halitosis - dr sanjana ravindra

Halitosis: Current concepts

on etiology, diagnosis

and management

E U R J D E N T 2 0 1 6 ; 1 0 : 2 9 2 - 3 0 0 .

Journal club : 12

PROLOGUE

An unpleasant or offensive odour

emanating from the breath regardless of whether the odour

originates from oral or non-oral sources.

G Campisi, A Musciotto. Halitosis: could it be more than mere bad breath?; Intern Emerg

Med (2011) 6:315–319.

AIM

Succinctly focuses on the development of a systematic flow of events to come to the

best management of the halitosis from the primary care

practitioner’s point of view.

INTRODUCTION

It was described as a clinical entity by HOWE (1874).

Halitosis should not be confused with the generally temporary oral odour caused by intake of certain foods, tobacco, or medications.

Originates from two

Latin words

◦ Halitus → breath

◦ Osis → disease

Armstrong BL, Sensat ML, Stoltenberg JL. Halitosis: A review of

current literature. J Dent Hyg 2010;84:65-74.

SYNONYMS

Bad or foul breath

Breath malodour

Oral malodour

Foetor ex-ore

Foetor oris

Stomato dysodia

van den Broek AM, Feenstra L, de Baat C. A review of the current literature on aetiology

and measurement methods of halitosis. J Dent 2007;35:627-35

DEFINITIONS

Halitosis is the general term used to describe a foul odor emanating from the oral cavity, in which proteolysis, metabolic products of the desquamating cells and bacterial putrefaction are involved.• Marita et al., 2001

Halitosis is the general term used to describe any disagreeable odor in expired air, regardless of whether the odorous substances originate from oral or non-oral sources. • -Tangerman, 2002

Halitosis is also termed as fetor ex ore or fetor oris. It is a foul or offensive odor emanating from the oral cavity.• Carranza(2003)

Unpleasant odor of the expired air whatever the origin may be. Oral malodor specifically refers to such odor originating from the oral cavity itself.• Jan Lindhe(2003)

J lindhe. Clinical periodontology and implant dentistry; vol 1: 5th edition

Newman ,Takei, Carranza. Clinical periodontology ; 10th and 11th edition

DEFINITIONS

Breath malodor, defined as foul or offensive odor of expired air, may be

caused by a number of factors, both intra-oral & extra-oral (gingivitis/

periodontitis, nasal inflammation, chronic sinusitis, diabetes mellitus, liver

insufficiency etc.,) & can be linked to more serious underlying medical

problems including primary biliary cirrhosis, uremia, lung carcinoma,

decompensated liver cirrhosis & trimethylaminuria.

Quirynen, Zhao, Avontroodt et al., 2003

HISTORY

The problem of halitosis has been reported for many years.

References were found in papyrus manuscripts dating back to 1550

BC.

During Christianity, the devil's supreme malignant odor smelled of sulfur & it was presumed that sins produced a more or less bad

smell.

Rayman S, Almas K. Halitosis among racially diverse populations: An update. Int J Dent Hyg 2008;6:2-7

A treaty in Islamicliterature from the year

850 talked about dentistry, referring to the treatment of fetid

breath & recommended the use of siwak when breath had changed or

at any time when getting out of bed.

Buddhist monks in Japan also

recommended teeth brushing & tongue

scraping before the first morning prayers.

HISTORY


HISTORY

The Hindus consider the mouth as

the body's entry door and, therefore,

insist that it be kept clean, mainly

before prayers. The ritual is not

limited to teeth brushing, but

includes scraping the tongue with a

special instrument and using

mouthwash.


EPIDEMIOLOGY

Miyazaki concluded that there was increased

correlation between older age and malodour with

aging resulting in greater intensity the of odor. In

above 60 years age group of the Turkish individuals, the incidence was around

28%.

A recent study had revealed a prevalence

of self-reported halitosis among Indian dental students ranging from 21.7% in males to

35.3% in females.

In the general population, halitosis

has a prevalence ranging from 50%

in the USA to between 6% and

23% in china,

Japan study 2,672 Individuals 6-23% of subjects had oral malodour (VSC) as in expired air at some period during the day (Miyazaki 1996).

Another study in the United States involving individuals older than 60 years found 24% had oral malodour (Rosenberg 1996).

Epidemiology

The prevalence of persistent oral malodor in a Brazilian study was reported to be 15%, was nearly three times higher in men than in women (regardless of age) and the risk was slightly more than three times higher in people over 20 years of age compared with those aged 20 years or under, controlling for gender .

CLASSIFICATION

Genuine halitosis

Physiologic halitosis

Pathologic halitosis

Intraoral Extraoral

CLASSIFICATION

PHYSIOLOGIC HALITOSIS

Morning breath odour

Decrease in

frequent liquid intake

Stagnation of saliva and putrefaction of

entrapped food particles and desquamated

epithelial cells by the accumulation of bacteria on the dorsum of the

tongue,

Genuine halitosis

Physiologic halitosis


Intraoral Extraoral

CLASSIFICATION

poor oral hygiene,

dental caries,

periodontal diseases in

particular NUG, NUP,

periodontitis,

pericoronitis, dry socket

tongue coating

oral carcinoma.

Intra oral origin


OTHER ORIGINS OF HALITOSIS

The resulting breath takes on a different odor that may last several hours

Transient oral malodor

Porter SR, Scully C. Oral malodour (halitosis). BMJ 2006;333:632-5.

• 10-20%• gastro intestinal diseases• infections or malignancy in respiratory tract• Chronic sinusitis and tonsillitis• stomach, intestine, liver or kidney affected by

systemic diseases

Extra oral origin


Maximally 10% of the oral malodor cases originate from the ears, nose and throat (ENT) region, from which 3% finds its origin at the tonsils.

The presence of acute/chronic tonsillitis and tonsilloliths represents a 10-fold increased risk of abnormal VSC levels due to deep tonsillar crypts formation.

Foreign bodies in the nose can become a hub for bacterial degradation and hence produce a striking odor to the breath


Examples of

systemic

pathological

conditions

that cause halitosis


CLASSIFICATION

Delusional halitosis

Pseudo halitosis Halitophobia.

Condition in which a subject believes that their breath odor is offensive and is a cause of social nuisance, however, neither any clinician nor any other confidant can approveof its existence

• Monosymptomatic

• Hypochondriasis

• Imaginary halitosis

Interestingly, advertisements of oral hygiene products are responsible for the increase in a number of patients with delusional halitosis.

IMAGINARY OR DELUSIONAL HALITOSIS


•Pseudo halitosis

–Apparently healthy individuals

•Haltophobia

– exaggerated fear of having halitosis

– also referred as delusional halitosis

– considered variant of monosymptomatic hypochondrial

psychosis.

Yaegaki K, Coil JM. Genuine halitosis, pseudo-halitosis and halitophobia: classification,

diagnosis, and treatment. Compend Cont Educ Dent 2000; 21(10A):880–886

Pseudo-halitosis patients complain of having oral malodor without actually suffering from the problem and eventually gets convinced of a disease free state during diagnosis and therapy

28% of patients complaining of bad breath did not show signs of bad breath


Halitophobia is fear of having bad breath seen in at least 0.5–1% of adult population

Such patients need psychologicalcounseling and should be given

enough time duringthe consultation.


OLFACTORY REFERENCE SYNDROME

Psychological disorder in which there is a preconceived notion about one having foul mouth breath or emits offensive body odor.

Halitosis generally arises as a result of the bacterial decomposition of food particles, cells, blood and some chemical compounds of the saliva.

Moss, 1998

Etiology

Yaegaki K, Sanada K. Volatile sulphur compounds in mouth air from clinically healthy

subjects and patients with periodontal disease. J Periodontol Res 1992;27:233-8.

Volatile sulphur compounds → hydrogensulphide [H2S, rotten egg smell], dimethyl sulphide [(CH3)2S, rotten cabbage smell, and methyl mercaptan [CH3SH, fecal smell].

Non - sulphur containing substances → diamines [cadaverine (cadaver smell) and putrescine (rotten meat smell), acetone and acetaldehyde

ETIOLOGY

Yaegaki K, Sanada K. Volatile sulphur compounds in mouth air from clinically healthy

subjects and patients with periodontal disease. J Periodontol Res 1992;27:233-8.

ROLE OF VOLATILE SULPHUR COMPOUNDS IN THE PATHOGENESIS OF HALITOSIS

MAJOR COMPOUNDS IMPLICATED IN HALITOSIS

VSC’s - Methylmercaptan, Hydrogen sulfide, dimethyl sulfide & Dimethyl disulfide.

Polyamides - Putrescein, Cadaverine, Skatole, Indole.

Short chain FA - Butyric, Propionic, Valeric & Isovaleric acid.

Others - Acetone, Acetaldehyde, Ethanol diacyl.

Miyazaki H, Sakao S, Katoh Y, Takehara T. Correlation between volatile sulphur compounds

and certain oral health measurements in the general population. J Periodontol 1995;66:679-84

It increases the permeability of oral mucosa and crevicular epithelium. It impairs oxygen utilization by host cells, and reacts with cellular proteins, and

interferes with collagen maturation.

It also increases the collagen solubility.

It decrease the DNA synthesis.

It increases the secretion of collagenases, prostaglandins from fibroblasts.

VSC reduce the intracellular pH; inhibit cell growth, and periodontal cell migration.

Miyazaki H, Sakao S, Katoh Y, Takehara T. Correlation between volatile sulphur compounds

and certain oral health measurements in the general population. J Periodontol 1995;66:679-84

Pathogenesis of oral malodor

Marawar PP, Sodhi NA, Pawar BR, Mani AM. Halitosis: A silent affliction!. Chron Young Sci 2012;3:251-7.

The role of tongue coatings in the aetiology of oral malodour has been

extensively documented.

Tongue coatings include desquamated epithelial cells, food debris, bacteria and salivary proteins and provide an ideal environment for the generation of VSCs and other compounds that

contribute to malodour

The purulent discharge from the paranasal sinuses, seen in regurgitation esophagitis, gets collected at the dorsum of the tongue resulting in halitosis.

Atrophic rhinitis is caused by Klebsiella ozenae, which inhibits the self-cleaning property of nasal mucosa. Acute pharyngitis and sinusitis, caused by streptococcal species, are also responsible for producing halitosis.

Carcinoma of the larynx, nasopharyngeal abscess, and lower respiratory tract infections such as bronchiectasis, chronic bronchitis, lung abscess, asthma, cystic fibrosis, bronchiectasis, interstitial lung diseases, and pneumonia have been known to cause halitosis


Kinberg et al. published a review in 2010, in which they examined 94 patients having halitosis out of which 54 had gastrointestinal pathology suggesting that gastrointestinal is one of the common extra oral causes of halitosis.

Gastrointestinal causes like Zenker’s diverticulum, Gastro-esophageal reflux disease (GERD),Gastric and peptic ulcers have been known to cause halitosis.

Helicobacter pylori is known to cause a gastric and peptic ulcer and is recently associated with oral malodor.

Congenital broncho esophageal fistula, gastric cancer, hiatus hernia, pyloric stenosis, enteric infections, dysgeusia, duodenal obstruction, and steatorrhea are some of the sources of pathological mouth odor


Metabolic disorders like Trimethylaminuria (fish odor syndrome) is characterized by the presence of trimethylamine (TMA), whose odor resembles of rotting fish in the urine, sweat and expired air.

Individuals with TMAuria have diminished the capacity to oxidize the dietary-derived amines TMA to its odorless metabolite TMA N-oxide resulting in an increased excretion of large amounts of TMA in body fluids.

In hypermethioninemia the body produces a peculiar odor, which resembles that of, boiled cabbage and is emanated through sweat, breath and urine.

If this condition is present, the extraoral origin should be determined, because the latter requires medical investigation and support in therapy.


MICROBIOLOGY AND BREATH MALODOR

Fusobacterium nucleatum,

Treponema denticola,

Prevotella intermedia,

Porphyromonas gingivalis,

Bacteroides forsythus,

Eubacterium.

Some of the evidence in support of periodontal disease is indirect, as it is based on the in vitro ability of species indigenous to the sub-gingival plaque to produce VSC’s.

produce large amounts of CH3

SH and H2 S from methionine,

cysteine, or serum proteins


DRUGS ASSOCIATED WITH HALITOSIS

DIAGNOSIS

Complaint,

Medical, dental and halitosis history,

Information about diet and habits,

Confirming an objective basis to the complaint

Discretely and intermittently recorded.

Questions such as frequency, duration, time of appearance within a day,

Whether others have identified the problem (excludes pseudo-halitosis from genuine halitosis),

List of medications taken,

Habits (smoking, alcohol consumption)

Other Symptoms (nasal discharge, anosmia, cough, pyrexia, and weight loss) should be carefully recorded

DIAGNOSIS

DIRECT

1. By directly sniffing the bad breath2. Determination of odoriferous sulfurcontaining substances by gas chromatography or halimetry and other methods

INDIRECT

These methods assess the products produced by microorganisms in vitro or identify odor producing microorganisms.


1. Self-assessment, 2. Whole mouth breath test, 3. Spoon test, 4. Dental floss odor

test, 5. Saliva odor test.

Direct tests - Organoleptic

Direct sniffing of the expired air (“organoleptic” and “hedonic”

assessment) is the simplest, most common method to evaluate oral

malodor. An organoleptic examination involves the dentist assessing the odor at a range of

distances from the patient

Organoleptic measurement is highly recommended for initial diagnosis.

One potential risk of the organoleptic measurement is the transmission of diseases via the expelled air


ORGANOLEPTIC MEASUREMENT (SNIFF TEST)

Organoleptic measurement is a sensory test scored on the basis of the examiner’s perception of a subject’s oral malodor.

Organoleptic measurement can be carried out simply by sniffing the patient’s breath and scoring the level of oral malodor.

By inserting a translucent tube (2.5 cm diameter, 10 cm length) into the patient’s mouth and having the person exhale slowly, the breath, undiluted by room air, can be evaluated and assigned an organoleptic score.

The tube is inserted through a privacy screen (50cm-70cm) that separates the examiner and the patient.

The use of a privacy screen allows the patient to believe that they have undergone a specific malodor examination rather than the direct-sniffing procedure.

Organoleptic Scores (0- 5)

0 - No appreciable odor1 - Barely noticeable odor

2 - Slight but noticeable odor 3 - Moderate odor

4 - Strong odor 5- Extremely

foul odor

By Rosenberg , Mulloch Et Al

1991.

Yaegaki & coil 2000

DIAGNOSIS

The subjects are instructed to smell the odor emanating from their entire mouth

by cupping their hands over their mouth and breathing through the nose.

The presence or absence of malodor can be evaluated by the patient

himself/herself.

SELF ASSESSMENT TESTS

Whole mouth malodor (Cupped breath)

Subjects are asked to extend their tongue and lick their wrist in a perpendicular

fashion.

The presence of odor is judged by

smelling the wrist after 5 seconds at a distance of about 3

cm.

Wrist lick test

Plastic spoon is used to scrape and scoop material

from the back region of the tongue.

The odor is judged by smelling the spoon after 5 seconds at a

distance of about 5 cm organoleptically.

Spoon test

Unwaxed floss is passed through interproximal contacts.

Dental floss test

Involves having the subject expectorate approx. 1-2 ml of

saliva into a petridish.

The dish is covered immediately, incubated at 370 C for five

minutes and then presented for odor evaluation at a distance of 4 cm from the examiner’s nose.

Saliva odor test

BANA TEST

If any of the these species are present, they hydrolyze the BANA enzyme-producing B-naphthylamide which in turn reacts with imbedded diazo dye to produce a permanent blue color indicating a positive test

It is a chair side, enzyme-based assay, which is used to determine the proteolytic activity of certain oral anaerobes that contribute to oral malodor and which are considered as active H2 SO4 producers.


VOLATILE SULFIDE MONITOR

This electronic (Haiimeter, InterScan, Chatsworth, Calif)

analyzes concentration of hydrogen sulfide and methyl-mercaptan , but

without discriminating between them.

GAS CHROMATOGRAPHY (GC):

GC, performed with apparatus equipped with a

flame photometric detector, is specific

for detecting sulphur in mouth

air.

It measures directly the three

VSC methyl mercaptan,

hydrogen sulfide and dimethyl

sulfide.

GC is considered the GOLD

STANDARD for measuring oral

malodor.

This device can analyze air, saliva, crevicular fluid for

a volatile component.

DIAMOND PROBE

The Probe is placed directly into the periodontal pocket or tongue.

The sulfide-sensing element generates an electrochemical voltage proportional to the concentration of sulfide ions present.

The control unit reports the sulfidelevel at each site in a digital score from: 0.0 to 5.0

NINHYDRIN METHOD OF DETECTING AMINE

COMPOUNDS

Iwanicka et al (2005)

showed that amine levels

were higher in the saliva of

subjects suffering from

halitosis and lower in

healthy controls.

Tanaka M et al used these electronic noses to clinically assess oral malodor and

examined the association between oral malodor strength and oral health status.

ELECTRONIC NOSE

HALITOX SYSTEM

Quick and simpleDetects VSCs and poly amines

TOPAS

It detects both VSC and polyamines in the

sample.

The absorbent point given with the kit is

inserted into the pocket. Left in place for 1

minute.

Submerge the absorbent point tip in the toxin

reagent .

Wait for 5 minutes and see for yellow color in the specimen on the

scale of 0-5, which is directly proportional to the level of toxins in the

sample.

PREVENTIVE MEASURES

Visit dentist regularly

Periodical tooth cleaning by dental professional.

Brushing of teeth twice daily with appropriate brushing techniques and

for a duration of 2-3 mins.

Use of a tongue scraper to get rid of the lurking odour causing bacteria in

the tongue surface.

Preventive measures rather than curative aspects are highly recommended.

Flossing after brushing to remove food particles stuck in between the tooth surfaces.

Limit intake of strong odour species.

Limit sugar and caffeine intake.

Drink plenty of liquids.

Chew sugar free gum for a minute when mouth feels dry.

Eat fresh fibrous vegetables such as carrots.

MANAGEMENT AND TREATMENT

1. Confirm the diagnosis, 2. Identify and eliminate the predisposing and modifying factors, 3. Identify any contributing medical conditions and refer for management, 4. Review and reassure.

The management of halitosis entails four steps:


MANAGEMENTTreatment needs (TN) for halitosis have been categorized into 5 classes in order to provide guidelines

for clinicians in treating halitosis patients:

Rosenberg M, McCulloch CA. Measurement of oral malodor: Current methods and future prospects. J Periodontol

1992;63:776-82.

Category DescriptionTN- 1 Explanation of halitosis and instruction of

oral hygieneTN- 2 Oral prophylaxis, Professional cleaning and

treatment for oral diseasesTN- 3 Referral to a physician or medical specialistTN- 4 Explanation of examination data, further professional instruction, education and reassurance TN- 5 Referral to a clinical psychologist , a psychiatrist or other psychology specialist

Mechanical reduction of

intraoral nutrients and

micro-organisms

Chemical reduction of oral microbial load

Conversions of VSCs

Masking the malodor.

MANAGEMENT

Mechanical reduction of intraoral nutrients and micro-organisms- Tongue cleaning

- Tooth brush

- Inter-dental cleaning

- Professional periodontal therapy

- Chewing gum

MANAGEMENT

2. Chemical reduction of oral microbial load

- Chlorhexidine

- Essential oils

- Chlorine dioxide

- Two-phase oilwater rinse

- Triclosan

- Aminefluoride/ Stannous fluoride

- Hydrogen peroxide

- Oxidising lozenges

-Roldan S 2005,2004,2003 scully 2006

MANAGEMENT

CHLORHEXIDINE (CHX)

Mouth rinses containing antibacterial agents such as CHX and cetylpyridinium chloride (CPC) may play an important role in reducing the levels of halitosis producing bacteria on the tongue.

Chlorine dioxide and zinc containing mouth rinses can be effective in neutralization of odoriferous sulfur compounds.

Roldan. S et al. evaluated five different commercial mouth rinses with respect to their anti-halitosis effect and anti-microbial activity on salivary bacterial counts.

Formulations that combine CHX and CPC achieved the best results, and a formulation combining CHX with NaF resulted in the poorest.

Essential oils: Listerine was found to be only relatively effective against oral malodor (±25% reduction vs. 10% of placebo) and caused a sustained reduction in level of odorigenic bacteria

Chlorine dioxide: It is a powerful oxidizing agent that oxidizes the sulfides of the VSC’s to nonodorous sulfates and raises the oxidation/reduction ratio of the saliva toward the more oxidizing state.


TWO-PHASE OILWATER RINSE: The efficacy of

oilwater CPC formulation is

thought to result from the

adhesion of a high proportion

of microorganisms to the oil droplet which is further enhanced by the

CPC.

TRICLOSAN: A broad-spectrum

antibacterial agent, has been

found to be effective against

most oral bacteria and has

a good compatibility

with other compounds used

for oral home care

AMINEFLUORIDE/STANNOUS

FLUORIDE (AMF/SNF2 ): The

association of AmF/SnF2 resulted in

encouraging reduction of

morning breath odor, even when oral hygiene is

insufficient

HYDROGEN PEROXIDE: Suarez et al. reported that

rinsing with 3% H2 O2 produced

impressive reductions

(±90%) in sulfurgas that persisted

for 8 h.

OXIDIZING LOZENGES: The

anti-malodor effect of lozenges may be

caused by the activity of

dehydroascorbicacid which is generated by

peroxide-mediated oxidation of

ascorbate present in the lozenges.


MANAGEMENT

3.Conversion of volatile sulfide compounds

- Metal salt solutions

- Toothpastes

- Chewing gum

MANAGEMENT

Metal salt solutions: Metal ions with affinity for sulfur are rather efficient in capturing the sulfur-containing gases. Zinc is nontoxic, noncumulative, and gives no visible discoloration

Tooth paste: Baking soda dentifrices have been shown to be effective, with a 44% reduction of VSCs level 3 h after tooth brushing versus a 31% reduction for fluoride dentifrices (Brunnet et al. 1998)

Chewing gums: Tsunoda et al. (1996) investigated the beneficial effects of chewing gums containing tea extract for its deodorizing mechanism.

MANAGEMENT

4. Masking the malodor

-Rinses

-Mouth sprays

-Lozenges containing volatiles

-Chewing gum

MANAGEMENT

Herbs and essential oils can be made into very

effective mouthwash remedies to sweeten

breath and help keep gums and teeth

healthy fennel not only improves digestion, but

also can reduce bad breath and body odor that originates in the intestines.

Give raw carrots as a midday treat to help scour

teeth of bacteria-laden plaque, a common cause

of bad breath.

Cardamom tea contains cineole, a potent antiseptic

that kills bad-breath bacteria and sweetens

breath.

Herbal treatment: MANAGEMENT

Thymol, one of the constituents of thyme, is contained in antiseptic

mouthwashes.

Neem leaf powder can be used as an effective tooth powder to

fight plaque and gingivitis when mixed with astringent herb powders and/or baking

soda.

A few drops of Tea tree oil , lemon or peppermint

essential oils can be added to warm water for an

effective mouth rinse to freshen breath

Herbal treatment: MANAGEMENT

CONCLUSIONIt’s a common complaint that may periodically affect most of the

adult population. Oral maldor, which is commonly noticed by patients, is an

important clinical sign and symptom that has many etiologies which include local and systemic factors.

It is often difficult for the clinician to find the underlying pathologies.

Although consultation and treatment may result in dramatic reduction in bad breathe, patients may find it difficult to sense the

improvement themselves

The field of halitosis research would benefit from: • More reliable, portable instruments for measuring VSC’s, • A

standard scale for assessing oral malodor, • Further studies with larger sections of the population, and • Development of

site-specific measurements.

REASON FOR

CHOOSING THIS

ARTICLE?

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