supported single crowns. Clin Oral Implants Res
2008;19:119–130.
  3. Lang NP, Pjetursson BE, Tan K, Bragger U, Egger M, Zwahlen M. A
systematic review of the survival and complication rates of fixed
partial dentures (FPDs) after an observation period of at least 5
years. II. Combined tooth—implant-supported FPDs. Clin Oral
Implants Res 2004;15:643–653.
  4. Nolan R, Kemmoona M, Polyzois I, Claffey N. The influence of
prophylactic antibiotic administration on post-operative morbidity
in dental implant surgery. A prospective double blind randomized
controlled clinical trial. Clin Oral Implants Res 2014;25:252–259.
  5. Balshi TJ, Wolfinger GJ, Slauch RW, Balshi SF. A retrospective analysis
of 800 Brånemark system implants following the all-on-four proto-
col. J Prosthodont 2014;23:83–88.
  6. Tonetti MS. Risk factors for osseodisintegration. Periodontol 2000
1998;17:55–62.
  7. Mombelli A, Muller N, Cionca N. The epidemiology of peri-implanti-
tis. Clin Oral Implants Res 2012;23(suppl 6):67–76.
  8. Atieh MA, Alsabeeha NH, Faggion CM, Jr, Duncan WJ. The frequency
of peri-implant diseases: A systematic review and meta-analysis. J
Periodontol 2012;84:1586–1598.
  9. Shibli JA, Melo L, Ferrari DS, Figueiredo LC, Faveri M, Feres M. Com-
position of supra- and subgingival biofilm of subjects with healthy
and diseased implants. Clin Oral Implants Res 2008;19:975–982.
10. van Winkelhoff AJ, Goene RJ, Benschop C, Folmer T. Early coloniza-
tion of dental implants by putative periodontal pathogens in par-
tially edentulous patients. Clin Oral Implants Res 2000;11:511–520.
11. Harris LG, Mead L, Muller-Oberlander E, Richards RG. Bacteria and
cell cytocompatibility studies on coated medical grade titanium
surfaces. J Biomed Mater Res A 2006;78:50–58.
12. Renvert S, Lindahl C, Renvert H, Persson GR. Clinical and micro-
biological analysis of subjects treated with Brånemark or Astra­
Tech implants: A 7-year follow-up study. Clin Oral Implants Res
2008;19:342–347.
13. Rayman S, Almas K. Halitosis among racially diverse populations: An
update. Int J Dent Hyg 2008;6:2–7.
14. Tonzetich J. Production and origin of oral malodor: A review of
mechanisms and methods of analysis. J Periodontol 1977;48:13–20.
15. Waler SM. On the transformation of sulfur-containing amino acids
and peptides to volatile sulfur compounds (VSC) in the human
mouth. Eur J Oral Sci 1997;105:534–537.
16. Yasukawa T, Ohmori M, Sato S. The relationship between physi-
ologic halitosis and periodontopathic bacteria of the tongue and
gingival sulcus. Odontology 2010;98:44–51.

17. Fedorowicz Z, Aljufairi H, Nasser M, Outhouse TL, Pedrazzi V.
Mouthrinses for the treatment of halitosis. Cochrane Database Syst
Rev 2008:1–23.
18. Rioboo M, Garcia V, Serrano J, O’Connor A, Herrera D, Sanz M.
Clinical and microbiological efficacy of an antimicrobial mouth
rinse containing 0.05% cetylpyridinium chloride in patients with
gingivitis. Int J Dent Hyg 2012;10:98–106.
19. Roldan S, Winkel EG, Herrera D, Sanz M, Van Winkelhoff AJ. The
effects of a new mouthrinse containing chlorhexidine, cetylpyri-
dinium chloride and zinc lactate on the microflora of oral halitosis
patients: A dual-centre, double-blind placebo-controlled study. J
Clin Periodontol 2003;30:427–434.
20. Sreenivasan PK, Haraszthy VI, Zambon JJ. Antimicrobial efficacy of
0.05% cetylpyridinium chloride mouthrinses. Lett Appl Microbiol
2013;56:14–20.
21. Leschine SB, Canale-Parola E. Rifampin as a selective agent for isola-
tion of oral spirochetes. J Clin Microbiol 1980;12:792–795.
22. Ayers KM, Colquhoun AN. Halitosis: Causes, diagnosis, and treat-
ment. N Z Dent J 1998;94:156–160.
23. Pitten FA, Kramer A. Efficacy of cetylpyridinium chloride used as
oropharyngeal antiseptic. Arzneimittelforschung 2001;51:588–595.
24. Furiga A, Dols-Lafargue M, Heyraud A, Chambat G, Lonvaud-Funel
A, Badet C. Effect of antiplaque compounds and mouthrinses on
the activity of glucosyltransferases from Streptococcus sobri-
nus and insoluble glucan production. Oral Microbiol Immunol
2008;23:391–400.
25. Steinberg D, Bachrach G, Gedalia I, Abu-Ata S, Rozen R. Effects
of various antiplaque agents on fructosyltransferase activity in
solution and immobilized onto hydroxyapatite. Eur J Oral Sci
2002;110:374–379.
26. Haps S, Slot DE, Berchier CE, Van der Weijden GA. The effect of
cetylpyridinium chloride-containing mouth rinses as adjuncts to
toothbrushing on plaque and parameters of gingival inflammation:
A systematic review. Int J Dent Hyg 2008;6:290–303.
27. Navada R, Kumari H, Le S, Zhang J. Oral malodor reduction from a
zinc-containing toothpaste. J Clin Dent 2008;19:69–73.
28. Porciani PF, Grandini S. The effect of zinc acetate and magnolia
bark extract added to chewing gum on volatile sulfur-containing
compounds in the oral cavity. J Clin Dent 2012;23:76–79.
© 2015 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Kang et al
29. Young A, Jonski G. Effect of a single brushing with two Zn-contain-
ing toothpastes on VSC in morning breath: A 12 h, randomized,
double-blind, cross-over clinical study. J Breath Res 2011;5:046012.
30. He G, Pearce EI, Sissons CH. Inhibitory effect of ZnCl(2) on glycolysis
in human oral microbes. Arch Oral Biol 2002;47:117–129.
31. Yaegaki K, Suetaka T. The effect of mouthwash on oral malodour
production [in Japanese]. Shigaku 1989;76:1492–1500.
32. Southard GL, Parsons LG, Thomas LG, Jr, Boulware RT, Woodall IR,
Jones BJ. The relationship of sanguinaria extract concentration and
zinc ion to plaque and gingivitis. J Clin Periodontol 1987;14:315–319.
33. Young A, Jonski G, Rolla G. Inhibition of orally produced volatile sul-
fur compounds by zinc, chlorhexidine or cetylpyridinium chloride-
-effect of concentration. Eur J Oral Sci 2003;111:400–404.
34. Young A, Jonski G, Rolla G. Combined effect of zinc ions and cat-
ionic antibacterial agents on intraoral volatile sulphur compounds
(VSC). Int Dent J 2003;53:237–242.
35. Rutar A, Lang NP, Buser D, Burgin W, Mombelli A. Retrospective
assessment of clinical and microbiological factors affecting periim-
plant tissue conditions. Clin Oral Implants Res 2001;12:189–195.
36. Loesche WJ, Kazor C. Microbiology and treatment of halitosis.
Periodontol 2000 2002;28:256–279.
37. Lee CH, Kho HS, Chung SC, Lee SW, Kim YK. The relationship
between volatile sulfur compounds and major halitosis-inducing
factors. J Periodontol 2003;74:32–37.
38. Spacciapoli P, Buxton D, Rothstein D, Friden P. Antimicrobial activity
of silver nitrate against periodontal pathogens. J Periodontal Res
2001;36:108–113.
39. Yoshida Y, Ito S, Kamo M, et al. Production of hydrogen sulfide by
two enzymes associated with biosynthesis of homocysteine and
lanthionine in Fusobacterium nucleatum subsp. nucleatum ATCC
25586. Microbiology 2010;156:2260–2269.
40. Yoshimura M, Nakano Y, Yamashita Y, Oho T, Saito T, Koga T. Forma-
tion of methyl mercaptan from L-methionine by Porphyromonas
gingivalis. Infect Immun 2000;68:6912–6916.
41. Yaegaki K, Qian W, Murata T, et al. Oral malodorous compound
causes apoptosis and genomic DNA damage in human gingival
fibroblasts. J Periodontal Res 2008;43:391–399.
42. ten Cate JM. Biofilms, a new approach to the microbiology of dental
plaque. Odontology 2006;94:1–9.
The International Journal of Oral & Maxillofacial Implants 1347