treatment of oral and nonoral sources of halitosis in elderly patients

DRUG THERAPY Drugs & Aging 6 (5) 397-408,1995 1170-229X/95/0005-0397/S06.00/0

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Treatment of Oral and Nonoral Sources of Halitosis in Elderly Patients John D. McDowell and Denise K. Kassebaum Department of Diagnostic and Biological Sciences, Division of Oral Diagnosis/Medicine/Radiology, University of Colorado School of Dentistry, Denver, Colorado, USA

Contents Summary , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 1, Treatment Planning for the Reduction or Elimination of Oral Malodours

1 ,1 Patient History , , , , , , , , , , , , , , 1,2 Screening for Neurological Disorders, 1,3 Tobacco Products , , 1.4 Diet Assessment , , , , , , , , , , , , , 1 ,5 Physical Examination , , , , , , , , , ,

1,5,1 Malodour in Nasally Expired Air 1 ,5.2 Malodour in Orally Expired Air , 1 ,5,3 Systemic Disease " 1 ,5,4 Candidosis , , , , , , 1,5,5 Ingested Substances

1 ,6 Oral Examination , , , , , , 1 ,6,1 Lips and Adjacent Skin 1 ,6.2 Oral Vestibules , , , , 1,6,3 Tongue , , , , , , , , , 1.6,4 Teeth and Prostheses , 1 ,6,5 Dental Pulpal Involvement , 1 ,6,6 Periodontal Tissues 1.6,7 Oropharynx " , , , , , , , 1 ,6,8 Xerostomia , , , , , , , , , ,

2, Laboratory Tests or Additional Diagnostic Studies 2,1 Biopsy ,',""" 2,2 Culture and Sensitivity 2,3 Psychological Factors

3, Conclusion "',,',"

397 400 400 401 401 401 401 402 402 402 402 403 404 404 404 404 405 405 405 405

, 405 406 406 407 407 407

Summary The increasing number of older patients being seen in medical and dental offices in the industrialised world emphasises the need for a thorough understanding of the normal aging process, Additionally, close attention must be paid to the disease processes that affect this special needs population. Although there are many positive psychosocial issues associated with the aging patient, many diseases and disabilities associated with the aging process place an increased

398 McDowell & Kassebaum

burden on the elderly patient. The relationship between general and oral health must be understood by the practitioner if therapies are to be effective.

Although it is not the objective of this article to provide a comprehensive review of oral healthcare, an attempt will be made to provide general information on the diagnosis and treatment planning for oral malodours often associated with poor oral and/or systemic health. Every healthcare provider treating the elderly patient for oral malodours must recognise that there is potentially a direct relationship between the oral and systemic health of the patient. While most oral malodours have a simple cause, no single therapy is always effective. For best results, a team approach to diagnosing and treating oral malodours involves the dentist, physician, dietician and pharmacist. This multidisciplinary approach should be arranged before the onset of any complex therapy. When indicated, supportive, responsible family members should be additionally involved to assure patient compliance.

The mouth and teeth can be a source of great pride and pleasure. A beautiful smile is one of the most pleasant greetings a human can offer. Enjoying a meal of fine food and drink is truly gratifying. Unfortunately, the oral hard and soft tissues can also be a source of pain, social discomfort and disease. Additionally, the mouth can be a valuable diagnostic tool. In fact, the oral environment has long been recognised as a potential early indicator of systemic disease. Unfortunately, in the presence of systemic or oral disease, the mouth and surrounding structures can be a source of a significant social problem - disagreeable breath odours. In severe cases, oral malodours can lead to social isolation and ostracism.

Disagreeable personal odours are not a phenomenon unique to the modern era. Unpleasant oral odours have long been a medical and social problem. References have been made to oral malodours in classic medical literature. The early Greeks, Romans and Chinese noticed a correlation between dirty mouths and bad breath. Anton van Leeuwenhoek is credited with first identifying the oral organisms that may cause oral disease and bad breath. However, comprehensive articles dealing with the terminology, documented causes and effective treatments of oral malodours are relatively recent in the literature. Excellent overviews of the problem can be found beginning as early as 1939.[1,21

mouth and associated sinusesPI Although it has also been recommended that the term halitosis be reserved for odours which have a systemic origin, most commonly the term halitosis is used to describe any disagreeable odour in the expired air. It has been suggested that another term, oral malodour, be used to describe the mouth's contribution to unpleasant breath. [41 Some physicians suggest that the terms halitosis and bad breath can be used interchangeably and that bad breath or other oral malodours be recognised as a symptom (sign) and not an actual disease.l51 More recently, the professionalliterature has not placed emphasis on terminology but has stressed the importance of the diagnosis and treatment of bad breath.

Halitosis, fetor ex ore, fetor oris and bad breath are terms that have been used to describe unpleasant or disagreeable oral odours emitted with the expired air. Historically, it has been recommended that the term fetor ex ore be used to describe mal odours arising from conditions within the

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In most societies, bad breath is considered socially unacceptable. A person who is socially isolated - either by personal choice or the choice of others - may not be aware that there is a problem with oral malodours. Testimonials and other anecdotes from family members support the premise

Drugs & Aging 6 (5) 1995

Treatment of Halitosis in the Elderly

that even patients with extremely bad breath may not personally be aware of the problem.

Even in the young and healthy, the sensations of taste and olfaction are both subject to the sensory phenomenon known as adaptation. Reduced ability to smell unpleasant odours can be related to the specialised olfactory bipolar neurons (peripheral receptors) being constantly occupied with the offensive substance making the person insensitive to the odour.

Although sensory complaints and irritations are common in the elderly population, the senses of smell and taste significantly decline with age. The loss of these 2 senses can have a significant impact on the elderly person's quality of life.

The diminution of the sense of smell can contribute to a patient's inability to detect offensive personal odours. While in some cases the patient might be aware of personal oral malodours, the problem of bad breath is usually related to the patient by those around them.

Patients may also present for treatment of bad breath because of their own sense of malodour resulting from an altered or disagreeable taste present in the mouth. Alterations in the chemical senses are affected by multiple factors including normal changes associated with aging, xerostomia, artificial dentition, poor oral hygiene, craniofacial abnormalities, psychiatric disorders and neoplasms)6l

For whatever reason the patient presents, it is essential to identify the pathophysiology leading to the malodour prior to developing and initiating an effective treatment plan.

Unpleasant oral odours are mainly the result of sulphur-containing proteins and peptides being hydrolysed by Gram-negative bacteria in an alkaline environment.14,7,8l During putrefaction of amino acids, unpleasant-smelling, volatile sulphur-containing end products, predominantly hydrogen sulphide and methylmercaptan, are created. Other breakdown products such as ammonia, indole, skatole, putrescine and cadaverine - compounds normally causing odours during putrefaction in biological systems - have been found not to

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399

be major contributors to oral malodours)4,9, lOl Production and release of the volatile compounds, and subsequent detection of these oral malodorous substances, appears to depend on multiple local factors which include salivary pH, reduced ambient oxygen concentration, bacterial population and the substrate available for bacterial metabolism)4,7,Jll

Production of putrid odours is associated with oral conditions contributing to a shift from Grampositive to Gram-negative bacteria)4,7,lll Factors contributing to this bacterial shift are reduced salivary flow, stagnation of saliva, reduced carbohydrates available as bacterial substrates and a rise in the oral pH)4l

Reduced salivary flow leading to a dry mouth (xerostomia) is a frequent complaint among the elderly population. Unfortunately, xerostomia is also a common cause of oral malodour. Reduced salivary flow can be caused by many factors: dehydration, anaemia, avitaminosis, diabetes, emotional stress, metabolic disease, inflammatory or autoimmune disease of the salivary glands, mechanical blockage, malignancy, multiple sclerosis, AIDS, head and neck irradiation, and medications)12,13l Although aging was previously thought to be a significant contributor to reduced salivary flow, no clinical studies absolutely support this premise.

It is especially important to take a complete drug history, as many medications commonly taken by the aged population are known to induce xerostomia. Drugs which decrease salivary flow include antidepressants, tranquillisers, antihistamines, decongestants, antihypertensive and cardiovascular agents. I12,13l

Not all reductions in salivary flow are caused by pathological or drug-induced conditions. As salivary flow is normally decreased during the sleeping hours, xerostomia and increased oral alkalinity occurring during sleep also contribute to oral malodours. Patients and their companions can be especially aware of bad breath in the morning because of reduced salivary flow and the absence of chewing activity occurring during sleep.

Mouth breathing caused by exercise, nasal obstruction, abnormal skeletal and/or dental anat-


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omy, or habit can also cause oral drying, contributing to oral malodours.

Oral malodour production may be directly related to the patient's periodontal condition. Salivary putrefaction and the production of disagreeable oral odours occurs more rapidly in patients with periodontal disease.[2,4,7] Generally, the conditions that provide a favourable environment for a shift from Gram-positive to Gram-negative bacteria also contribute to the production of bad breath.

In the presence of periodontal disease, increased growth factors and substrates are available from the inflammatory process which stimulate the growth of bacterial populations on the oral soft and hard tissues.l4,7,ll,14] Meticulous oral hygiene combined with a professional hygiene programme is essential to the maintenance of periodontal health. Elimination of periodontal disease and maintaining periodontal health are essential to reducing oral malodours.

1. Treatment Planning for the Reduction or Elimination of Oral Malodours

The development of an accurate differential diagnosis and effective treatment plan requires the collection of a comprehensive patient history (in some cases requiring an interview of family members), a thorough physical examination, and the accurate interpretation of any indicated tests.

1.1 Patient History

It is essential that the interviewer listen closely to the information provided so an effective treatment plan be developed. An accurate diagnosis depends on the analysis of pertinent data collected from the patient's history. Whenever possible, the patient interview must be performed in a supportive' quiet, private environment and should be free from interruptions.

The patient's chief complaint (usually a single cause for the patient to present for care) must be investigated and related to the history of present illness. The patient should be encouraged to speak openly about the chief complaint and why it is of

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McDowell & Kassebaum

concern. Emphasis must be placed on when the patient (or others) first detected the oral malodours and on any potential initiating factors. The clinician should try to determine whether the malodours are constantly present or intermittent in their presentation. Precipitating, aggravating or relieving factors should be recorded and thoroughly investigated.

A thorough historical evaluation requires that significant aspects of the patient's family and social history be reviewed. The patient's dental, medicaVsurgical and drug histories must be comprehensively reviewed and thoroughly examined. Special emphasis must be placed on the patient's drug history, as drug pharmacodynamics play an important role in developing oral malodours. The patient history must include a complete review of the patient's past illnesses, hospitalisations and surgeries (table I).

Although there are no conclusive data indicating gender differences in chemosensory acuity,

Table I. Developing a treatment plan for halitosis

Developing a diagnosis Patient history:

review the patient's chief complaint and history of present iIIness(es)

review the patient's past history of malodour review the patient's current history (investigate diet and

medications)

Physical examination: extra-oral examination

intra·oral examination Analysis of tests or special studies:

radiographs microbiologic cultures and sensitivity studies findings and diagnoses of consultants

A final or working diagnosis is often derived from detected abnormalities of structure, function or mentation.

Developing a treatment plan The therapy selected must be appropriate to the diagnosis. For

instance, odour-masking agents should not be used as the sole therapeutic agent to cover the signs and symptoms associated with an inflammatory, infectious or neoplastic disease of the oral structures

Evaluate the patient's response to trial therapy. If there is no response to therapy in a compliant patient, re-evaluate the working diagnosis



some studies indicate lower sensory thresholds for women.l6] The temporal relationship of odour changes should be investigated in women as olfactory and taste sensations have been reported to change over the menstrual cycle.l 16] If aware of the malodour problem, the patient is often able to provide an accurate history as to the progression of symptoms/signs. Questions dealing with whether the mal odours are getting worse, staying the same or diminishing can be helpful in determining potential disease course.

1 .2 Screening for Neurological Disorder

A neurological assessment with special emphasis on cranial nerve evaluation is an essential part of the physical examination. If sensory dysfunction is suspected while developing the history, the patient's ability to perceive the malodours should be investigated. A simple check of olfactory nerve (CNl) function can be quickly performed in the office using common aromatic substances like soaps, tobacco and aromatic oils (orange, wintergreen, cloves, etc.). Ammonia should not be used to test olfaction as it stimulates the pain receptors of the trigeminal nerve (CN5) rather than the olfactory nerve (CNl))17]

The patient should also be questioned regarding associated symptoms, including taste disorders. Central lesions and potential dysfunctions of the facial (CN7), glossopharyngeal (CN9) and vagus (CNlO) nerves should be investigated if taste disorders are suspected. Disease or dysfunction can exist at any point of reception, transmission or interpretation as gustatory information is received by the receptor cells, and then projects to the medulla, pons, thalamus and cortical taste area.[6]

1.3 Tobacco Products

In the presence of a positive history of tobacco use, the patient should be questioned regarding the type, technique and frequency of use. In particular, patients should be asked if a change in tobacco usage has been associated with the oral malo dour detection by the patient or others. Although studies are equivocal, a history of smoking has been im-


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plicated in bitter tastes and a deterioration in olfactory sensitivity.[6]

At some point during the interview, the patient must be informed about the dangers associated with the use of cigarettes, cigars, pipes and smokeless tobacco. Tobacco cessation counselling should become a routine part of the patient interview.

1 .4 Diet Assessment

The examiner should carefully consider the patient's dietary habits as related to the chief complaint. Bogdasarian[20] has reported that the hunger state contributes to the creation of objectionable breath odours resulting from pulmonary excretion of metabolic breakdown products of fats and proteins. While certain foods have been implicated in imparting an offensive odour to the breath, the act of eating has been reported to actually reduce oral malodours)20] Increased salivary flow and oral cleansing from mastication reduce - at least temporarily - oral malodours.

To assist with good nutrition and to help reduce oral malodours, the examiner should consider suggesting that the elderly patient eat nutritionally balanced, noncariogenic snacks during the waking hours PO] A careful patient record of diet and malodour production should be kept if the examiner or patient believes that the oral mal odours are related to the patient's food or fluid intake. Consultation with a physician or dietitian may be necessary to assist in developing alternative diet plans should certain foods be identified as contributing to oral mal odours.

1 .5 Physical Examination

A systematic, thorough examination of the head and neck area must be performed as bad breath can originate from several regions in the upper aerodigestive tract. In some cases it is possible to distinguish between oral and nasal sources of malodours by separating the expired air (see table 11))5]

Instruct the patient to pinch the nose closed and exhale through the mouth, then to close the mouth and exhale through the nose. The patient's expired


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Table II. Subjective assessment 01 expired air

Possible nasal source 01 malodour detected by:

instructing the patient to close the mouth and exhale through the nose

Possible oral source 01 malodour detected by:

instructing the patient to pinch the nose closed and exhale through the mouth

The relative intensity 01 the malodour should give a reasonably reliable indicator 01 odour source. II redirecting the expired air does not significantly alter the malodour, a systemic or respiratory tract source should be investigated

air can be wafted across the nose of the examiner with the palm of the hand or a card. If the malodour changes when altering the course of expired air, further investigation of the suspected site should be undertaken.

1.5. 1 Malodour in Nasally Expired Air

A stronger smell from the nasally expired air can indicate lesions or disease of the nasopharynx, nose or sinuses. The nasopharynx is a common site of bacterial overgrowth contributing to bad breath. Conditions altering the mucous blanket of the nose, including atrophic rhinitis or rhinitis medicamentosa, can contribute to bacterial overgrowth and malodour.l51 Chronic sinusitis, unilateral choanal atresia and nasal foreign bodies have been reported to cause halitosis.l5,181 Tumours of the nasal cavity can have malodour as an early symptom.l51 Referral to a otolaryngologist is indicated if an infection, foreign body or neoplasm is suspected.

1.5.2 Malodour in Orally Expired Air

A more noxious odour found in the orally expired air can indicate an oral, oropharyngeal, hypopharyngeal or, rarely, a gastric source. Pharyngeal ulcers, tonsillitis, nasopharyngeal discharge or post-tonsillectomy necrotic eschar can harbour anaerobic bacteria contributing to bad breathJ51 Nearly every physician or dentist is aware of the noxious odours associated with tonsillitis, pharyngitis, mononucleosis, and other viral or bacterial infections of the oropharynx. Retaining ingested or regurgitated food in the hypopharyngeal diverticulum can lead to stagnation and putrefaction, producing malodorous volatile substances in

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the expired air. [51 Lucente and coworkers[51 have also reported that patients with hiatus hernia can have gastroesophageal reflux giving rise to a sense of bad taste in the mouth. A patient with an oesophageal stricture or cardiospasm can on rare occasion request medical and/or dental evaluation with bad breath as a presenting symptom. [201

In the healthy elderly individual, gases from the upper gastrointestinal tract do not normally mix with the expired air. Vomiting or eructation (belching) can result in bad breath. Patients with a positive history of bad breath in the presence of dyspepsia, or constipation or other bowel disturbance should be referred to an internist/gastroenterologist for further evaluation.l201

1.5.3 SystemiC Disease If the expired air is equally offensive, whether

expired through the nose or mouth, a systemic source should be investigated. Bad breath has been reported to rise from systemic disease such as hepatic failure (lending a sulphur odour), uraemia (ammonia odour) and diabetic ketoacidosis (acetone odour). Other oral and systemic malodours have been suggested to have diagnostic value to practitioners.l61 Schiffman has stated that specific emitted odours detected on physical examination can be associated with infectious, nutritional and mental diseases.l6]

Expired air with an unpleasant odour can be an indicator of disease of the upper respiratory tree. Neoplasms anywhere along the respiratory tract can cause bad breath. Bronchitis, pneumonia and bronchiectasis (a congenital or acquired disorder marked by chronic dilatation and destruction of the large bronchi) have been reported to cause foul odours in the expired airJ5,191 Signs and symptoms associated with bronchiectasis include a paroxysmal cough productive of a malodorous mucopurulent exudate.

1.5.4 Candidosis Patients with bronchiectasis and other respira

tory diseases are frequently treated with combination therapy, including corticosteroids and antibiotics. Such therapy can contribute to the development of oropharyngeal candidosis. Long



tenn use of inhaled corticosteroids in asthma patients can lead to a change in the respiratory tract flora,[5) contributing to the development of oropharyngeal candidosis.

Oropharyngeal candido sis caused by local and/or systemic factors can frequently be associated with foul breath in the elderly patient. Although the growth of the candidal organisms does not directly cause the malodour, the associated oral conditions can contribute to the production of noxious aromas.

Healthcare providers must be aware that whereas candidosis can be seen in patients receiving chronic steroid therapy or broad spectrum antibiotics, candido sis can also be found in patients with cancer, diabetes or xerostomia. Immunocompromised or immunosuppressed patients or any patient with a debilitating systemic disease can also develop candidal infections. Poor oral hygiene and prosthetic appliances are local factors potentially contributing to the development oral candidosis.

Identifying and treating the cause of oropharyngeal candidosis utilising the appropriate antifungal agent should relieve the problem. A topical antifungal agent which is commonly used is nystatin pastilles 200 000 units. The patient should be instructed to slowly dissolve 1 or 2 pastilles in the mouth 4 to 5 times per day for 14 days. Clotrimazole 10mg troches can also be used as 1 troche slowly dissolved in the patient's mouth 5 times a day for 14 days. When prescribing clotrimazole in the presence of pre-existing liver disease, consider periodic evaluation of liver function, as elevated liver enzymes have been reported in a small number of patients on clotrimazole therapy.

Close medical supervision is frequently required for patients who have developed oropharyngeal, oesophageal or pulmonary fungal infections. When oropharyngeal candidosis does not respond to topical therapies, the condition can be treated with a systemic antifungal agent. Systemic antifungal therapy is especially valuable in the immunocompromised, extremely ill or severely debilitated elderly patient. [29) Two commonly


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prescribed systemic antifungal agents are ketoconazole and fluconazole. In most cases, treatment of oropharyngeal or oesophageal candidosis with fluconazole consists of two 100mg tablets on the first day followed by one 100mg tablet per day for a total of 14 days' therapy. Ketoconazole 200mg tablets should be taken once daily for 2 weeks. Itraconazole is a newer, less commonly prescribed systemic antifungal drug with varying activity against a wide range of fungal organisms. Itraconazole is available as 100mg capsules with the usual dosage of 200mg once daily for a minimum of 3 months.

Clinicians must be aware that many systemic antifungals have been associated with hepatotoxicity, and that appropriate monitoring is indicated when prescribing these drugs. Ketoconazole and itraconazole are contraindicated in patients receiving concomitant therapy with terfenadine and astemizole because of the risk of adverse cardiovascular events.

When any new or additional medication is prescribed for a patient on combination therapy, the patient's drug history must be thoroughly reviewed. Many elderly patients are being seen by several different healthcare providers. Combined therapies require that all healthcare providers be familiar with their patient's current medications and potential drug interactions prior to prescribing any new medications.

1.5.5 Ingested Substances Food, drink and medications can be absorbed

from the mouth, stomach or intestines, then absorbed into the bloodstream and later transferred to the pulmonary alveoli. Pulmonary excretion of malodorous substances dissolved in the bloodstream can contribute to noxious aromas in the expired air. Certain foods including garlic, onions and other spices are absorbed from the intestine, metabolised in the liver, released into the bloodstream and excreted via the lungs and other routes.[20] Drug-specific halitosis has been associated with iodine-based medications, amyl nitrate and chloral hydrate.l20]


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1 .6 Oral Examination

While the nonoral physical examination is important to some diagnoses of oral mal odours, the vast majority of cases of bad breath have their origin in the oral cavity. During oral examination, careful attention must be paid to each area of the hard and soft tissues. As with the nonoral examination, an organised, systematic approach to the oral examination is essential to developing a definitive diagnosis. Without a clear diagnosis, an effective treatment plan cannot be developed. While this article cannot provide a comprehensive description of the diagnostic process, the more common oral conditions and diseases that can contribute to malodours are described.

The oral examination must be made recognising that some patients are skilled at masking the oral malodours with candies, chewing gums, sprays or drops to freshen the breath, or various mouth rinses. In order to decrease the possibility of totally masking the malodour, patients should be counselled to discontinue the breath fresheners shortly prior to the physical examination.

1.6.1 Ups and Adjacent Skin The patient's lips should be examined and any

deviations from normal should be recorded in the patient chart. Because of the close anatomic relationship between the lips and nose, inflammatory or degenerative processes of the lip tissues can cause the patient to become aware of malodours.

Lip ulcerations can be caused by trauma, local infections or neoplasms. Of particular importance are any ulcerations or necrotic areas that harbour Gram-negative bacteria and other opportunistic infective agents such as those often seen in HIVpositive patients. Rarely, a foul-smelling odour may be detected from neoplasms or large ulcers of the skin or lip. Patients with large herpes labialis lesions or major aphthous ulcers can complain of noxious odours associated with the ulceration. Any lip or skin ulceration or erosion suspected of being a neoplasm should be biopsied and appropriately treated.

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If the lip ulcers are found to be aphthous ulcers, topical steroids are useful in treatment. Triamcinolone, fluocinonide and clobetasol are commonly used therapeutic agents. A steroid/oral paste combination can be sparingly applied to the ulcer 4 to 5 times per day and at bedtime. Antibiotics, when indicated, can also be used to treat major aphthous ulcers. In HIV-positive patients, large, atypical, nonhealing ulcers should be biopsied to rule out opportunistic infections or neoplasms.

1.6.2 Oral Vestibules The vestibules should be examined for evidence

of infection or neoplasms. When indicated, patients with ulceration affecting bone or fistulae that emanate from bone should be examined radiographically. Other advanced imaging techniques [computerised tomography (CT) or magnetic resonance imaging (MRI)] may be necessary if the lesions are suspected of being malignant.

Oral-antral fistulae can be created after extraction of maxillary teeth that are in close approximation to the maxillary sinuses. Although rare, peripheral manifestations of sinus cancer can present as destructive oral lesions. Fistulae from the maxillary sinus or an abscessed tooth can be the cause of oral malodours.

1.6.3 Tongue The tongue, especially the dorsal surface, is a

common source of bad breath. The filiform papillae, appearing as pinkish-white, hairlike projections, cover most of the tongue's dorsal surface. The surface anatomy of the tongue provides an ideal environment for collection of desquamated cells, food debris and anaerobic bacterial growth capable of malodour productionp,1l,17) A normal anatomic structure, the midline depression, can be of varying depths predisposing to the collection of food debris. A fissured tongue (sometimes called scrotal tongue) can also contribute to food collection and putrefaction.

Tonzetich and Ng[8) reported that combining tooth and tongue brushing was the most effective technique for reducing oral malodour emanating from the tongue. Bosy and colleagues[21) have reported that there is a discrete subpopulation of



patients complaining of oral malodours who do not have periodontal disease. In the population studied by Bosy, the mucosal surface of the tongue was the major source of oral malodour production. Various mixtures of toothpaste, mouth rinses (chlorhexidine 0.12%) and pumice, applied to the toothbrush to gently but thoroughly clean the tongue, have been suggested to have value in reducing the tongue's bacterial load. The patient should be counselled not to overbrush the tongue as traumatic ulcers might develop in the overzealous patient.

1.6.4 Teeth and Prostheses During every oral examination, the teeth should

be examined for evidence of decay and food impaction. Sulser and colleagues[2] reported that carious lesions provided sites for food retention and putrefaction. A dental referral is indicated when carious lesions are suspected or detected during the oral examination. The lesions should be removed and the tooth restored to functional, cleansable anatomy. When possible, all conditions leading to food impaction should be corrected. Poorly contoured restorations should be replaced or recontoured. Crowns, appliances, and fixed and removable prostheses should be examined and replaced or repaired if defective.

Proper cleaning of removable prostheses (full dentures or partial dentures) is essential to maintaining nonoffensive breath. Patients should be counselled to thoroughly clean dental prostheses at least once per day. Whenever possible, patients should refrain from wearing removable prostheses during sleep. Patients who wear their dentures for prolonged periods without removal are at risk of tissue hyperplasia and candidal infections. Antifungal therapy (clotrimazole 1% ointment or gel, or nystatin powder) applied to the denture base can be effective in reducing candida colonisation. When used conscientiously, commercially available denture cleansers offer an effective method of reducing the bacterial and fungal population on dental prostheses.

1.6.5 Dental Pulpal Involvement Advanced, untreated dental caries or trauma can

lead to exposure of the dental pulp. Diseases of the

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dental pulp can provide an environment favourable to noxious gas production. Any teeth with exposed pulpal tissues, irreversible pulpitis, necrotic pulps, apical periodontitis or periapical abscesses should be treated endodontically. Alternatively, tooth extraction is indicated. Draining abscesses of odontogenic origin should be immediately treated. When indicated, endodontic treatment with antibiotic therapy should allow for the retention of the natural dentition. Teeth should only be extracted when effective alternative care is not in the patient's best interest.

1.6.6 Periodontal Tissues Periodontal disease is another common cause of

oral malodours. A complete periodontal examination is essential for every dental patient. In the presence of periodontal disease, there are elevated concentrations of volatile sulphur compounds in the mouth airp·11.14.20] Effective periodontal treatment, including patient-performed oral hygiene procedures, should reduce the level of noxious oral gases detectable in the expired air.l24-26.28] Plaque removal is essential to reducing the dental bacterial load. Retained food, salivary proteins, large molecular weight products, blood elements, inflammatory exudates and epithelial cells all provide nutrients rich in sulphur-containing substrate.

1.6.7 Oropharynx Along with the other oral structures, the oro

pharynx should be examined for potential causes of bad breath. Food and other particles trapped in the enlarged foliate papillae and/or the lingual tonsils at the base of the tongue can contribute to bad breath. Cryptic tonsils can also retain food particles, thus contributing to bad breath.l5] Bacterial, fungal or viral infections of the oropharynx can contribute to oral malodours. Any infections, ulcerations, swellings or suspected neoplasms of the oropharynx require immediate referral to the appropriate dental/medical specialist trained in the diagnosis and treatment of these disorders.

1.6.8 Xerostomia Approximately one-third of patients over the

age of 50 complain of a dry mouth. Because of this


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high symptom rate, patients should be routinely questioned about xerostomia (dry mouth) as part of the patient history. The oral tissues should be examined for signs of xerostomia. Signs and symptoms of xerostomia include diminution of taste, inability to swallow food, and loss of the salivary electrolytes and immunoproteins that protect against microbial infections. [6) Ahigh rate of dental decay, especially the decay that encircles the tooth at the cervical margin, is highly suggestive of reduced salivary flow. Additional oral changes can include painful, parched, inflamed and erythematous oral mucosa. The filiform papillae may be reduced or lost from the dorsal surface of the tongue causing the tongue to appear shiny and erythematous. Decreased salivary flow can contribute to a reduced cleansing action and a change in the oral flora toward the Gram-negative organisms responsible for oral malodours. Many pathological oral conditions can be caused at least in part by a reduced salivary flow.

Whenever possible, the causes for xerostomia should be identified and treated. In cases where the xerostomia is drug-related, a medical or pharmacological consultation can identify alternative medications that cause less reduction in salivary flow. Increased fluid intake, salivary stimulation with sugarless candies, artificial salivary substitutes (usually compounds based on carboxymethyl cellulose), reduction of caffeine intake, and the use of sialogogues can reduce the effects of a dry mouth. A cholinergic agonist, pilocarpine, has been shown to increase salivary flow at dosages of 5 to 10 mg/day. Higher dosages can be considered for patients not responding adequately and who can tolerate the lower dosages. As with all medications, the prescriber should have a thorough knowledge of the drug's actions, potential adverse effects and drug-drug interactions before prescribing this medication.

Advanced age is risk factor for cancer. Oral cancers can be associated with mal odours either from debris collecting on an ulcer or from tissue necrosis. Oral and perioral cancers represent less than 10% of all human cancers, yet the morbidity and



mortality associated with these cancers is high. Head and neck (including oral) cancers often require surgery, chemotherapy and radiation therapy. Any of these therapies, individually or collectively, can cause or exacerbate previously existing xerostomia.

Red, crusted or fissured oral commissures (corners of the mouth) can indicate skin and mucosal candidal infection. Topical nystatin-triamcinolone acetonide ointment used in conjunction with intraoral antifungal therapy can quickly eliminate candidal infections of the commissures. Because angular cheilitis is not frequently seen in the absence of oral candidosis, effective therapy should include treatment of the oral fungal infection.

2. Laboratory Tests and Additional Diagnostic Studies

As described above, the taking of the patient's history and physical examination are critical components of the data-gathering process, yet the final diagnosis often depends on the results of specific tests. Additional information leading to a final diagnosis can be acquired through ordering and analysing appropriate laboratory tests or diagnostic studies. Radiographs and other imaging modalities can be essential for the diagnosis of diseases of the teeth, jaws or adjacent structures.

2.1 Biopsy

Although some diagnoses can be made on the clinical and/or radiographic appearance of a lesion, there is no substitute for a properly performed biopsy and microscopic examination of the submitted tissue. With the biopsy specimen, the pathologist should be provided with an adequate history including symptoms and signs associated with the lesion and any photographs or radiographs made of the area in question. Biopsy is indicated if vesiculo-bullous or ulcerative disease is included in the differential diagnosis of the source of malodour. Except in rare instances where the patient's medical status dictates otherwise, biopsy is essential when neoplasia is suspected.



2.2 Culture and Sensitivity

If an infection of the oral cavity is suspected as the cause of oral malodours, cultures and sensitivity studies should be considered. Maximum information regarding the infective organism(s) and appropriate antibiotic therapy can be gained from the microbiology laboratory. The healthcare provider should be prepared to collect specimens representative of the micro-organisms at the site of suspected infection. Sensitivity testing can be essential to effectively treating severe infections. Culture and sensitivity studies should also be performed for those infections that have not responded to initial antimicrobial therapy in compliant patients when such studies were not performed prior to initiating treatment.

2.3 Psychological Factors

If at the completion of the physical examination and diagnostic process there are no clinical findings supporting the history of oral malodours, consider the potential for a psychological component to the patient's chief complaint. Referral is indicated when a nonphysical cause for perceived oral malodour is suspected. Although uncommon, selfperception of bad breath might be a delusion associated with a monosymptomatic hypochondriacal psychosis.

Bishop[23] has reported that patients can present with monosymptomatic (single fixation) hypochondriasis manifesting as a delusion of offensive personal odours. Malasi and colleagues[22] have reported convictions of malodours that have been associated with overvalued ideas, depression, schizophrenia and organic brain syndrome. It has also been reported that the olfactory hallucination may be a rationalisation for difficulties in interpersonal relationships or a manifestation of low selfesteem,l22] Bogdasarian counsels otolaryngologists to recognise neuroses as a condition causing patients to compulsively use mints, mouthwashes and oral spray deodorants PO] Without supportive physical findings, request a psychiatric consultation when personal malodours are reported.[22]


407

3. Conclusion

Although foul odours in the expired air can come from several sources, the oral cavity is the most common source of volatile compounds causing bad breath. Eliminating oral disease and meticulous oral hygiene are critical to maintaining nonoffensive breath. The practitioner should be prepared to provide specific information to the patient regarding oral hygiene and the use of mouth rinses and other agents that reduce the oral bacterial load. Recognising that the expired air may be a source of great social anxiety, the healthcare provider should be able to perform the examination of the patient complaining of halitosis without adding to patient embarrassment. Every health professional should be keenly perceptive to the psychosocial issues associated with personal malodours and avoid complicating an already sensitive processPO]

Once the source(s) of oral malo dour is identified, a diagnosis can be made. Subsequently, an appropriate treatment plan can be developed and, with the patient's informed consent, that treatment plan should be implemented. Subjective complaints can be reduced and the patient's quality of life increased through appropriate therapy.

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© Adis International Lirnited. All rights reserved.


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Correspondence and reprints: Professor John D. McDowell, Department of Diagnostic and Biological Sciences, Division of Oral Diagnosis/Medicine/Radiology, University of Colorado School of Dentistry, 4200 East Ninth Avenue, Denver, CO 80262, USA.


treatment of oral and nonoral sources of halitosis in elderly patients

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