Reng-rengan REFERAT GILUT

Bau Mulut (Halitosis) atau dalam bahasa medis “fetor ex ore” adalah bau nafas yang tidak enak,dan tidak menyenangkan serta menusuk hidung. Bau mulut bukan merupakan suatu penyakit,melainkan suatu gejala adanya kelainan/penyakit yang tidak disadari. Bau mulut merupakanakibat dari proses perubahan bahan dalam rongga mulut yang mengandung ikatan sulfur.Penyebab HalitosisBau mulut biasanya disebabkan oleh masalah dari rongga mulut itu sendiri. Namun tidakmenutup kemungkinan bau mulut berasal dari luar mulut, seperti hidung, faring, paru-paru danlambung. Normalnya, bau dari rongga mulut tidak tetap, tetapi berubah dari waktu ke waktusepanjang hari dan dipengaruhi oleh factor : usia, jenis kelamin, keadaan perut lapar danmenstruasi. Bau mulut akan terjadi pada seseorang yang sehat bila rongga mulut tidakmelakukan aktivitas selama kira-kira 1-2 jam. Misalnya pada keadaan puasa, bangun tidur,orang yang menggunakan gigi palsu yang jarang atau tidak pernah dibersihkan.Jika bau nafas yang sebelumnya normal berubah menjadi halitosis, maka penyebabnya adalah:1. Makanan (misalnya bawang mentah, bawang putih, kol, jengkol, pete)2. Vitamin (terutama dalam dosis tinggi)3. Kebersihan gigi yang jelek4. Gigi karies5. Merokok6. Alkohol7. Peradangan8. Sindroma Sjögren9. Benda asing di hidung (biasanya terjadi pada anak-anak)10. Obat-obatan (paraldehid, triamteren dan obat bius yang dihirup, suntikan insulin).Penyakit-penyakit yang bisa menyebabkan bau mulut: Gingivitis ulseratif nekrotisasi akut,Mukositis ulseratif nekrotisasi akut, Gangguan ginjal, Gangguan hati, Penyumbatan usus,Penyakit Periodontal, Bronkiektasis, Diabetes mellitus, Kanker kerongkongan, Karsinoma

lambung, fistula gastrojejunokolik, Ensefalopati hepatikum , Ketoasidosis diabetikum, Absesparu, Ozena, Faringitis, Divertikulum Zenker.DiagnosaDiagnosis ditegakkan berdasarkan gejala dan hasil pemeriksaan fisik yang menyeluruh padamulut dan hidung. Biakan tenggorokan dilakukan jika terdapat luka di tenggorokan atau dimulut.1 / 2

Bau Mulut (Halotosis)Pemeriksaan lainnya yang mungkin dilakukan adalah:1. Halimeter : Yaitu suatu test untuk mengetahui kadar sulfur didalam mulut.2. Gas kromatografi : Untuk mengukur kadar tingkatan molecular ketiga factor utama VSCsdi dalam mulut (sulfida hidrogen, metil mercaptan, dan dimethyl sulfida).3. BANA test ; Test ini digunakan untuk mengetahui adanya bakteri penyebab bau mulutyang berasal dari ludah.4. ß- galactosidase test5. Endoskopi6. Rontgen perut7. Rontgen dadaPengobatanPengobatan khusus bau mulut tergantung kepada penyakit yang menyebabkan terjadinya baumulut tersebut. Akan sangat membantu jika kita mengunjungi dokter gigi untuk memastikanpenyebabnya, untuk kemudian dicari solusinya. Daun parsley segar atau permen mint bisamenghilangkan bau mulut yang bersifat sementara. Rajin membersihkan pangkal lidah akanmembantu mengurangi bau mulut.Pencegahan1. Periksakan gigi ke dokter gigi secara teratur.2. Bersihkan sela-sela gigi dengan dental floss, pilih yang netral tanpa pengharum. Cekbaunya. Bersihkan lagi kalau berbau.3. Gosok gigi dan bersihkan gusi secara teratur.4. Banyak minum.5. Berkumur dan gosok gigi setelah makan atau minum produk susu, ikan, dan daging.6. Malam hari, rendam gigi palsu dalam cairan antiseptik, kecuali bila dokter gigi melarang.

7. Tanyakan kepada dokter gigi, obat kumur mana yang secara klinis telah terbuktiefektivitasnya dalam melawan bau mulut. Paling baik menggunakannya di saat menjelang tidurmalam.8. Hindari makanan yang berbau menyengat misalnya bawang putih, bawang merah, petaidan lain-lain9. Tidak merokok karena mempertinggi risiko timbulnya bau mulut.10. Bisa dengan mengkonsumsi : Tumbuh-tumbuhan, Yogurt, Sayur dan buah renyah2 /

Bau mulut dalam bahasa medis disebut sebagai Halitosis atau Fetor Ex Ore.

Istilah Halitosis digunakan apabila kondisi bau mulut yang ada berhubungan dengan

keadaan tubuh secara umum (sistemik), sedangkan Fetor Ex Ore digunakan apabila bau

mulut berasal dari faktor-faktor yang ada dalam rongga mulut itu sendiri.

Bau mulut dapat terjadi karena beberapa faktor, antara lain faktor lokal yang ada

di dalam rongga mulut, faktor di luar rongga mulut, faktor fisiologis, dan faktor psikis. Di

dalam rongga mulut terdapat zat yang disebut volatile sulfur compound (VSCs). Zat ini

mengandung hidrogen sulfid, metil mercaptan, dan dimetil disulfid yang merupakan

produk bakteri atau flora normal rongga mulut. Pada orang yang menderita bau mulut,

kadar VSCs di dalam mulutnya mengalami peningkatan. Peningkatan kadar VSCs dalam

mulut disebabkan oleh adanya peningkatan aktivitas bakteri anaerob yang menyebabkan

bau VSCs tercium indera penciuman. Aktivitas bakteri anaerob itu terjadi apabila rongga

mulut mengandung sedikit oksigen, terutama saat mulut kering di mana aliran liur atau

saliva rendah. Kondisi bau mulut ini dapat diperberat apabila seseorang memiliki

kebersihan mulut yang rendah. Rendahnya kebersihan mulut ini biasanya ditandai oleh

dua hal yaitu banyaknya gigi yang berlubang atau karang gigi yang menumpuk. Bila ada

gigi yang berlubang maka sisa-sisa makanan akan tertinggal di dalam lubang dan di sela-

sela gigi yang pada akhirnya akan membusuk dan menyebabkan bau mulut. Demikian

pula dengan karang gigi yang menumpuk karena sejatinya pada karang gigi banyak

terdapat bakteri-bakteri yang produk metabolismenya juga dapat menyebabkan bau

mulut.

Selain faktor di dalam rongga mulut, bau mulut juga dapat disebabkan oleh faktor

di luar rongga mulut. Penyebabnya dapat berasal dari hidung, jantung, atau karena

penyakit tertentu, misalnya kencing manis, infeksi paru-paru, serta infeksi lambung atau

usus. Infeksi karena kanker atau radang amandel kronis juga bisa membuat napas tak

sedap. Penyebab lain adalah asam lambung tinggi, misalnya pada penderita maag. Bau

mulut timbul karena asam dan basa tidak seimbang. Pada penderita maag, misalnya, asam

lambungnya meningkat. Begitu maag kumat, otomatis tingkat keasaman mulut naik ke

atas tenggorokan, sehingga timbul bau mulut.

Pada saat berpuasa, bau mulut dapat terjadi karena beberapa hal. Penyebab

pertama adalah karena tidak aktifnya pengunyahan pada saat berpuasa. Hal ini memiliki

implikasi berkurangnya produksi kelenjar liur. Dengan demikian, produksi zat-zat VSCs

seperti yang telah disebutkan di atas akan meningkat dan menimbulkan timbulnya bau

yang tak sedap. Penyebab kedua adalah konsumsi makanan atau minuman yang

menimbulkan bau tajam seperti bawang putih, bawang merah, petai, jengkol, dan lain-

lain pada saat sahur. Penyebab yang ketiga adalah karena adanya faktor lokal dalam

rongga mulut berupa gigi berlubang atau karang gigi.

Untuk mengatasi bau mulut pada saat berpuasa maka disarankan untuk minum

lebih banyak air putih pada saat sahur. Konsumsi makanan berserat dan buah seperti buah

semangka atau bengkuang juga dianjurkan karena memiliki sifat sebagai cleaner atau

pembersih dalam perut. Jadi, selain untuk gigi, juga untuk kesehatan. Menggosok gigi

setelah sahur dibantu dengan berkumur-kumur cairan antiseptik mulut juga dapat

membantu mengurangi bau mulut. Selain itu, apabila diketahui ada gigi yang berlubang

atau karang gigi, segeralah pergi ke dokter gigi untuk menambal dan membersihkannya.

Puasa identik dengan bau mulut??? Tidak lagi tentunya! Semoga puasa Ramadhan kali

ini dapat membawa banyak keberkahan.

Halitosis secara umum terjadi sebagai hasil dari dekomposisi bakteri pada makanan, sel, darah maupun beberapa komponen dari saliva. Namun, 90 % penyebabnya berasal dari dalam mulut. Protein serta senyawa kimia lain yang ada pada material tersebut dipecah menjadi komponen yang lebih sederhana seperti asam amino dan peptide, beberapa substansi yang mudah menguap (asam lemak dan sulfur) dihasilkan dari proses dekomposisi tersebut. Beberapa diantaranya yaitu asam propionic (bau muntah), asam butirat (berbau mentega tengik), asam valerat, aston, asetaldehid, ertanol, propanol dan diacyl.Hasil lain dari dekomposisi ini berperan pada metabolisme bakteri di mulut, dan lebih jauh membusuk menjadi bahan yang dikenal dengan istilah VSC

WIKI

MULUTTerdapat lebih dari 600 jenis bakteri ditemukan di dalam rongga mulut, beberpa diantaranya dapat menghasilkan bau busuk saat dilakukan inkubasi di laboratosium. Bau busuk ini terutama hasil dari pemecahan secara anaerob dari protein menjadi asam amino, dan lebih jauh lagi pemecahan beberapa asam amino yang menghasilkan bau busuk.Sebagai contoh pemecahan cystein, dan methionin menhasilkan hydrogen sulfide dan methyl mercaptan. Sulfur telah terbukti berhubungan dengan adanya bau mulut.Bagian lain dari mulut juga ikut andil pada bau mulut, namun tidak sesering pada bagian bawah lidah. Daerah –daerah ini juga berperan: inter dental, sub gingival niche, abses, gigi palsu yang tidsk bersih dll.

LIDAHLokasi yang paling sering berhubungan dengan bau mulut ialah lidah. Sejumlaj besar bakteri ditemukan di posterior dorsum dari lidah yang mana pada daerah tersebut tidak terganggu oleh aktivitas normal. Daerah ini biasanya relatif kering dan kurang bersih sehingga populasi bakteri dapat tumbuh subur dari sisa-sisa makanan, sel epitel yang telah mati dan postnasal drip. Struktur lidah bagian ini mejnadi tempat yang ideal bagi bakteri anaerob untuk tumbuh subur di bawah lapisan yang terbentuk dari sisa-sisa

makanan, sel epitel yang telah mati dan postnasal drip. Hasil respirasi anaerob dari bakteri ini dapat menghasilkan bau indol, skatole, polyamine atau ’telur busuk’ dari VSCs (volatile sulfur compounds) seperti hidrogen sulfid, methyl mercaptan, allyl methyl sulfide dan dimethyl sulfide.

MEMBERSIHKAN LIDAHKeebanyakan alasan membersihkan lidah adalah untuk menghilangkan bau mulut seperti dengan menggunakan mints, mouthwash, permen karet dll. Hal ini hanya bersifat sementara dan tidak mengatasi sumber bau mulut. Untuk mengatasinya, bakteri, sisa makanan harus dibersihkan. Beberapa menggunakan tounge cleaner (tounge scarper) atau sikat gigi. Namun biasanya tounge cleaner lebih efektif dalam membersihkan dibanding sikat gigi yang terkadang justru meratakan akumulasi bakteri

GUSITerdapat beberapa kontroversi mengenai ada tidaknya peran penyakit periodontal menyebabkan bau mulut.

HIDUNGSumbr terbanyak kedua yang menyebabkan bau tidak sedap yakni hidung, namun bau tidak sedap yang berasal dari hidung ini berbeda dari bau yang berasal dari mulut. Yang berasal dari hidung biasanya karena sinusitis, benda asing.

TONSILBau busuk yang berasal dari tonsil hanya sekitar 3-5 % kasus. Biasanya karena tonsilolith yang menyebabkan bau busuk yang sangat.

PERUTPerut juga dapat sebagai penyebab bau tak sedap (kecuali sendawa). Esofagus merupakan tabung yang kolaps dan tertutup, ketika ada bau busuk dai dalam perut mengindikasikan masalah kesehatan seperti adanya reflux atau fistula antara lambung dan esofagus.

Penyakit SistemikAda beberapa kondisi dari penyakit sistemik yang dapat menyebabkan bau mulut menjadi tak sedap, antara lain:

1. Fetor hepaticus: dapat terjadi pada gagal hepar kronis2. Infeksi traktus respiratorius bagian bawah (Infeksi paru dan bronkhial).3. Infeksi pada ginjal dan gagal ginjal4. Karsinoma5. Trimethylaminuria ("fish odor syndrome").6. Diabetes mellitus.7. Metabolic dysfunction.[14]

Halitosis merupakan suatu keadaan di mana terciumnya bau mulut pada saat seseorang mengeluarkan nafas (biasanya tercium pada saat berbicara). Bau nafas yang bersifat akut, disebabkan kekeringan mulut, stress, berpuasa, makanan yang berbau khas, seperti petai, durian, bawang merah, bawang putih dan makanan lain yang biasanya mengandung senyawa sulfur. Setelah makanan di cerna senyawa sulfur tersebut diserap kedalam pembuluh darah dan di bawa oleh darah langsung ke paru-paru sehingga bau sulfur tersebut tercium pada saat mengeluarkan nafas.

 

Selain itu juga kebersihan mulut yang sangat kurang sempurna karena kebanyakan kita menyikat gigi hanya sekitar 40 detik, menurut literature diperlukan sedikitnya 3 menit untuk membersihkan gigi dan meng eliminasi bakteri merugikan yang berperan dalam produksi senyawa sulfur. Bau nafas pagi hari hampir pada semua orang dewasa, merupakan contoh bau nafas yang bersifat sementara (karena kekeringan mulut selama tidur). Bau nafas khronis dilaporkan menimpa 25 % populasi penduduk di berbagai macam kalangan. Keadaan ini dapat berpengaruh dalam hubungan personal atau bahkan dapat menyebabkan bencana terhadap hubungan bisnis.

 

Beberapa penelitian telah di lakukan untuk mengetahui bakteri-bakteri spesifik penyebab bau mulut tersebut. Di dalam mulut normal diperkirakan rata2 terdapat sekitar 400 macam bakteri dengan berbagai tipe. Meskipun penyebab bau mulut belum diketahui dengan jelas, kebanyakan dari bau tersebut berasal dari sisa makanan di dalam mulut. Masalah akan muncul bila sebagian bakteri berkembang biak atau bahkan bermutasi secara besar2an. Kebanyakan dari bakteri ini bermukim di leher gigi bersatu dengan plak dan karang gigi, juga di balik lidah karena daerah tersebut merupakan daerah yang aman dari kegiatan mulut sehari-hari. Bakteri tersebut memproduksi toxin atau racun, dengan cara menguraikan sisa makanan dan sel-sel mati yang terdapat di dalam mulut. Racun inilah yang menyebabkan bau mulut pada saat bernafas karena hasil metabolisme proses anaerob pada saat penguraian sisa makanan tersebut menghasilkan senyawa sulfide dan ammonia.

 

Bau mulut juga dapat di sebabkan oleh penyakit diabetes, penyakit ginjal, sinusitis, tonsillitis, kelainan fungsi pencernaan, penyakit liver, alkohol dan juga berbagai macam obat-obatan yang dapat menyebabkan kekeringan mulut.Perawatan yang dilakukan, berdasarkan penyebab bau mulut tersebut, bila perlu dilakukan pemeriksaan mikrobiologi untuk melihat bakteri penyebab, sebaiknya hubungi dokter gigi untuk pemeriksaan lebih lanjut.

 

Penggunaan penyegar nafas, permen karet dan obat kumur, biasanya bersifat asimptomatis dan sangat terbatas kerjanya hanya sementara saja, pada saat efek dari penyegar nafas hilang bau mulut akan kembali tercium.

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Halitosis

Halitosis, or bad breath, may be acute or chronic, depending on the underlying cause. It may indicate the need for improved dental hygiene or may be a symptom of an underlying infection or chronic disease. Oral causes constitute about 90% of the etiologies of halitosis, whereas nasal causes constitute nearly 10%; thus, other etiologies are relatively uncommon.

Differential Diagnosis

Head and neck etiologies –Foods (e.g., onion, garlic) –Dental conditions (periodontal disease, gingivitis, denture odor, dental abscesses, food particles not cleaned from teeth) –Postnasal drip –Dry mouth (xerostomia): Mouth breathing, side effect of medications, salivary gland disease, dehydration –Nasal foreign body –Gastroesophageal reflux disease –Chronic sinusitis –Allergic rhinitis –Tonsillar disease (e.g., streptococcal pharyngitis) –Zenker's (pharyngoesophageal) diverticulum: Presents as dysphagia, regurgitation, cough, and extreme halitosis –Tobacco or alcohol use

Systemic etiologies –Diabetes mellitus, especially with ketoacidosis –Uremia –Pulmonary disorders (e.g., bronchiectasis, pneumonia, neoplasms, tuberculosis) –Trimethylaminuria (fishy breath odor) –Liver failure (fetor hepaticus) –Menstruation may exacerbate halitosis

Workup and Diagnosis

Careful dental and medical history, including dental hygiene habits and dietary history –Note associated symptoms that suggest systemic etiology (e.g., cough, nasal congestion) –Odor after sleeping, dieting, or exercising suggests xerostomia –Odor upon talking suggests postnasal drip –Bleeding gums suggests periodontal disease

Dental examination to rule out treatable dental causes (e.g., periodontal disease) Physical examination should include careful oral, nasal, sinus, neck, pulmonary,

and abdominal examinations –Assess odor from mouth and nose separately –Small malodorous whitish stones on tongue suggest tonsilloliths –Place dentures into plastic bag for several minutes and then smell to evaluate for denture odor –Spoon test involves scooping mucous/saliva from back of tongue and evaluating for malodor; if present, suggests postnasal drip –Nasolaryngoscopy if nasal cause is suspected but specific cause cannot be identified

Zenker's diverticulum is diagnosed by contrast barium swallow

Treatment

Maintain good oral hygiene (e.g., brush teeth at least twice per day, floss daily, treat underlying periodontal disease)

Avoid exacerbating medications or foods Tongue cleaning with toothbrush Gargle with chlorhexidine mouthwash twice a day for a week to assess

improvement Treat postnasal drip (e.g., antihistamines, nasal steroids, polyp removal) Treat sinusitis with appropriate antibiotics Decrease or eliminate alcohol and tobacco use Zenker's diverticulum may require surgical resection if symptomatic Treat other underlying medical diseases (e.g., diabetic ketoacidosis, uremia,

GERD)

Book Source Details

Book Title: In a Page: Signs and Symptoms Author(s): Scott Kahan, Ellen G. Smith Year of Publication: 2004 Copyright Details: In a Page: Signs and Symptoms, Cop

Halitosis

Halitosis is a relatively infrequent pediatric chief complaint; however, it frequently emerges as part of the HPI. Acute causes are usually upper respiratory infections (such as stomatitis, tonsillitis, or sinusitis), whereas chronic halitosis is more likely to be due to dental issues. However, chronic sinusitis may cause halitosis either from the presence of bacterial colonies or from secondary mouth breathing.

Differential Diagnosis

Upper respiratory –Stomatitis: Painful ulcerated lesions on oral mucosa and gingiva; coxsackie virus is commonly called hand-foot-and-mouth disease; herpangina refers to herpetic lesions on the soft palate and posterior pharynx; trench mouth refers to necrotizing gingivostomatitis with pseudomembrane caused by spirochetes or fusiform bacteria –Sinusitis: Acute or chronic; pathogens are Streptococcus pneumoniae, β-hemolytic strep, Haemophilus influenzae, and Moraxella catarrhalis; maxillary sinuses are most frequently involved –Pharyngitis/tonsillitis/tonsillar abscess: Group A strep

Pulmonary disorders –Pulmonary abscess –Bronchiectasis

Gastric disorders –GERD –Bezoar

Dental etiologies –Poor oral hygiene: Bacterial accumulation on the teeth or tongue; gingival inflammation; food concretions within tonsillar crypts –Dental abscess: May be sequela of baby-bottle tooth decay, untreated dental caries, dental fracture, or poor hygiene –Orthodontic devices

Chronic mouth breathing –Seen in children with nasal polyps, adenoid hypertrophy, allergic rhinitis, and chronic sinusitis –Rarely due to a nasopharyngeal tumor such as a hemangioma or fibromas –Resultant dryness causes alteration of the oral mucosa and resultant bad breath; taste and smell may be affected

Nasal foreign body –Seen most often in the toddler/preschool age group –History of foreign body placement is not always forthcoming –Usually accompanied by unilateral nasal discharge

Workup and Diagnosis

History –Onset, duration, severity of symptoms –Accompanying signs and symptoms, especially fever, nasal congestion, nasal discharge, sore throat, cough, tachypnea –History of recurrent pneumonia –History of GI upset, digestive problems –Dental history and frequency of dental care

Physical exam –Examination of the oral cavity for dental hygiene, dental caries, gingival swelling, orthodontic devices that are poorly fitting or poorly maintained –HEENT examination including nasal cavity, oral lesions, tonsillar hypertrophy, asymmetry, exudate, or concretions –General medical evaluation including respiratory and GI systems

Labs –Throat culture if streptococcal pharyngitis is suspected

Radiology –X-ray or CT of sinuses for mucosal thickening or air-fluid levels –Lateral X-ray for adenoid hypertrophy –Chest X-ray if pulmonary lesion is suspected

Studies –Endoscopy may be required for suspicion of GERD or bezoar

Treatment

Scrupulous oral hygiene Stomatitis is usually treated supportively with acetaminophen and oral

hydration (Popsicles) –Viscous lidocaine should be used sparingly, if ever –Herpetic lesions may be treated with oral acyclovir –Trench mouth is treated with penicillin

Streptococcal pharyngitis is treated with penicillin Sinusitis requires longer duration of antibiotic therapy Bronchiectasis and pulmonary abscess are treated with systemic antibiotics and

nonsurgical or surgical drainage Adenoidectomy and treatment of concurrent allergies and sinusitis rectifies most

mouth breathing

GERD is treated with H2 blockers and promotility agents Endoscopy may be therapeutic and diagnostic for bezoar Removal of nasal foreign body is usually sufficient treatment

Book Source Details

Book Title: In A Page: Pediatric Signs and Symptoms Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Year of Publication: 2007 Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007

Lippincott Williams & Wilkins.

Other Book Chapters Relat

Halitosis

Mark Douglas Andrews

Halitosis (fetor oris) is a common problem, usually thought to be merely a social handicap related to poor oral hygiene or disease of the oral cavity. However, it can represent a marker for a more serious systemic illness that requires diagnosis and treatment (1). In modern society, oral malodor has been continually stigmatized, giving rise to a commercial market for mouthwash and mouth fresheners exceeding $800 million annually (2). Despite this publicity, patients only occasionally present with a primary complaint of halitosis and generally are unaware of the problem, but at some time more than half the population will be affected. Unfortunately, physicians and dentists remain relatively indifferent and unconcerned about this health issue.

Approach

Persistent or abnormal halitosis (usually noted by persons around the patient) exceeds in severity the more common and benign morning halitosis. The important initial task is to categorize the halitosis as either localized to the oral cavity or originating systemically. In addition, causes of halitosis can be subcategorized into common pathologic and nonpathologic types. The cause of halitosis can be attributed to bacterial activity in disorders of the oral cavity in 80% to 90% of patients, with the remaining 10% to 20% of cases attributed to nonoral or systemic sources (2,3).

A. Nonpathologic causes

 1. Morning breath is caused by decreased salivary flow during sleep associated with increased fluid pH, and resulting elevated gram-negative bacterial growth and volatile sulfur compounds production (4).

 2. Xerostomia, regardless of cause (e.g., sleep, diseases, medication side effects, mouth breathing), can contribute to halitosis. Age-related changes in salivary gland physiology result in a gradual decline in saliva quantity and quality.

 3. Missed meals. Dieting or missed meals can lead to halitosis secondary to decreased salivary flow and absence of food’s mechanical action on the tongue surface to wear down filiform papillae.

4. Tobacco or alcohol use is usually considered to be a contributing cause of halitosis.

5. Food sources. Metabolites from ingested food are absorbed into the circulatory system and then excreted through the lungs, thereby contributing to halitosis. Onions, garlic, alcohol, pastrami, and other meats are common offenders.

6. Medications. Drugs with anticholinergic side effects can cause xerostomia, especially in the elderly. An assortment of other agents can have a role in the production of offensive breath by a diversity of mechanisms. These agents include amphetamines, anticholinergics, antidepressants, antihistamines, decongestants, antihypertensives, anti-Parkinsonian agents, antipsychotics, anxiolytics, chemotherapeutic agents, diuretics, narcotic analgesics, and radiation therapy.

B. Pathologic causes

 1. Local oropharynx. Chronic peridontal disease and gingivitis are the most common sources caused by the promotion of bacterial overgrowth. Stomatitis and glossitis caused by systemic disease, medication, or vitamin deficiencies can lead to trapped food particles and desquamated tissue. An improperly cleaned prosthetic appliance can be a local contributor as can primary pharyngeal cancer. Also important are conditions associated with parotid dysfunction (e.g., viral and bacterial infections, calculi, drug reactions, systemic conditions including Sjögren’s syndrome).

 2. Gastrointestinal tract. Important sources include gastroesophageal reflux disease (GERD), gastrointestinal bleeding associated with a decayed odor, gastric cancer, malabsorption syndromes, and enteric infections.

 3. Respiratory tract. Chronic sinusitis, nasal foreign bodies or tumors, postnasal drip, bronchitis, pneumonia, bronchiectasis, tuberculosis, and malignancies may be causative.

4. Psychiatric causes are less common, but a complaint of halitosis can represent a delusional syndrome associated with somatization, depression, organic brain syndrome, or schizophrenia. Halitophobia refers to imaginary halitosis (3).

5. Systemic sources include diabetic ketoacidosis (sweet, fruity, acetone breath), renal failure (ammonia or “fishy” odor), hepatic failure (“fetor hepaticus”—a sweet amine odor), high fever with dehydration, and vitamin or mineral deficiencies leading to dry mouth.

History

A focus on the characteristics of the bad breath is critical, although the patient is often unable to self-diagnosis or describe accurately because of olfactory desensitization. Is the odor transient or constant? A constant odor suggests chronic systemic disease or serious disorders of the oral cavity. What are the precipitating, aggravating, or relieving factors? What are the patient’s smoking habits, medications, dietary preferences, and brushing and flossing routines?

Physical examination

A. Physical examination should be undertaken with an emphasis on the evaluation of the oral cavity, particularly looking for ulceration, dryness, trauma, postnasal drainage, infections, cryptic tonsils, or neoplasms.

B. Techniques for localizing the odor source (systemic versus oral cavity).

1. Seal lips and blow air through the nose. If fetid odor is noted, this is suggestive of a systemic source.

2. Pinch nose with lips closed. Hold respiration and exhale gently through the mouth. Odors detected in this fashion, generally are local in origin.

Testing

For most patients with complaints of halitosis, clinical laboratory testing and diagnostic imaging are unnecessary and should only be pursued on the basis of specific findings indicated by the history and physical examination. The Schirmer’s test may be useful in identifying xerophthalmia and associated xerostomia seen with Sjögren’s syndrome and some other rheumatologic conditions (Chapter 12.1). If indicated, radiologic studies and imaging procedures of the sinuses, thorax, and abdomen may be used to identify infectious processes, neoplasms, and GERD with its complications.

Halitosis

Halitosis describes any breath odor that’s unpleasant, disagreeable, or offensive. Certain types of halitosis characterize specific disorders — for example, a fruity breath odor typifies ketoacidosis. (See also specific breath odor types.) Other types of halitosis include putrid, foul, fetid, and musty breath odors.

Halitosis may result from a disorder of the oral cavity, nasal passages, sinuses, respiratory tract, or esophageal diverticula. It may also stem from a GI disorder and be associated with belching, regurgitation, or vomiting, or it may be an adverse effect of an oral or inhaled drug. Other causes of halitosis include cigarette smoking, ingestion of alcohol and certain foods (such as garlic and onions), and poor oral hygiene — especially in patients with an orthodontic device, dentures, or dental caries. Surprisingly, offensive skin odors — for example, from foot perspiration — may be absorbed locally and later expelled by the lungs, resulting in halitosis.

History

If you detect halitosis, try to characterize the odor. Does it smell fruity, fecal, or musty? If the patient is aware of it, find out how long he has had it. Does he also have a bad taste in his mouth? Does he have difficulty swallowing or chewing? Does he have reflux or regurgitation? Does he have pain or tenderness? Ask the patient if he has a problem with flatus and about his pattern and description of bowel movements.

Find out if the patient smokes or chews tobacco. Have him describe his diet and daily oral hygiene. Does he wear dentures? Complete the history by asking about chronic disorders and recent respiratory tract infection. If the patient reports a cough, find out if it’s productive.

Physical assessment

Begin the physical examination by examining the patient’s mouth, throat, and nose. Look for lesions, bleeding, drainage, obstruction, and signs of infection, such as redness and swelling. Check for tenderness by percussing and palpating over the sinuses. Then auscultate the lungs for abnormal breath sounds. Auscultate the abdomen for bowel sounds; percuss, noting any tympany. Finally, take vital signs.

Medical causes

Bowel obstruction

Halitosis is a late sign of both small- and large-bowel obstruction. With a small-bowel obstruction, vomiting of gastric, bilious, and then feculent material produces a related breath odor. Other findings include constipation, abdominal distention, and intermittent periumbilical cramping pain. With a large-bowel obstruction, fecal vomiting produces

fecal breath odor. Abdominal pain is milder and more constant than that associated with a small-bowel obstruction and is usually located lower in the abdomen.

Bronchiectasis

Bronchiectasis usually produces foul or putrid halitosis, but some patients may have a sickeningly sweet breath odor. The patient typically also has a chronic productive cough with copious, foul-smelling, mucopurulent sputum. The cough is aggravated by lying down and is most productive in the morning. Associated findings commonly include exertional dyspnea, fatigue, malaise, weakness, and weight loss. Auscultation reveals coarse or moist crackles over the affected lung areas during inspiration. Digital clubbing is a late sign.

Common cold

A musty breath odor may accompany a common cold, which usually also causes a dry, hacking cough with sore throat, sneezing, nasal congestion with rhinorrhea, headache, malaise, fatigue, and aching joints and muscles.

Esophageal cancer

With esophageal cancer, halitosis may accompany classic findings of dysphagia, hoarseness, chest pain, and weight loss. Nocturnal regurgitation and cachexia are late signs.

Gastric cancer

Halitosis is a late sign of gastric cancer. Accompanying findings include chronic dyspepsia unrelieved by antacids, a vague feeling of fullness, nausea, anorexia, fatigue, pallor, weakness, altered bowel habits, weight loss, and muscle wasting. Hematemesis and melena are signs of associated gastric bleeding.

Gastrocolic fistula

With gastrocolic fistula, fecal vomiting is responsible for fecal breath odor, which is typically preceded by intermittent diarrhea.

Gingivitis

Characterized by red, edematous gums, gingivitis may also cause halitosis. The gingivae between the teeth become bulbous and bleed easily with slight trauma.

Acute necrotizing ulcerative gingivitis also causes fetid breath, a bad taste in the mouth, and ulcers — especially between the teeth — that may become covered with a gray exudate. Severe ulceration may occur with fever, cervical adenopathy, headache, and malaise.

Hepatic encephalopathy

A characteristic late sign of hepatic encephalopathy is fetor hepaticus, a musty, sweet, or mousy (new-mown hay) breath odor. Major late effects also include coma, asterixis (flapping tremor), and hyperactive deep tendon reflexes.

Lung abscess

A lung abscess typically causes putrid halitosis, but its major sign is a productive cough with copious, purulent, often bloody sputum. Other findings include fever with chills, dyspnea, headache, anorexia, malaise, pleuritic chest pain, asymmetrical chest movement, weight loss, and temporary clubbing.

Ozena

Ozena — a severe, chronic form of rhinitis — causes a musty or fetid breath odor as well as thick, green mucus and progressive anosmia.

Periodontal disease

With periodontal disease, halitosis occurs with an unpleasant taste. Typically, the patient’s gums bleed spontaneously or with slight trauma and are marked by pus-filled pockets around the teeth. Related findings include facial pain, headache, and loose teeth covered by calculi and plaque.

Pharyngitis (gangrenous)

Halitosis is a chief sign of gangrenous pharyngitis. The patient also complains of a foul taste in the mouth, an extremely sore throat, and a choking sensation. Examination reveals a swollen, red, ulcerated pharynx, possibly with a grayish membrane. Fever and cervical lymphadenopathy are also common.

Renal failure (chronic)

Chronic renal failure produces a urinous or ammonia breath odor. Among its widespread effects are anemia, emotional lability, lethargy, irritability, decreased mental acuity, coarse muscular twitching, peripheral neuropathies, muscle wasting, anorexia, signs of GI bleeding, ecchymoses, yellow-brown or bronze skin, pruritus, anuria, and increased blood pressure.

Sinusitis

Acute sinusitis causes a purulent nasal discharge that leads to halitosis. Besides a characteristic postnasal drip, the patient may exhibit nasal congestion, sore throat, cough, malaise, headache, facial pain and tenderness, and fever.

Chronic sinusitiscauses a continuous mucopurulent discharge that leads to a musty breath odor. Postnasal drip, nasal congestion, and a chronic, nonproductive cough may accompany the musty odor.

Other causes

Drugs

Drugs that can cause halitosis include triamterene, inhaled anesthetics, paraldehyde (which is excreted through the lungs), and any drugs known to cause metabolic acidosis such as nitroprusside.

Special considerations

If examination of the mouth and sinuses doesn’t reveal the cause of halitosis, prepare the patient for upper GI and chest X-rays or endoscopy.

Pediatric pointers

In children, halitosis commonly results from physiologic causes, such as continual mouth breathing and thumb or blanket sucking. Phenylketonuria — a metabolic disorder that affects infants — may produce a musty or mousy breath odor.

Geriatric pointers

Extensive dental caries, mouth dryness, and poor oral hygiene can cause halitosis in elderly patients.

Patient counseling

To help control halitosis, encourage good oral hygiene. If halitosis is drug-induced, reassure the patient that it will disappear as soon as his body completely eliminates the drug.

What does the term halitosis mean?

Just in case you are wondering, halitosis is medical

terminology for bad breath. Halitosis is derived from the Latin word "halitus," which means breath, and the Greek suffix "osis," which means condition.

It's somewhat fitting that the formal term for bad breath

has been derived from words from ancient languages. Hebraic literature (the Talmud) dating back over two thousand years ago states that a marriage license (the Ketuba) can be broken if one of the partners has breath malodor. Similar references can be found in the literature of the Greeks, Romans and early Christians.

How do you test for halitosis?

Researchers have for tried to develop scientific methods that can quantify the severity of halitosis. This is because a human's sense of smell, at least for research purposes, introduces too many variables.

It's easy to understand how an olfactory appraisal of halitosis might vary from one individual tester to another. But research has also shown that any one tester's evaluation of a single person's halitosis will be inconsistent too. This variance is due to factors such as hunger, menstrual cycle, head positioning, and the number of consecutive times the tester has been exposed to an odor.

Several types of scientific apparatuses have been borrowed from other scientific fields or specifically designed to quantify degrees of halitosis. The list of these tools includes gas chromatographs, sulfide meters (Halimeters), and chemiluminescence detectors.

Bad breath: Causes and risk factors.

Conditions and circumstances that cause or place a person at risk for having halitosis.

In most cases bad breath (halitosis) is caused by the presence of oral bacteria. There can be, however, other factors that influence the odor associated with one's breath and, in fact, the quality of a person's breath will ultimately depend on a number of different variables.

The next portion of our discussion details some of these specific risk factors and conditions. When reading this information you should take notice of the fact that many of the items we list directly relate to:

Oral bacteria. Conditions which promote the growth of oral bacteria.

Not cleaning, or not being able to clean, those areas where oral bacteria reside.

Later on our pages will describe in greater detail how bacteria cause mouth odors and outline methods for cleaning these bacteria away. Right now however, at this point in our discussion, just realize that anything that promotes the growth of oral bacterial will most likely heighten a person's problems with bad breath too.

How do foods cause bad breath?

Everyone knows that certain foods have a reputation for causing bad breath. Two of the most notorious ones are garlic and onions.

When we eat our digestive system breaks the food we have consumed down in to its component molecules, some of which have very unpleasant and characteristic odors. As these molecules are created they are absorbed into our circulatory system so they can subsequently be distributed throughout the remainder of our body as nourishment.

As our blood travels through our lungs some of these molecules will be released into them. As a result, as we exhale our breath will contain some of these offending molecules, thus producing breath malodor.

While this type of bad breath can be annoying or embarrassing, this is not the type of breath problem we discuss on the subsequent pages of this topic. Bad breath caused by the consumption of certain foods will resolve on its own in a day or so as your body completes the process of breaking down and utilizing, or else excreting, the offending molecules. You can control this type of breath problem simply by avoiding or minimizing your consumption of these foods.

Why is smoking a risk factor for halitosis?

You are probably familiar with people who have "smoker's breath." While even though the precise odor associated with smoking depends on a number of factors, a great part of it is directly related to the tar, nicotine, and other foul smelling substances derived from tobacco's smoke that accumulates on a person's teeth and oral soft tissues (tongue, cheeks, gums,...).

Once again, while this type of breath malodor can be a problem, this is not the precise type of bad breath we address on the pages of this topic. Short of quitting smoking there is no effective way to totally eliminate smoker's breath, although immaculate oral hygiene can help to minimize it.

As a contributing risk factor, the act of smoking does have a drying effect on oral tissues. Decreased moisture in the mouth limits the washing and buffering effect of saliva on oral bacteria and their waste products, thus aggravating a person's problems with bad breath. More information about breath problems

associated with dry mouth conditions is discussed just below.

It is also known that people who smoke are at greater risk for having problems with periodontal disease ("gum disease") than people who do not smoke. Gum disease, as it relates to bad breath, is discussed in more detail below.

Why is having a dry mouth (xerostomia) a risk factor for bad breath?

Even if you don't have much of a problem with bad breath you have probably noticed that your breath is least pleasant in the morning when you first wake up. This is because during the night a person's mouth dries up somewhat, due to the human body's natural tendency to reduce salivary flow when a person sleeps. This same souring effect is sometimes noticed by teachers, lawyers, and anyone else whose mouth has become dry after having to speak for a prolonged period of time. Additionally, people who breathe through their mouth, are fasting, or else are under stress can find that they have comparatively dry mouths and therefore persistent problems with breath odors.

One explanation for this phenomenon is that the moisture found in our mouth helps to cleanse it. The presence of oral fluids encourages us to swallow. With each swallow we take we wash away bacteria, as well as the food and debris on which they feed. This same moisture also dilutes and washes away the waste products that oral bacteria produce.

Additionally, saliva is a very special form of mouth moisture. It's the body's natural mouth rinse. Beyond the washing and diluting effect that any oral moisture can provide, saliva has the added benefit that it contains compounds that can kill bacteria and buffer their waste products. So, when our mouth becomes dry, all of the benefits provided by each source of oral moisture are minimized. The net result is that the conditions for bacterial growth are enhanced while the neutralization of bacterial waste products is reduced.

Some people have chronically dry mouths. This condition is termed "xerostomia." Xerostomia can be a side effect of the medication a person is taking. Antihistamines (allergy and cold medications), antidepressants, blood pressure agents, diuretics, narcotics, or anti-anxiety medications are each known to produce xerostomia.

Another contributing factor associated with xerostomia is a person's age. It is commonplace that as people age they find that chronic mouth dryness becomes more and more of a problem. With age our salivary glands tend to work less effectively and the composition of the saliva that they produce changes too. Both of these factors create a situation where the effects of salivary cleansing and buffering are reduced.

A factor that compounds the problems associated with mouth dryness is that people who suffer from xerostomia are more at risk for having periodontal disease ("gum disease"). As discussed in our next section, periodontal disease is a causative factor for bad breath.

How does periodontal disease (gum disease) cause bad breath?

Periodontal disease, often just called "gum disease," can be the source of a person's breath problems. Ask any dentist

, the odor coming from the mouth of a person with active gum disease can be so distinctive that a dentist will often correctly anticipate the presence of gum problems even before they begin their examination of the patient.

Periodontal disease is the second most common (fundamental) cause of bad breath. Since periodontal disease is typically more of a problem for people over the age of 35 or so, the older we get the more likely that the source of our bad breath is related to conditions associated with the health of our gums.

Periodontal disease is a bacterial infection located in the tissues that surround a person's teeth. Advanced forms of periodontal disease typically result in serious damage to the bone that holds teeth in place. As this bone damage occurs, deep spaces form between the teeth and gums (termed "periodontal pockets"). These pockets provide an ideal location for bacteria to live in.

In many cases it is waste products coming from the bacteria that reside in these periodontal pockets, pockets which are often so deep that a person cannot effectively cleanse them, that is the cause of a person's bad breath. In addition, researchers have found that the amount of coating (as measured by weight) that is present on the tongues of people with periodontitis is greater than those in control groups. They have also found that the level of volitile sulfur compounds coming from this coating is four times greater than in people who do not have periodontal disease.

How can sinus conditions promote bad breath?

Sinus conditions can have an effect on the quality of a person's breath. Upper respiratory infections and allergies can create postnasal drip that deposits onto the back portion of a person's tongue (by way of the oral-nasal pathway found in the area of a person's soft palate). This discharge often has a foul taste and smell. What's worse, oral bacteria will feed upon this

discharge and create their own smelly waste products thus adding to the problems the person is having with bad breath.

As a compounding factor, people with sinus conditions will often have stuffed up noses and therefore will have a need to breathe through their mouth. The drying effect of mouth breathing can create an environment that promotes bad breath. Additionally, sinus sufferers are likely to be taking antihistamines, a type of medicine that is known to create mouth dryness.

Can untreated medical conditions cause bad breath?

Although the most common source of breath odors is related to the accumulation of bacteria in the mouth, certain medical conditions can be the cause of a person's breath odors. If a person's bad breath persists after they have consulted with their dentist and tried the usual simple solutions, then a consultation with a medical doctor may be indicated. Your doctor will of course know what types of conditions to look for but, in general, they will look for problems associated with the respiratory (pulmonary or bronchial), hepatic (liver), renal (kidney), and gastrointestinal (stomach and intestine) systems.

What types of dental conditions can cause bad breath?

There can be some types of untreated dental pathology that can contribute the problems a person is having with their breath. Any active infections in a person's mouth, such as those associated with abscessed teeth or a partially erupted wisdom tooth, can cause bad breath. Teeth having extensive untreated decay can trap enough debris and bacteria that they become the source of foul odors. Your dentist can identify and treat these problem dental conditions if they exist.

Can bad breath be caused by dentures?

Dentures (complete dentures, full dentures, partial dentures, etc...) can have a big influence on the quality of a person's breath. If you have dentures try this test to see if they might be the source of your breath malodor:

Remove your dentures and place them in a baggie. Seal the baggie shut and let it sit for about four or five minutes. Now, crack the baggie open and take a whiff. For better or worse, the odor you smell is representative of what your breath smells like to others.

While the most common cause of breath malodor is that caused by the accumulation of bacteria either on a person's tongue or on and around their teeth (periodontal disease), bacteria can and do accumulate on the surface of dentures and this can be the source of bad breath for some.

HALITOSIS AND OTHER BREATH ODORS

What are the various causes of bad breath and how can they be recalled with ease? The best method is to visualize the respiratory and upper gastrointestinal (GI.5pt) tree, because this is where the substances (mucus, sputum, and vomitus or regurgitant material) that produce these odors may be found.

In the mouth, pyorrhea due to poor dental care and infection may cause halitosis. A stomatitis (e.g., aphthous) may also be a cause. Sinusitis and atrophic rhinitis are causes in the nasal passages. Anyone who has a friend with large tonsils knows that this is a frequent cause, especially when the tonsils become infected. Any form of pharyngitis may also cause halitosis. Carcinoma and tuberculosis (TB) of the larynx and lower respiratory tract may cause halitosis. More likely causes are bronchiectasis and lung abscess. Proceeding down the esophagus to the stomach, one should recall the accumulation of food in diverticula, cardiospasm of the esophagus, and the frequent foul odor of chronic membranous or granulomatous esophagitis associated with a hiatal hernia. Carcinoma of the esophagus may also cause obstruction and allow putrefaction of food that accumulates there. A chronic gastritis or gastric carcinoma may also cause halitosis. A sweet odor to the breath may be found in diabetes mellitus and alcoholism. Uremia will often present with an ammoniac and urinous odor to the breath, whereas the breath of hepatic coma may be fishy (fetor hepatis). The feculent odor of a gastrocolic fistula and late states of intestinal obstructions should also be recalled.

Approach to the Diagnosis

The workup of bad breath involves a careful examination of the mouth and nasal passages. If this is negative, chest and sinus x-rays and upper GI series with barium swallow should be done. If the studies are still unrewarding, then endoscopy of the respiratory and upper GI tract would be indicated. Appropriate liver and renal function tests will be ordered when uremia or hepatic coma is suspected. If pyorrhea is suspected, refer the patient to a dentist.

HAND AND FINGER PAIN V I N D

Vascular Inflammatory Neoplasm Degenerative

      and Deficiency

Skin Periarteritis nodosa Gangrene

Carbuncle Ulcers Folliculitis Herpes zoster

Carcinoma

Fascia, Ligaments, Tendon Sheaths, Subcutaneous Tissue

Felon Abscess Cellulitis Tendon sheath infection

Sarcoma

Arteries Arteriosclerosis Subacute bacterial endocarditis

Macroglobulinemia  

Veins ThrombophlebitisMuscles Myositis  Peripheral Nerves (Carpal Tunnel)

  Multiple myeloma

 Brachial Plexus

Ischemic neuritis Myocardial infarction

Bursitis Arthritis Pneumonia

Pancoast tumor

Spinal Cord and Cervical Roots

Tuberculosis Primary or metastatic tumors of cord

Cervical spondylosis Syringomyelia

Bone Gonococcal arthritis

Osteoarthritis

  

Pictures

Book Source Details

Book Title: Differential Diagnosis in Primary Care Author(s): R. Douglas Collins MD, FACP Year of Publication: 2007 Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007

Lippincott Williams & Wilkins.

Curing bad breath: What approach do dentists take with their patients when treating halitosis?

What is the right approach for treating bad breath?

Since the most common cause of bad breath (halitosis) is the odorous waste products (volatile sulfur compounds) created by anaerobic oral bacteria, the most important message a dentist can convey to their patients is that they must clean their mouth in a manner which helps to:

Minimize the amount of food available to these bacteria. Minimize the total number of these bacteria that exist. Minimize the availability of the types of environments in which these bacteria

prefer to live.

Make any environment in which these bacteria do live less hospitable.

On a second front the patient can:

Use products that help to neutralize volatile sulfur compounds.

Minimize the food supply available to the bacteria that cause halitosis.

The volatile sulfur compounds that cause bad breath are actually waste byproducts created by anaerobic oral bacteria when they digest proteins. This would imply that those persons who maintain a vegetarian diet (a diet composed mostly of fruits and vegetables) should have fewer breath problems, as compared to people who have diets that are high in protein rich foods such as meat.

It is important for a person to clean their mouth thoroughly after eating, and especially after eating foods that are high in protein content. This is because even after we have finished a meal minute particles of food still remain in our mouth. Much of this food debris ends up lodged between our teeth and incorporated into the coating found on the posterior part of our tongue. Since these are precisely the same locations in which the anaerobic bacteria that cause bad breath live, if a person does not clean their mouth thoroughly a food supply is provided for these bacteria over an extended period of time.

How cleaning your teeth and gums can help to cure bad breath.

Some of the oral bacteria that create the waste products that are responsible for causing bad breath live in the dental plaque that accumulates on and around a person's teeth, both at and below the gum line. Thorough brushing and flossing technique is needed so to effectively remove this plaque and also any food debris that is left in the person's mouth after eating that could serve as a food supply by these bacteria.

Take notice of the fact that we have used the term "brushing and flossing" here. It is not realistic to think that a mouth odor emanating from the areas around the teeth can be diminished unless flossing is an integral part of a person's daily cleaning routine.

Make an appointment with your dentist.

If your bad breath problem persists, even after a period of following all of the tips and suggestions we make on this topic's pages, you should schedule an examination and cleaning appointment with your dentist so you can discuss your problems with them. During this visit the following can be accomplished:

1) Sometimes effective brushing and flossing technique can be difficult to learn. After examining you your dentist can provide you with instructions, tips, and pointers that will be helpful for your specific situation.

2) Tartar (dental calculus) accumulation can interfere with effective brushing and flossing. Your dental cleaning will remove this debris from your teeth.

3) A part of your dentist's examination will include a periodontal evaluation. Periodontal disease ("gum disease") can cause significant damage to your gums and the bone that lies underneath them. This damage can result in the creation of deep spaces between your teeth and gums called "periodontal pockets." These pockets are often impossible for you to clean effectively and therefore make an

ideal environment for the bacteria that cause bad breath to live. If a periodontal problem is found your dentist can outline the treatment that will be needed to get this condition under control.

4) During your examination your dentist will check to see if there are any untreated dental conditions that could be causing or aggravating your breath problems.

5) Your dentist can help to determine if it is unlikely that oral conditions are the cause of your bad breath and that a referral to a doctor for a medical evaluation is indicated.

Using a tongue scraper or brush can cure bad breath.

Get rid of your halitosis by cleaning your tongue more thoroughly.

Most people overlook cleaning their tongue but starting to do so on a regular basis can be the single most beneficial treatment for bad breath (halitosis) that a person can institute.

Remember the breath tests we suggested you perform at the beginning of this topic? They revealed that the smell of the anterior portion of a person's tongue is usually less offensive than the smell found emanating from the posterior part.

The reason for this is related to the fact that the anterior portion of the tongue is somewhat self-cleansing and therefore less likely to harbor large numbers of odor producing bacteria. Many tongue functions require that the anterior portion of the tongue touches firmly against the hard palate. This friction produces a cleansing action, therefore

preventing any significant bacterial accumulation.

The posterior portion of the tongue, in comparison, rubs up against the soft palate. And these contacts are relatively gentle.

This soft palate contact does not provide enough friction to produce any significant cleansing. And for this reason it is typically the posterior aspect of the tongue that is found to harbor the bacteria that cause a person's breath problems. Because of this, the posterior tongue is the most important area to clean.

How should your tongue be cleaned?

There are various techniques that you can use to clean the posterior portion of your tongue. Each of these methods, however, has the same goal, to scrape away the bacteria and debris that have accumulated on

your tongue's surface.

No matter which method of tongue cleaning you choose to use, you should try to clean as far back on your tongue as possible. Don't be surprised if you find you have an active gag reflex. Gagging is a natural reaction but with time the intensity of this reflex should diminish.

How to clean your tongue using a toothbrush or a tongue brush.

Your toothbrush or a specialized tongue brush can be used to clean your tongue. To do so, start as far back as possible and then make brush strokes outward, toward the front of your mouth. You need to use some pressure but of course not enough to cause irritation to your tongue.

As a way of improving the effectiveness of your tongue brushing efforts, you can use a toothpaste that provides one or both of the benefits listed below. Since the ingredients that provide these benefits are often the same ones included in the formulations of mouthwashes, we have placed a more detailed discussion about these agents on our mouthwash page.

Toothpastes that neutralize volatile sulfur compounds. In most cases it is the malodorous volatile sulfur compounds (VSC's) produced by anaerobic bacteria that are the actual source of a person's bad breath. Using a toothpaste that contains VSC neutralizing agents such as chlorine dioxide or zinc can help to alleviate breath problems.

Toothpastes which have antibacterial properties. If the toothpaste you are using contains antibacterial agents such as chlorine dioxide or cetylpyridinium chloride, your tongue brushing efforts will both dislodge and kill odor-causing bacteria.

How to clean your tongue using a tongue scraper.

While cleaning your tongue with a brush can be satisfactory, many people find that scraping their tongue with a tongue scraper is more effective. As an added benefit, some people find that they have less tendency to gag when using a tongue scraper as opposed to a brush.

It's easy to experiment with tongue scraping. To do so, pick out a spoon (smaller is usually better than larger), invert it, and then go ahead and give tongue scraping a try. Place the spoon on the posterior portion of your tongue and then draw it forward. Be thorough but also gentle. Don't scrape so hard or vigorously that you irritate your tongue.

If tongue scraping seems to be an acceptable technique for you then you might investigate those products that have been specifically designed as tongue scrapers. You will probably find that they are more effective at cleaning than your spoon is.

Halitosis treatments: Using mouthwashes and mouth rinses to get rid of bad breath.[ Our brief overview of this subject. >>   Effective treatments for bad breath.  ]

What types of mouthwashes can help to cure halitosis?

Mouthwashes, when used in conjunction with a regimen of effective tongue cleaning, tooth brushing, and flossing, can play a role in the treatment of bad breath (halitosis). You cannot, however, expect that a mouthwash will be an effective cure for your condition on its own.

The effectiveness of a particular mouthwash will be founded on its possessing one or both of the following characteristics:

A) Antibacterial mouthwashes.

If a mouthwash has the ability to kill bacteria, it can play a part in helping to minimize the total number of anaerobic bacteria that are present in a person's mouth. Since these bacteria are the source of the volatile sulfur compounds that cause of bad breath, the fewer of them that are present in a person's mouth the better.

B) Mouthwashes that neutralize volatile sulfur compounds. The ingredients that are found in some mouthwashes have the capability to neutralize volatile sulfur compounds (VSC's) and/or the compounds from which they are formed. Since volatile sulfur compounds are the malodorous substances that actually cause bad breath, if a mouthwash can help to decrease the concentration of these compounds in a person's breath, then the more pleasant that person's breath will be.

Some of the different types of over-the-counter mouthwashes that have been created for the treatment of bad breath are listed below. In an attempt to increase a particular product's effectiveness, some mouthwash formulations contain a combination of these agents.

A) Mouthwashes that contain chlorine dioxide or sodium chlorite.

        Properties: Antibacterial  and  Neutralizes Volatile Sulfur Compounds

Mouthwashes that contain chlorine dioxide, or its parent compound sodium chlorite, have been used in the treatment of bad breath. Research has suggested that chlorine dioxide's mechanism of action is twofold:

Chlorine dioxide is an oxidizing agent (this means that it releases oxygen). Because most of the bacteria that cause bad breath are anaerobic (meaning, they prefer to live in environments devoid of oxygen), exposing them to an oxidizing agent can help to minimize their numbers.

Chlorine dioxide has the ability to neutralize volatile sulfur compounds. It also has the ability to degrade the precursor components utilized by bacteria use when making VSC's. The net effect is that the overall concentration of volatile sulfur compounds found in a person's breath is reduced, and as a result their breath will be more pleasant.

B) Mouthwashes that contain zinc.

        Properties: Neutralizes Volatile Sulfur Compounds

Research has suggested that mouthwash products that contain zinc ions can reduce the concentration of volatile sulfur compounds found in a person's breath. This action is

presumed to be related to the fact that the zinc ions bind to the precursor compounds that anaerobic bacteria require to produce volatile sulfur compounds.

C) "Antiseptic" type mouthwashes.

        Properties: Antibacterial

"Antiseptic" mouthwash (i.e., Listerine and its generic equivalents) has been suggested as suitable product for the treatment of bad breath. The effectiveness of this type of rinse is related to its ability to kill the anaerobic oral bacteria that produce volatile sulfur compounds. Antiseptic mouthwash has not been shown to have a neutralizing effect directly on the volatile sulfur compounds themselves.

Some dentists feel that antiseptic type mouthwashes are not the best choice for treating bad breath. This criticism stems from the fact that these products often contain significant amounts of alcohol (on the order of 25%). Alcohol is a desiccant (a drying agent) and therefore can have the effect of drying out the tissues of the mouth. Our discussion about xerostomia explains how mouth dryness can aggravate a person's breath problems.

D) Cetlyperadium chloride mouthwashes.

        Properties: Antibacterial

The compound cetylpyridinium chloride is often included in the formulation of mouthwashes. It has antibacterial properties and therefore can help to control the number of anaerobic bacteria that are found in a person's mouth.

Are breath mints, lozenges, drops, sprays, and chewing gum an effective treatment for bad breath?

Just like with mouthwashes, breath mints, lozenges, drops, sprays and chewing gum, on their own, are usually not an effective means by which to cure bad breath. However, when these products are used in conjunction with diligent tongue cleaning and tooth brushing and flossing they can be valuable adjuncts. Especially if they contain agents that have the ability to neutralize volatile sulfur compounds (such as chlorine dioxide, sodium chlorite, and zinc).

As an added benefit, the use of mints, lozenges, and chewing gum stimulates the flow of saliva. As discussed previously, saliva has a cleansing and diluting effect on the bacteria and bacterial waste products that are found in a person's mouth, thus helping to minimize breath odor problems.

How to use mouthwash so to get the most benefit from its antibacterial properties.

The bacteria that cause bad breath live both on the surface and also deep within the dental plaque that accumulates on and around a person's teeth, gums and tongue. An antibacterial mouthwash will not have the ability to significantly penetrate into and through the plaque on its own. This means that the most effective use of a mouthwash will be after your brushing, flossing and tongue cleaning efforts have removed, or at least disrupted, the dental plaque. Rinsing after your cleaning routine allows the mouthwash to get at any of the free floating bacteria you have dislodged. It also allows the mouthwash to have an effect on those bacteria that, while not

dislodged, have become exposed due to the disruption of their dental plaque colony.

When you rinse with a mouthwash it is best that you gargle it. As you gargle, make an "aaahhh" sound. This will extend your tongue outward and allow the mouthwash to contact a greater portion of the posterior portion of your tongue. This area is the precise region where the largest accumulation of bad breath producing bacteria typically reside.

All mouth rinses should be spit out after gargling. Children should not be given mouthwash because of the possibility that they may swallow it.

How to clean dentures.

Your dentist should provide you with specific instructions regarding suitable methods for cleaning the dentures they have made for you. Since dental plaque will form on your dentures just like it does on natural teeth and gums, a dentist's recommendations will usually include instructions that involve thoroughly scrubbing your dentures with a toothbrush or specialized denture brush, both inside and out. After scrubbing your dentures you might place them in whichever antiseptic denture soak your dentist suggests. More about the causes of denture breath and how to treat it. >>

emedies that can help to minimize bad breath.

Simple tips that can help to minimize your potential for having halitosis.

1) Drink plenty of water.

Drinking plenty of water throughout the day can help to minimize a person's problems with bad breath (halitosis) This can be an especially important

consideration for those people who suffer from xerostomia (chronically dry mouths).

If you allow yourself to become dehydrated, your body will attempt to conserve moisture by reducing its production of saliva. Saliva has a cleansing and diluting effect on the bacteria and bacterial waste products that cause bad breath. A reduction in the amount of saliva in your mouth will make it more likely that you will experience breath problems.

2) Rinse your mouth with water throughout the day.

Rinsing with water can mitigate bad breath problems for brief periods of time. Rinsing will both dilute and partially remove the bacterial waste products that are the cause of breath odors.

3) Stimulate your mouth's flow of saliva.

You can help to minimize breath malodor by stimulating your body's flow of saliva. This is because saliva has a cleansing and diluting effect on the bacteria and bacterial waste products that cause bad breath.

One way to stimulate salivary flow is to chew on something. Doing so will trick your body in to thinking that it is getting a meal. In preparation for digesting this meal, your body will increase its production of saliva. You might choose to chew on cloves, fennel seeds, or a piece of mint or parsley.

Chewing gum, breath mints, or lozenges can also be used to stimulate salivary flow. If you elect to use one of these products, make sure it is sugar-free since sweets will promote the growth of bacteria that cause tooth decay.

4) Clean your mouth well, especially after eating foods that are high in protein content.

The bacterial waste products that cause of bad breath are created when oral anaerobic bacteria digest proteins. After you eat a meal or snack, especially one that is high in protein content, make sure that you clean your mouth promptly and thoroughly. Doing so will minimize both the time duration and amount of food that is available for the offending bacteria.

Do you have bad breath?

How is your breath? Not sure? No doubt each of us has, at some point, unwittingly had bad breath (halitosis) only to be subsequently embarrassed by the reactions of others in response to it.

For any individual, the exact status of their own breath can be difficult to ascertain. The reason for this lies in the fact that the oral cavity is connected to our nose by way of an opening which lies in the back of our mouth (in the region of our soft palate). Since noses tend to filter out and ignore background odors, it filters out and ignores the quality of our own breath. This means that it is quite possible for a person to have bad breath, yet not be aware of it.

How can you tell if you have a breath problem?

If our noses can't reliably help us judge the quality of our own breath, how can we determine if we do have bad breath? One solution is to ask the opinion of a spouse or significant other. If you don't feel you can ask them, ask your dentist or hygienist at your next dental appointment, after all, evaluating oral conditions is part of their job. If you find this type of question too personal to ask an adult, don't overlook asking a child. As we all know, sometimes the least inhibited and most honest responses come from children.

Symptoms: How can a person can test the quality of their own breath?

There are ways you can objectively smell your own breath. However, you have to take a slightly indirect route.

Try this technique. Lick your wrist, wait

about five seconds while the saliva dries somewhat, and then smell it. What do you think?

That's the way you smell. Or, more precisely, that's the way the end of your tongue smells (your tongue's "anterior" portion). How was it? Did you pass this first check?

Now try this second experiment. It will check the odor associated with the back portion of your tongue (your tongue's "posterior" aspect).

Take a spoon, turn it upside down, and use it to scrape the very back portion of your tongue. (Don't be surprised if you find you have an active gag reflex.) Take a look at the material that has been scrapped off, usually it's a thick whitish material. Now, take a whiff of it. Not so bad? Pretty nasty? This smell, as opposed to the sampling from the anterior portion of your tongue, is probably the way your breath smells to others.

You now know. The fundamental cause of bad breath is...

Just as your experimentation has suggested, for most people the fundamental cause of bad breath is the whitish coating that covers the surface of the posterior portion of their tongue. More accurately, bad breath is caused by the bacteria that live in this coating. (The second most common fundamental cause of bad breath is bacteria that accumulate elsewhere in a person's mouth.)

The remainder of the text on this page describes the various methods by which dental researchers attempt to quantify bad breath. If you're interested in this topic of course please read on, otherwise you may want to skip to our

next page which continues on with our discussion about causes of halitosis.

How academic researchers test for the presence of halitosis.

   ( Related page: How academic researchers and dental professionals categorize types of bad breath. )

Before a dental researcher can evaluate the effectiveness of a cure for bad breath they must first have a way to quantify the person's level of malodor, both initially and after the

cure they are studying has been administered. Some of the different methods researchers use to measure bad breath are discussed below.

Organoleptic testing for bad breath.

Judging a person's breath by way of organoleptic testing simply means that the researcher performing the breath evaluation has used their sense of smell (their nose) as the means for making a determination. Historically this method of breath testing has been a frequent choice among dental researchers. Noses are readily available, inexpensive to obtain and operate, and to their credit, noses can detect up to 10,000 different smells.

One of the problems associated with using organoleptic testing is that this technique is not totally objective. Another is that factors other than just breath odors can and do influence organoleptic evaluations. As examples, research has shown that factors such as hunger, menstrual cycle, head position, and the degree of attentiveness and expectation can each influence a judge's interpretation of what they smell. Additionally, consumption or use of coffee, tea, juice, tobacco products and scented cosmetics by subjects prior to their evaluation can influence the testing.

As for quantifying the organoleptic measurement itself, what exactly does constitute a weak, strong, or average level of bad breath? Will each judge participating in the research be able to make equivalent comparisons? Complicating things even more, as we all know, when we are repeatedly exposed to a bad odor our sense of smell acclimates to the odor and therefore loses much of its sensitivity. Breath malodor that seems exceedingly objectionable at the beginning of testing may seem quite less so as the evaluation continues.

Evaluating bad breath with gas chromatography.

A number of scientific fields utilize gas chromatographs to identify compounds found in the samples they are studying. Likewise, gas chromatographs have been employed by dentists conducting halitosis studies and have provided a means by which a researcher can definitively quantify the precise levels of various compounds present in someone's breath. It is considered to be the "gold standard" for measuring breath malodor.

While gas chromatography is probably the best way to test for the compounds associated with bad breath, it has not been widely utilized in research studies for several reasons. Gas chromatographs are relatively expensive and require personnel with special training to operate them. The equipment is not portable and a significant amount of time is needed to make each breath measurement.

Using Halimeters to quantify halitosis.

A specialized type of sulfide monitor (termed a Halimeter) has been developed and it provides a means by which a tester can quantify certain aspects of a person's breath.

These machines, first introduced in 1991, measure levels of sulfide gases. Some sulfides, such as hydrogen sulfide and methyl mercaptan (collectively referred to in dental literature as volatile sulfur compounds or "VSC's"), are known to be causative agents of bad breath. A Halimeter's reading showing a high level of sulfides in a person's breath suggests that a corresponding high level of VSC's are present, although the apparatus does not test for individual types of VSC's specifically.

Since a Halimeter tests for a fewer number of compounds (sulfides only) than gas chromatographs, and in fact test for no individual compounds at all but instead just sulfides as a class, Halimeters provide for a less definitive evaluation of a person's breath malodor than gas chromatographs. Additionally, compounds such as ethanol (alcohol) and essential oils (both of which are frequently found in mouthwashes) interfere with a Halimeter's ability to make a measurement. The advantages of using a Halimeter for a study rather than a gas chromatograph are that a Halimeter requires no special training to use, is portable, breath measurements can be made quickly and the apparatus itself is comparatively inexpensive.

The BANA test.

Some of the bacteria that cause periodontal disease (gum disease) produce waste products that are quite odiferous and as a result contribute to a person's breath problems. The presence of some of these types of bacteria can be tested for by way of performing a BANA test.

The bacteria in question have the characteristic of being able to produce an enzyme that degrades the compound benzoyl-D, L-arginine-naphthylamide (abbreviated BANA). When a sample of a patient's saliva that contains these bacteria is placed in with the BANA testing compound they cause it to break down, thus creating a color change in the testing medium.

Utilizing chemiluminescence to detect bad breath.

One of the more recently developed methods of testing for the presence of compounds associated with bad breath relies on the principle of chemiluminescence. This type of testing was first introduced in 1999. When a sample containing sulfur compounds (such as VSC's, the types of compounds which cause bad breath) is mixed in with the test's mercury compound, the resulting reaction causes fluorescence. The strength of chemiluminescence methodology is that it can provide better selectivity and sensitivity when measuring low levels of sulfur compounds, as compared to testing with a Halimeter.

Do you have bad breath?

How is your breath? Not sure? No doubt each of us has, at some point, unwittingly had bad breath (halitosis) only to be subsequently embarrassed by the reactions of others in response to it.

For any individual, the exact status of their own breath can be difficult to ascertain. The reason for this lies in the fact that the oral cavity is connected to our nose by way of an opening which lies in the back of our mouth (in the region of our soft palate). Since noses tend to filter out and ignore background odors, it filters out and ignores the quality of our own breath. This means that it is quite possible for a person to have bad breath, yet not be aware of it.

How can you tell if you have a breath problem?

If our noses can't reliably help us judge the quality of our own breath, how can we determine if we do have bad breath? One solution is to ask the opinion of a spouse or significant other. If you don't feel you can ask them, ask your dentist or hygienist at your next dental appointment, after all, evaluating oral conditions is part of their job. If you find this type of question too personal to ask an adult, don't overlook asking a child. As we all know, sometimes the least inhibited and most honest responses come from children.

Symptoms: How can a person can test the quality of their own breath?

There are ways you can objectively smell your own breath. However, you have to take a slightly indirect route.

Try this technique. Lick your wrist, wait

about five seconds while the saliva dries somewhat, and then smell it. What do you think?

That's the way you smell. Or, more precisely, that's the way the end of your tongue smells (your tongue's "anterior" portion). How was it? Did you pass this first check?

Now try this second experiment. It will check the odor associated with the back portion of your tongue (your tongue's "posterior" aspect).

Take a spoon, turn it upside down, and use it to scrape the very back portion of your tongue. (Don't be surprised if you find you have an active gag reflex.) Take a look at the material that has been scrapped off, usually it's a thick whitish material. Now, take a whiff of it. Not so bad? Pretty nasty? This smell, as opposed to the sampling from the anterior portion of your tongue, is probably the way your breath smells to others.

You now know. The fundamental cause of bad breath is...

Just as your experimentation has suggested, for most people the fundamental cause of bad breath is the whitish coating that covers the surface of the posterior portion of their tongue. More accurately, bad breath is caused by the bacteria that live in this coating. (The second most common fundamental cause of bad breath is bacteria that accumulate elsewhere in a person's mouth.)

The remainder of the text on this page describes the various methods by which dental researchers attempt to quantify bad breath. If you're interested in this topic of course please read on, otherwise you may want to skip to our

next page which continues on with our discussion about causes of halitosis.

How academic researchers test for the presence of halitosis.

   ( Related page: How academic researchers and dental professionals categorize types of bad breath. )

Before a dental researcher can evaluate the effectiveness of a cure for bad breath they must first have a way to quantify the person's level of malodor, both initially and after the

cure they are studying has been administered. Some of the different methods researchers use to measure bad breath are discussed below.

Organoleptic testing for bad breath.

Judging a person's breath by way of organoleptic testing simply means that the researcher performing the breath evaluation has used their sense of smell (their nose) as the means for making a determination. Historically this method of breath testing has been a frequent choice among dental researchers. Noses are readily available, inexpensive to obtain and operate, and to their credit, noses can detect up to 10,000 different smells.

One of the problems associated with using organoleptic testing is that this technique is not totally objective. Another is that factors other than just breath odors can and do influence organoleptic evaluations. As examples, research has shown that factors such as hunger, menstrual cycle, head position, and the degree of attentiveness and expectation can each influence a judge's interpretation of what they smell. Additionally, consumption or use of coffee, tea, juice, tobacco products and scented cosmetics by subjects prior to their evaluation can influence the testing.

As for quantifying the organoleptic measurement itself, what exactly does constitute a weak, strong, or average level of bad breath? Will each judge participating in the research be able to make equivalent comparisons? Complicating things even more, as we all know, when we are repeatedly exposed to a bad odor our sense of smell acclimates to the odor and therefore loses much of its sensitivity. Breath malodor that seems exceedingly objectionable at the beginning of testing may seem quite less so as the evaluation continues.

Evaluating bad breath with gas chromatography.

A number of scientific fields utilize gas chromatographs to identify compounds found in the samples they are studying. Likewise, gas chromatographs have been employed by dentists conducting halitosis studies and have provided a means by which a researcher can definitively quantify the precise levels of various compounds present in someone's breath. It is considered to be the "gold standard" for measuring breath malodor.

While gas chromatography is probably the best way to test for the compounds associated with bad breath, it has not been widely utilized in research studies for several reasons. Gas chromatographs are relatively expensive and require personnel with special training to operate them. The equipment is not portable and a significant amount of time is needed to make each breath measurement.

Using Halimeters to quantify halitosis.

A specialized type of sulfide monitor (termed a Halimeter) has been developed and it provides a means by which a tester can quantify certain aspects of a person's breath.

These machines, first introduced in 1991, measure levels of sulfide gases. Some sulfides, such as hydrogen sulfide and methyl mercaptan (collectively referred to in dental literature as volatile sulfur compounds or "VSC's"), are known to be causative agents of bad breath. A Halimeter's reading showing a high level of sulfides in a person's breath suggests that a corresponding high level of VSC's are present, although the apparatus does not test for individual types of VSC's specifically.

Since a Halimeter tests for a fewer number of compounds (sulfides only) than gas chromatographs, and in fact test for no individual compounds at all but instead just sulfides as a class, Halimeters provide for a less definitive evaluation of a person's breath malodor than gas chromatographs. Additionally, compounds such as ethanol (alcohol) and essential oils (both of which are frequently found in mouthwashes) interfere with a Halimeter's ability to make a measurement. The advantages of using a Halimeter for a study rather than a gas chromatograph are that a Halimeter requires no special training to use, is portable, breath measurements can be made quickly and the apparatus itself is comparatively inexpensive.

The BANA test.

Some of the bacteria that cause periodontal disease (gum disease) produce waste products that are quite odiferous and as a result contribute to a person's breath problems. The presence of some of these types of bacteria can be tested for by way of performing a BANA test.

The bacteria in question have the characteristic of being able to produce an enzyme that degrades the compound benzoyl-D, L-arginine-naphthylamide (abbreviated BANA). When a sample of a patient's saliva that contains these bacteria is placed in with the BANA testing compound they cause it to break down, thus creating a color change in the testing medium.

Utilizing chemiluminescence to detect bad breath.

One of the more recently developed methods of testing for the presence of compounds associated with bad breath relies on the principle of chemiluminescence. This type of testing was first introduced in 1999. When a sample containing sulfur compounds (such as VSC's, the types of compounds which cause bad breath) is mixed in with the test's mercury compound, the resulting reaction causes fluorescence. The strength of chemiluminescence methodology is that it can provide better selectivity and sensitivity when measuring low levels of sulfur compounds, as compared to testing with a Halimeter.