Effects of aroma mouthwash on stress level, xerostomia, and halitosis in healthy nurses: A non-randomized controlled clinical trial

Accepted Manuscript Title: Effects of aroma mouthwash on stress level, xerostomia, and halitosis in healthy nurses: a non-randomized controlled clinical trial Author: Eun-Young Seo Ji-Ah Song Myung-Haeng Hur Mi-kyoung Lee Myeong Soo Lee PII: DOI: Reference:

S1876-3820(17)30032-X http://dx.doi.org/doi:10.1016/j.eujim.2017.03.001 EUJIM 654

To appear in: Received date: Revised date: Accepted date:

8-4-2016 3-3-2017 3-3-2017

Please cite this article as: Seo E-Y, Song J-A, Hur M-H, Lee M-k, Lee MS, Effects of aroma mouthwash on stress level, xerostomia, and halitosis in healthy nurses: a nonrandomized controlled clinical trial, European Journal of Integrative Medicine (2017), http://dx.doi.org/10.1016/j.eujim.2017.03.001 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Effects of aroma mouthwash on stress level, xerostomia, and halitosis

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in healthy nurses: a non-randomized controlled clinical trial

Eun-Young Seoa , Ji-Ah Songb, Myung-Haeng Hurc,* , Mi-kyoung Leec , Myeong Soo

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Eulji University Hospital, Daejeon, Republic of Korea

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Department of Nursing, Woosong College, Daejeon, Republic of Korea

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College of Nursing, Eulji University, Daejeon, Republic of Korea

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Clinical Research Division, Korea Institute of Oriental Medicine, Daejeon, Republic of

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Korea

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Running title: Aroma mouthwash for stress level in nurses

Funding : None

* Corresponding author Myung-Haeng Hur, PhD, RN College of Nursing, Eulji University 77 Gyeryong-ro771 beon-gil, Jung-gu, Daejeon 34824 Republic of Korea Tel: 82(0)10-3348-0870 E-mail: [email protected], [email protected]

Word count: 4158 Ref: 41

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Abstract Introduction: Stress may increase halitosis. As aromatherapy is known to reduce stress, this study aimed to investigate the effects of aroma mouthwash using peppermint, lemon, teatree,

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and ylang ylang oil on stress level, xerostomia, halitosis, and salivary pH of nurses. Methods: One hundred twenty nurses were allocated to one of three groups, aroma

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gargling(N=40), saline gargling (N=40) or no-treatment (N=40). The aromatic gargle solution

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was blended by a certified aromatherapist and researcher. Peppermint (mentha piperita), lemon (citrus limon), tea tree (melaleuca alternifolia), and ylang ylang (cananga odorata)

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were mixed in 1: 1: 2: 1 ratios. For gargling, the nurses who consented to participate in the study used 15 - 30 cc of the blended aromatic gargle solution 3 times every day. The time

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spent on gargling was about 10 - 15 seconds each time.

Results: The perceived stress in the aroma gargling group lowered significantly compared

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with control group and saline group at 10 (p<.001) and 30 minutes (p<.001). Xerostomia in

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the aroma group decreased significantly compared with the saline solution and control groups after the treatment (p<.001). Aroma gargling reduced objective halitosis (p<.001 after 10minutes; p<.001after 30 minutes). Salivary pH in the aroma group significantly increased compared with control and saline group (p<.001 after10 minutes; p<.001 after 30minutes). Conclusion: The aroma gargle was an effective intervention for relieving stress of the nurses, decreasing xerostomia, and reducing objective halitosis. Using an aroma gargle may enhance the quality of life of nurses.

Keywords: aromatherapy; gargling; mouthwash; stress; halitosis; non-randomised controlled trial

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Introduction Nurses, as medical professionals, should not only provide high-quality nursing services, but also satisfy healthcare consumers' demands in order to meet health needs. However, nurses

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due to insufficient nursing manpower, heavy workload, and change of work shifts, it is

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difficult for them to take time off. It is therefore important for them to acquire self -help approaches and techniques which can ameliorate stress and its sequala. Especially, juggling

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pregnancy and childcare within shift work adds even more stress [1]. Symptoms of stress in nurses appear to be higher than the average worker, and interventions to manage such

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symptoms in clinical nurses should be a priority [2]. If prolonged stress is not addressed, it

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will have physical and psychological effects and impact on quality of life and well-being. As well as increasing susceptibility to illness it may also impact on the quality of patient care by

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potentially affecting task efficiency and work motivation [3, 4] .

Generally, stress may induce physiological changes to body functions such as the nervous system, endocrine system, immune system, etc. [5], and may affect oral health and bad breath [6, 7]. Studies on the relationship between stress and diseases in the oral area show that there is a correlation between stress and various symptoms and signs such as dry mouth, bad breath, other intra-oral diseases, etc [8-10]. Subjective xerostomia is related to psychological factors [6], and stress-related medical history is observed mostly in those who experience oral dryness [11]. Stress reduces the salivary flow rate and increases the concentration of volatile sulfur compounds that result in halitosis [7, 12, 13]. The salivary flow rate and pH are closely related to bad breath: As the salivary flow amount decreases, the density of microorganisms in the saliva increases, leading to a reduction in deglutition movements which means the contact time of microorganisms on the tongue and sulfur-containing substances in the saliva 3

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is longer [14]. Also, the lower the salivary pH, the more halitosis [15].

Halitosis, an unpleasant odor present on the exhaled breath, greatly affects one's social life. Besides, it makes nurses, who deal with many patients and medical professionals, feel

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discouraged psychologically and may cause others as well as the nurses themselves feel

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uncomfortable. Furthermore, if one has bad breath, they cannot talk with others confidently and convey everything he/she needs to say because they worry that their bad breath might

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make others feel unpleasant. Consequently, it is likely that people who have many

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interpersonal relations have a problem with social life [16].

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For nurses, stress may induce saliva secretion to decrease and halitosis to increase. Since bad breath can make nurses themselves and others feel uncomfortable and embarrassed , and

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active intervention to reduce halitosis is crucial. Complementary and alternative therapies are

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used more and more to relieve stress. Therapies include music, meditation, exercise, dietary therapy, etc., and the scope is wide. Among them, aromatherapy, a type of treatment that has almost no side effects, helps maintain physical, mental and psychological health and promotes energy, using aromatic compounds extracted from plants [17, 18]. The experimental treatment in this study was to let them gargle with aroma gargling solution blended by certified aromatherapist. Aroma gargling solution was blended with peppermint (Mentha piperita) as a refreshing essential oil, lemon(Citrus limon) as a antimicrobial oil, tea tree(Melaleuca alternifolia) as an antibacterial oil and ylang-ylang(Cananga odorata) as a stress reduction oil [18]. Moreover, research recognizes that it demonstrates treatment effects such as anti-bacterial and anti-microbial effects, wound healing, immune-boosting effects, anti-depression and soothing effects, etc. depending on the characteristics of oils [17, 18]. In particular, an oral rinse made with aroma oils has antioxidant, anti-inflammatory, and anti4

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microbial effects, so it is effective in alleviating halitosis in average people[19], critical patients [20], and fasting patients [21-24]. Additionally, when manuka and kanuka, among aromatherapy essential oils, were used, they had a positive effect on stomatitis induced by

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radiation therapy [25].

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Research about the use of aromatherapy to release stress show that aroma inhalation has a positive effect on stress of healthy adults [26-28], and studies for which nurses were selected

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as subjects also have found that aroma inhalation and massage are effective in relieving stress [29, 30]. Therefore, aromatherapy essential oils may be effective in reducing bad breath and

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stress.

For that reason, this study aimed to verify the effects of aromatherapy by using it in order to

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achieve both effects reducing xerostomia and halitosis on top of relieving stress. Specifically,

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using aromatic gargle solutions among the methods of using aromatherapy is a good way for consumers to use it on their own as an effective approach to reducing halitosis. An aromatherapy textbook was used to identify which oils were appropriate and peppermint, spearmint, rosemary, lemon, mandarin were chosen to rinse mouth to achieve fresher breath [31]. Therefore, this study used aromatherapy as a way of relieving stress in nurses, by using and an aromatic gargle solution was applied among others. In particular, stress is one of the factors that causes xerostomia, which then induces halitosis by decreasing the salivary flow rate. Therefore, xerostomia, halitosis and salivary pH were compared as well as stress of nurses in this study in order to verify the effects of aromatherapy.

Therefore, this study attempted to compare the use of an aromatic gargle as intervention to reduce stress and halitosis in nursing staff with saline gargle or no treatment, 5

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Participants and methods Study design This study was a non-randomized controlled trial. Aromatherapy gargling solution was uses

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by the experimental group, saline was used for the placebo group, and no treatment was given to the control group. Stress, xerostomia, halitosis, and salivary pH were measured as

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the outcome variables to confirm the effect of experimental treatment.

Participants

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The study subjects were nurses working for the Eulji University Hospital in the Daejeon city. According to the inclusion criteria, this study selected dayshift nurses who worked in the ICU,

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understood the purpose of this study, provided a written consent to participating in the study by a research assistant, and had no contraindications for aromatherapy. The exclusion criteria

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in this study were pregnancy and allergy to aroma essential oils.

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The study protocol was reviewed and approved by the Institutional Review Board of the Eulji University Hospital that the investigator belonged to (11-089). The study commenced after participants had provided their written consent. An ID number was allocated to each participant to ensure anonymity and to conform with data protection.

Intervention

The experimental treatments in this study were blending aromatherapy essential oils and applying the diluted solution by gargling. The used aroma products and solubilizer were manufactured by Neumond (Germany) and Dr. Wendy Maddocks-Jennings, Natural Products New Zealand (New Zealand). The aromatic gargle solution was blended by a researcher who was a certified aromatherapist, mixing peppermint (mentha piperita) that is refreshing, lemon

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(citrus limon) that is effective in sterilizing and reinforcement of immunity, tea tree (melaleuca alternifolia) that has an excellent sterilizing effect, and ylang ylang (cananga odorata) that has disinfection and anti-stress effects in 1: 1: 2: 1 ratio. This mixture was dissolved in a solubilizer (oil-soluble substance used in routine aroma care, MJ Health LTD,

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New Zealand), then diluted in deionized water to 0.15%, and refrigerated before use. Because

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aroma essential oil does not dissolve in water and floats in water and we used solubilizer in this study. In this blended essential oil, lemon and tea tree oils, which have antibacterial and

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immune-boosting effects, prevent bad breath and oral infections[21], and peppermint is a cooling aroma oil that effectively controls tea tree aroma [25]. Ylang ylang is an essential oil

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with anti-stress, disinfection, soothing and anti-depression effects.

For gargling, the nurses who consented to participate in the study used 15 - 30 cc of the

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blended aromatic gargle solution once daily for 3 days. The time spent on gargling was about

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10 - 15 seconds at a time. The content of one gargle was based on the literature presenting that 10 - 22 cc of most prescription oral solutions were applied daily to treat oral or esophageal candidiasis or other yeast infections in the clinic [32].

Procedures

1) The study subjects were recruited using a convenience sample of nurses who worked in the medical/surgical intensive care unit of the Eulji University Hospital 2) The baseline test for the three groups was conducted after 'finished their nursing shift, and general characteristics, stress, xerostomia, halitosis and salivary pH were measured prior to the experimental treatments. 3) As to experimental treatments, 15 - 20 cc of the aromatic gargle solution was used by the experimental group, similarly 15 - 20 cc of a saline solution by the saline group for gargling 8

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at 4:00 p.m. once daily for 3 days. No treatment was provided to the control group. Tooth brushing after meals in the experimental group, the saline group and the control group might affect halitosis, xerostomia or salivary pH, but this was not controlled during the study for ethical reasons. The subjects who brushed teeth were analyzed as a subgroup.

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4) In order to verify the effects of the experimental treatments, the perceived stress, halitosis

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and salivary pH of the control group, saline group and aroma group were measured before and 10 minutes after the experimental treatments from the first day to the third day of the

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experimental treatments. Additionally, on the third day of the experimental treatments, the perceived stress, xerostomia, halitosis and salivary pH were measured 30 minutes after the

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experimental treatments. The pH of saliva was measured by a research assistant who was

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blind to the individuals’ group allocation. Measurements were taken seven times: three days before the intervention? and immediately before ? and 30 minutes after the intervention for

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each day .

Outcome Measures Stress level

In order to verify the effects of aromatic gargling, the visual analog scale (VAS) was used as a tool for measuring stress [33]. The subjects are asked to indicate the level of stress they feel on a 10cm horizontal line from 0 points of "Not stressed at all" to 10 points of "Extremely stressed out," and then the distance to the indicated position is measured in millimeters. The higher the point, the more severe the stress level.

Xerostomia The VAS was used as a tool for measuring xerostomia [34]. The scale consisted of a total of 8 questions including 4 questions about dryness of the oral mucosa (lips, mouth, tongue and 9

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the throat), 2 questions about dysphagia and speech impediments, 1 question about the amount of saliva in the oral cavity, and 1 question about thirst. The scale spans from the minimum of 0 points to the maximum of 80 points. A higher score means that xerostomia is

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serious.

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Halitosis

In order to measure the degree of objective halitosis, the portable breath checker (HC-205,

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Tanita Co., Tokyo, Japan) was used. Main components of bad breath are volatile sulfur compounds such as methylmercaptan, hydrogen sulfide, dimethyl sulfide, etc. or hydrocarbon

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gases, and so on. The portable breath checker can measure these causative gases using the

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highly-sensitive semiconductor gas sensor. There are 6 levels of halitosis measured by the portable breath checker from level 0 "no bad breath" to level 5 "severe bad breath." In this

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score means more severe halitosis.

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study, the mean of 2 measurements taken by the portable breath checker was used. A higher

The normal pH of saliva is slightly acidic ranging from 5.3 to 7.8 [35]. Test papers bromothymol blue (BTB) and bromocresol purple (BCP) were used as a tool for measuring salivary pH. For accurate testing, two types of test papers (advantec, Toyo Roshi Kaisha, Ltd., Tokyo, Japan) were used for ph test: pH 6.2 - 7.8 (bromothymol blue; BTB) and pH 5.6 - 7.2 (bromocresol purple; BCP). BTB and BCP test papers can take precise measurements with the pH range at 0.2 intervals, and measure from subacidity to alkalescence. To test salivary pH, the test papers were placed on the tongue to absorb saliva, and it was determined by the closest color after comparing with a standard color chart. If the values of the two test papers are completely different, the mean of the two results was used. The lower the salivary pH measurement, the higher the acidity, meaning severe halitosis.

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Sample size calculation Sample size was calculated by the G. Power analysis. The effect size used for sample size calculation was 0.30, significance level (α) of 0.05, and statistical power (1-β) 0.80. The effect size was calculated by mean, standard deviation of perceived oral malodor derived

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from the existing study [19]. Calculated sample size for this study was 108 for three group

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target recruited number was total 120 participants for this study.

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when ANOVA among F-tests is analyzed. Considering the possible withdrawal number, final

Statistical Analysis

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The collected data were analyzed using SPSS Ver. 20.0. General characteristics of the

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subjects were analyzed using real numbers and percentages, and general characteristics and dependent variables of the aroma group, saline group and no-treatment group were analyzed 

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-test and ANOVA for homogeneity test. To compare the effects of the experimental

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by

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treatments, the perceived stress, xerostomia, halitosis and salivary pH of the aroma group, saline group and no-treatment group were analyzed using ANOVA, and Scheffe' methods were used for the post-hoc test. In order to test the differences in the perceived stress, halitosis and salivary pH according to the change in time, the repeated measures ANOVA was performed.

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Results One-hundred twenty nurse were recruited into the study; 40 each in the aroma group, saline group, and control group. None of the participants were drop-out or withdraw from the study.

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The result of the homogeneity test of the aroma group, saline group and no-treatment group

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showed that there were no significant differences among the three groups and they were

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homogeneous (Table 1).

Aroma mouthwash alleviates stress level

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The perceived stress was measured 7 times before and after the experimental treatments using

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the VAS. Before the first experimental treatments, the three groups did not demonstrate statistically significant differences, but there were statistically significant differences between

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the aroma group (4.58), saline solution group (5.38), and control group (5.88) after the

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experimental treatments (F = 8.26, p < .001). Before the second experimental treatments, the three groups did not demonstrate statistically significant differences, and there were statistically significant differences between the aroma group (4.63), saline solution group (5.38), and control group (5.60) after the experimental treatments (F = 4.911, p = .009). Before the third experimental treatments, the three groups demonstrated significant differences (F = 5.43, p = .006). As to the stress measurements taken twice at time intervals (after 10 minutes and after 30 minutes) after the last experiment, there were significant differences between 4.35 of the aroma group, 5.38 of the saline solution group, and 5.83 of the control group after 10 minutes (F = 11.82, p < .001). Also, after 30 minutes, there were significant differences between 4.38 of the aroma group, 5.40 of the saline solution group, and 5.73 of the control group (F = 10.42, p < .001) (Table 2).

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The results of variance analysis of a total of 4 repeated measurements after the first, second treatments and 10 and 30 minutes after the third treatments displayed significant differences among the times (F = 5.77, p < .001) and groups (F = 6.15, p = .003), and there were

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significant interactions among the groups and times (F = 7.60, p < .001) (Table 2).

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Aroma mouthwash improves xerostomia

For the effects of aromatic gargle on xerostomia of nurses, the three groups did not show

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significant differences before the experimental treatments, and there were significant differences between the aroma group (27.93), the saline solution group (32.03), and control

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group (34.68) after the experimental treatments (F = 6.60, p = .002). The differences in

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xerostomia between before and after the experimental treatments were - 6.00 of the aroma group, -2.76 of the saline solution group, and 1.33 of the control group, indicating that

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xerostomia of the aroma group decreased significantly (F = 46.59, p < .001) (Table 3).

Aroma mouthwash reduces halitosis

For the effects of aromatic gargle on objective halitosis, the three groups did not present significant differences before the first experimental treatments, and there were significant differences between the aroma group (1.58), the saline solution group (2.23), and the control group (2.50) after the experiment (F = 23.60, p < .001). Before the second experimental treatments, the three groups did not show significant differences, and there were significant differences between the aroma group (1.38), saline solution group (2.33), and control group (2.60) after the experiment (F = 48.64, p < .001). Before the third experimental treatments, the three groups showed significant differences even before the treatments (F = 8.89, p < .001). As to the degree of objective halitosis measured twice at time intervals (after 10 minutes and after 30 minutes) after the experiment, there were significant differences 13

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between 1.25 of the aroma group, 2.08 of the saline solution group, and 2.60 of the control group after 10 minutes (F = 57.23, p < .001). Also, after 30 minutes, there were significant differences between 1.23 of the aroma group, 2.38 of the saline solution group, and 2.60 of

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the control group (F = 70.81, p < .001) (Table 4).

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The results of variance analysis of a total of 4 repeated measurements after the first, second treatments and 10 minutes and 30 minutes after the third treatments presented significant

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differences among the times (F = 48.24, p < .001) and groups (F = 29.90, p < .001), and there

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were significant interactions among the groups and times (F = 44.59, p < .001) (Table 4).

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Effects of aroma mouthwash for pH

For the effects of aromatic gargle on salivary pH, the three groups did not display significant

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differences before the first experimental treatments, and there were significant differences

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between the aroma group (6.99), saline solution group (6.92), and control group (6.67) after the experimental treatments (F = 14.71, p < .001). Before the second experimental treatments, the three groups did not demonstrate significant differences, and there were significant differences between the aroma group (7.04), saline solution group (6.88), and control group (6.66) after the experiment (F = 27.10, p < .001). After the third experiment, salivary pH was measured twice at time intervals (after 10 minutes and after 30 minutes). The three groups had a significant difference before the experimental treatments (F=6.73, p=.002), and the salivary pH levels measured 10 minutes after the experimental treatments demonstrated a significant difference between 7.10 of the aroma group, 6.93 of the saline solution group, and 6.65 of the control group (F = 36.34, p < .001). The measurements taken after 30 minutes showed a significant difference between 7.14 of the aroma group, 6.88 of the saline solution group, and 6.65 of the control group (F = 40.09, p < .001) (Table 5). 14

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The results of variance analysis of a total of 4 repeated measurements after the first, second treatments and 10 minutes and 30 minutes after the third treatments presented significant differences among the times (F = 67.14, p < .001) and groups (F = 13.47, p < .001), and there

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were significant interactions among the groups and times (F = 23.05, p < .001) (Table 5).

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Discussion Aromatherapy is one of the most commonly used complementary therapies and has the advantage that it can easily use by the public [36]. Nursing jobs are highly stressful, and

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stress causes a variety of complications. Stress, xerostomia and halitosis are highly correlated.

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In the past, halitosis was not recognized as a particular disease. But as the quality of life is emphasized recently, halitosis draws attention gradually as a social disease, which affects

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one's social life, causing lack of confidence in interpersonal relations, hindrance to communication, and so on.

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Therefore, this study attempted to verify the effects of essential oils on stress, xerostomia,

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halitosis and salivary pH inhalation by providing a blend of peppermint, tea tree, lemon, and

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ylang ylang as a gargle to nurses.

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Stress experienced by the nurses was measured using the VAS. The results showed that the subjective reported stress levels of the aroma group was reduced more compared to the saline solution and control groups. These results are consistent with the results of a study with ordinary people [26-28], nurses [29],

patients with high blood pressure [37, 38], and dental

patients [39]. The essential oils used in these previous studies were lavender, ylang ylang, bergamot, marjoram, neroli, geranium and peppermint, and when used as an inhalation were effective in relieving stress. Gargling used in this study was found to be effective for dealing with stress. In addition, since ylang ylang which has

a sedative effect on the nervous system

was used, it seems to have been effective when the subjects inhaled the scent while gargling.

The results showed that xerostomia in the aroma group significantly decreased compared to the saline solution group and control group. As there were no available preceding studies on 16

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the effects of the aromatic gargle on xerostomia a direct comparison was not possible. But this study result can be considered consistent with the results of a study which showed that unpleasant feelings in the mouth and dry mouth of old people were relieved on gargling with aroma [40]. It is possible that lemon or peppermint, among the essential oils used for gargling

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in this study, mitigated xerostomia by stimulating saliva secretion. However, the mechanism

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operating is unclear.

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For the purpose of comparing the effects of the aroma gargle on objective halitosis level, this was measured by the portable breath checker. After experimental treatment, halitosis levels

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were reduced in the aroma group. This result is consistent with a previous study that verified

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the effects of gargling with an essential oil solution in which a blend of tea tree, peppermint and lemon was diluted [24]. Halitosis is caused by volatile sulfur compounds that is the end

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product of putrefaction by oral bacteria. Both tea tree oil and peppermint oil used for this

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study have excellent antimicrobial and antiseptic effects, and also lemon, an aroma of refreshing scent, promotes digestion and saliva secretion and has antiseptic and antifungal functions [36]. These oils seem to have had effects on reduction of halitosis. Also, it could be synergy created by using a blend of tea tree, lemon and peppermint essential oils. Although a decrease in halitosis was observed in the saline solution group, this seemed to be a temporary effect of rinsing rather than an antimicrobial effect. In particular, halitosis was reduced 10 minutes after the third experimental treatment with the aromatic gargle, and the effect continued after 30 minutes. In this regard, the aroma gargle is verified to have an immediate and continuous effect in decreasing halitosis. In the saline solution group, halitosis was reduced 10 minutes after the third experimental treatment, but notably after 30 minutes halitosis rose, which displayed an immediate effect only. When compared with this result, the continuous effect of the aromatic gargle has a cumulative effect. 17

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The aromatic gargle on salivary pH increased salivary pH levels more than those of in saline solution group and control group. According to the previous studies, the amount of saliva secretion of people with halitosis is less than that of average people [41], and when saliva is

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acid, the halitosis incidence is higher, while saliva is neutralized, the halitosis incidence is

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slightly reduced [15]. In this study, xerostomia decreased and salivary pH increased in the

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aroma group, which verified that the aroma gargle was effective in reducing halitosis.

One of the limitations of this study was that on recruitment, subjects did not appear to have

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serious bad breath. A future study should target people with severe halitosis. Furthermore,

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our study is non-randomized placebo controlled trial and the lack of an equivalent-treatment control group to estimate the superior effectiveness of aroma mouthwash. Therefore, it is not

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clear whether the positive effects were due to the aroma mouthwash. Aromatherapy is

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difficult to keep an experimental procedure completely blind. This is because there is no way to mask the fragrance of aromatherapy essential oils. In this experiment, it is difficult to keep the experimental procedure completely blind, so the experiment was performed in the order of the control group, the saline group, and the experimental group. Another limitation is no restriction of the number of times of brushing and intake of food. Furthermore, the personal oral hygiene behavior maybe different and may influence the results. However, no participants did tooth brushing during the experimental procedures Further placebo controlled randomised studies should be carried out to explain the specific effects of aroma mouthwash.

In conclusion, the aroma gargle used in this study appeared to be an effective intervention for relieving stress, decreasing xerostomia, and reducing halitosis in nurses. Additionally, as it is an intervention that takes little time and is convenient to use, and may be helpful in 18

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enhancing the quality of life of nurses who do shift work.

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Conflict of interest statement The authors declare that they have no potential conflict of interest. References

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Health 47(5) (2005) 378-83.

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Table 1. Demographics and characteristics of study subject among three groups. Characteristics

Category

Aroma G. (n=40)

Saline G. (n=40)

Control G. (n=40)

F or χ²

p

24

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특성

구분

Age

p

F or χ²

Mean ± SD or n(%)

Mean ± SD or n(%)

(yr)

26.0 ± 3.2

26.4 ± 3.7

25.3 ± 2.8

1.04

.36

Employment

(month)

45.8 ± 39.0

46.0 ± 40. 5

40.3 ± 30.2

0.30

.74

Alcohol (times/wk)

Almost no

31(77.5)

36(90.0)

37(92.5)

4.47

.11

9(22.5)

4(10.0)

3(7.5)

26(65.0)

27(67.5)

33(82.5)

1-2times/day

8(20.0)

6(15.0)

5(12.5)

4.54

.34

Irregular

6(15.0)

7(17.5)

2(5.0)

cr

3times/day

Score

5.40 ± 1.32

5.48 ± 1.47

5.93 ± 1.86

1.32

.27

Xerostomia

Score

33.93 ± 8.42

34.80 ±10.37

33.35 ± 9.93

0.23

.79

Halitosis

Score

2.60 ± 1.01

2.50 ± 0.56

2.45 ± 0.55

0.43

.65

Salivary pH

pH

6.65 ± 0.26

6.67 ± 0.41

6.71 ± 0.38

0.29

.75

Ac ce pt e

d

an

Stress

M

Brush teeth (times/day)

us

1-2times/wk

ip t

Mean ± SD or n(%)

25

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Table 2. Comparison of perceived stress after experimental treatment Saline G.b (n=40)

Control G.c (n=40)

Mean ± SD

Mean ± SD

Mean ± SD

Pre gargling

5.23 ± 1.39

5.38 ± 1.35

5.78 ± 1.41

1.69(.19)

Post gargling(10)

4.58 ± 1.57

5.38 ± 1.35

5.88 ± 1.40

8.26(<.001) a
Pre gargling

5.03±1.29

5.35±1.37

5.63±1.41

1.96(.146)

Time 5.77(<.001)

Post gargling(10)

4.63±1.56

5.38±1.41

5.60±1.39

4.91(.009) a
Group 6.15(.003)

Pre gargling

4.75±1.26

5.35±1.42

5.73±1.32

5.43(.006)

Post gargling(10)

4.35±1.37

5.38±1.43

5.83±1.38

11.82(<.001) a
Post gargling(30)

4.38±1.33

5.40±1.41

5.73±1.40

10.42(<.001) a
T1

an

T3

us

T2

F(p) (Scheffe)

F(p)*

ip t

Stress

cr

Times

Aroma G.a (n=40)

Group*Time 7.60(<.001)

Ac ce pt e

d

M

T1 : Treatment 1st day / T2 : Treatment 2nd day / T3 : Treatment 3rd day Mean ± SD : Mean ± Standard Deviation * Repeated measures of ANOVA, Scheffe test post hoc analysis

26

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Table 3. Comparison of xerostomia after experimental treatment Control G.c (n=40)

Mean ± SD

Mean ± SD

Mean ± SD

Pre gargling

33.93 ± 8.42

34.80 ± 10.37

33.35 ± 9.93

Post gargling(30)

27.93 ± 6.91

32.03 ± 9.36

34.68 ± 8.65

Difference(post-pre)

-6.00 ± 2.85

-2.76 ± 4.36

1.33 ± 2.75

Stress

0.23(.79) 6.60(.002) (a
46.59(<.001)

Ac ce pt e

d

M

an

us

Mean ± SD : Mean ± Standard Deviation Scheffe test post hoc analysis

F(p) (Scheffe)

ip t

Saline G.b (n=40)

cr

Aroma G.a (n=40)

27

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Table 4. Comparison of halitosis after experimental treatment Saline G.b (n=40)

Control G.c (n=40)

Mean ± SD

Mean ± SD

Mean ± SD

Pre gargling

2.53 ± 0.55

2.45 ± 0.55

2.45 ± 0.55

0.25(.78)

Post gargling(10)

1.58 ± 0.59

2.23 ± 0.73

2.50 ± 0.51

23.60(<.001) (a,
Pre gargling

2.35 ± 0.48

2.53 ± 0.51

2.53 ± 0.55

1.54(.219)

Time 48.24(<.001)

Post gargling(10)

1.38 ± 0.60

2.33 ± 0.62

2.60 ± 0.55

48.64(<.001) (a
Group 29.90(<.001)

Pre gargling

2.05 ± 0.60

2.53 ± 0.51

2.48 ± 0.55

8.89(<.001)

Post gargling(10)

1.25 ± 0.44

2.08 ± 0.73

2.60 ± 0.50

57.23(<.001) (a
Post gargling(30)

1.23 ± 0.42

2.38 ± 0.71

2.60 ± 0.50

70.81(<.001) (a
T1

an

T3

us

T2

F(p) (Scheffe)

F(p)*

ip t

Halitosis

cr

Times

Aroma G.a (n=40)

Group*Time 44.59(<.001)

Ac ce pt e

d

M

T1 : Treatment 1st day / T2 : Treatment 2nd day / T3 : Treatment 3rd day Mean ± SD : Mean ± Standard Deviation * Repeated measures of ANOVA, Scheffe test post hoc analysis

28

Page 28 of 29

Table 5. Comparison of salivary pH after experimental treatment Saline G.b (n=40)

Control G.c (n=40)

Mean ± SD

Mean ± SD

Mean ± SD

Pre gargling

6.61 ± 0.24

6.70 ± 0.31

6.68 ± 0.34

1.05(.35)

Post gargling (10min)

6.99 ± 0.24

6.92 ± 0.27

6.67 ± 0.32

14.71(<.001) (a
Pre gargling

6.74 ± 0.18

6.69 ± 0.23

6.65 ± 0.29

1.59(.208)

Time 67.14(<.001)

Post gargling(10)

7.04 ± 0.21

6.88 ± 0.21

6.66 ± 0.27

27.10(<.001) (a
Group 13.47(<.001)

Pre gargling

6.82 ± 0.19

6.68 ± 0.19

6.63 ± 0.31

6.73(.002)

Post gargling(10)

7.10 ± 0.22

6.93 ± 0.20

6.65 ± 0.28

36.34(<.001) (a
Post gargling(30)

7.14 ± 0.20

6.88 ± 0.23

6.65 ± 0.29

40.09(<.001) (a
T1

an

T3

us

T2

F(p) (Scheffe)

F(p)*

ip t

Salivary pH

cr

Times

Aroma G.a (n=40)

Group*Time 23.05(<.001)

Ac ce pt e

d

M

T1 : Treatment 1st day / T2 : Treatment 2nd day / T3 : Treatment 3rd day Mean ± SD : Mean ± Standard Deviation * Repeated measures of ANOVA, Scheffe test post hoc analysis

29

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