A seminar on

Halitosis

By,Dr. Dandu Sivasai prasad

I Year M.D.SDepartment of periodontics 

Mamata dental college

Contents• Introduction

• History

• Epidemiology

• Classification

• Etiology

– Intra oral causes

– Extra oral causes

• Role of volatile sulphur compounds in the pathogenesis of halitosis

• Association between halitosis and periodontal disease

• Correlation between the presence of a pathogenic microflora in the subgingival microbiota and halitosis

• Diagnosis of malodor

• Preventive measures

• Treatment of oral malodor

• Conclusion

• References

Introduction

• Halitosis is a general term used to define an unpleasant or

offensive odour emanating from the breath regardless of

whether the odour originates from oral or non-oral sources.

• Originates from two Latin words

– Halitus → breath

– Osis → disease

Introduction (Contd.)

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

• Halitosis should not be confused with the generally

temporary oral odour caused by intake of certain foods,

tobacco, or medications.

Synonyms

• Bad or foul breath

• Breath malodour

• Oral malodour

• Foetor ex-ore

• Foetor oris

• Stomato dysodia

Definitions• Halitosis is the general term used to describe a foul odor emanating from the oral cavity,

in which proteolysis, metabolic products of the desquamating cells and bacterial putrefaction are involved.

– Marita et al., 2001

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

-Tangerman, 2002

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

– Carranza(2003)

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

– Jan Lindhe(2003)

–

Definitions (Contd.)

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

may be caused by a number of factors, both intra-oral & extra-oral

(gingivitis/ periodontitis, nasal inflammation, chronic sinusitis,

diabetes mellitus, liver insufficiency etc.,) & can be linked to more

serious underlying medical problems including primary biliary

cirrhosis, uremia, lung carcinoma, decompensated liver cirrhosis &

trimethylaminuria.

– Quirynen, Zhao, Avontroodt et al., 2003

History• Odors are essential clues in the creation & conservation of

social bonds, as they are loaded with cultural values. The

problem of halitosis has been reported for many years.

References were found in papyrus manuscripts dating back to

1550 BC.

• During Christianity, the devil's supreme malignant odor

smelled of sulfur & it was presumed that sins produced a more

or less bad smell.

History (Contd.)

• A treaty in Islamic literature from the year 850 talked

about dentistry, referring to the treatment of fetid breath &

recommended the use of siwak when breath had changed

or at any time when getting out of bed.

• Buddhist monks in Japan also recommended teeth

brushing & tongue scraping before the first morning

prayers.

History (Contd.)

• The Hindus consider the mouth as the body's entry door

and, therefore, insist that it be kept clean, mainly before

prayers. The ritual is not limited to teeth brushing, but

includes scraping the tongue with a special instrument and

using mouthwash.

– Anand Choudhary, 2012

Epidemiology

• Bad breath has been a common problem for thousands of years.

• It is a considerable social problem.

- Its incidence remains poorly documented in most countries.

- In vast majority- The cause is originated from the oral cavity

i.e. gingivitis, periodontitis, and tongue coating.

• Japan study 2,672 Individuals 6-23% of subjects had oral

malodour (VSC) as in expired air at some period during

the day (Miyazaki 1996).

• Another study in the United States involving individuals

older than 60 years found 24% had oral malodour

(Rosenberg 1996).

• The prevalence of persistent oral malodor in a Brazilian

study was reported to be 15%, was nearly three times

higher in men than in women (regardless of age) and the

risk was slightly more than three times higher in people

over 20 years of age compared with those aged 20 years

or under, controlling for gender .

Classification

• Genuine halitosis

• Physiologic halitosis

• Pathologic halitosis

• Pseudo halitosis

• Halitophobia.

Genuine halitosis

• Physiological halitosis

– Morning breath odour, tobacco smoking & certain foods

& medications.

• Pathological halitosis

– intra oral or extra oral origin

– 90% of patients → oral cavity

– Bacteria, volatile sulphur compounds.

• Intra oral origin

– poor oral hygiene, dental caries, periodontal diseases in

particular NUG, NUP, periodontitis, pericoronitis, dry

socket, other oral infections, tongue coating & oral

carcinoma.

• The role of tongue coatings in the

aetiology of oral malodour has been

extensively documented.

• Tongue coatings include desquamated

epithelial cells, food debris, bacteria and

salivary proteins and provide an ideal

environment for the generation of VSCs

and other compounds that contribute to

malodour

• Extra oral origin

– 10-20%

– gastro intestinal diseases

– infections or malignancy in respiratory tract

– Chronic sinusitis and tonsillitis

– stomach, intestine, liver or kidney affected by systemic

diseases

Examples of systemic pathological conditions that cause halitosis

Systemic condition• Diabetes mellitus

• Renal failure

• Liver failure

• Tuberculosis/ lung abscess

• Internal hemorrhage/ blood disorders

• Fever , dehydration

Characteristic odour• Acetone , sweet fruity.

• Urine or ammonia

• Fresh cadaver

• Foul, putrefactive

• Decomposed blood

• Odour due to xerostomia and poor oral hygiene.

-Lu DP.oral surgery 1982;54:521-526

• Pseudo halitosis

– Apparently healthy individuals

• Haltophobia

– exaggerated fear of having halitosis

– also referred as delusional halitosis

– considered variant of monosymptomatic hypochondrial

psychosis.

Etiology

• Halitosis generally arises as a result of the bacterial

decomposition of food particles, cells, blood and some

chemical compounds of the saliva.

– Moss, 1998

Etiology (Contd.)

• Volatile sulphur compounds → hydrogensulphide [H2S,

rotten egg smell], dimethyl sulphide [(CH3)2S, rotten

cabbage smell, and methyl mercaptan [CH3SH, fecal

smell].

• Non - sulphur containing substances → diamines

[cadaverine (cadaver smell) and putrescine (rotting meat

smell), acetone and acetaldehyde

Etiology (Contd.)

• Food impaction

• Acute necrotising ulcerative gingivitis

• Acute gingivitis

• Adult and aggressive periodontitis

• Pericoronitis

• Dry socket

• Xerostomia

• Oral ulceration

• Oral malignancy

Common causes of halitosis

1) Local Causes

A.Oral disease

Etiology (Contd.)

B. Respiratory disease

• Sinusitis

• Tonsillitis

• Malignancy

• Bronchiectasis

C. Volatile foodstuffs

• Garlic

• Onions

• Spiced foods

Etiology (Contd.)

• Acute febrile illness

• Leukaemias

• Respiratory tract infection (usually

upper)

• Helicobacter pylori infection

• Pharyngo-oesophageal

diverticulum

• Gastro-oesophageal reflux disease

• Pyloric stenosis or duodenal

obstruction

• Hepatic failure (fetor hepaticus)

• Renal failure (end stage)

• Diabetic ketoacidosis

• Trimethylaminuria

• Hypermethioninaemia

• Menstruation (menstrual breath)

2) SYSTEMIC CAUSES

Role of volatile sulphur compounds in the pathogenesis of halitosis

Major compounds implicated in halitosis

• VSC’s - Methylmercaptan, Hydrogen sulfide, dimethyl

sulfide & Dimethyl disulfide.

• Polyamides - Putrescein, Cadaverine, Skatole, Indole.

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

• Others - Acetone, Acetaldehyde, Ethanol diacyl.

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

• It also increases the collagen solubility.

• It decrease the DNA synthesis.

• It increases the secretion of collagenases, prostaglandins from fibroblasts.

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

Putrefaction products

Oral malodor

Diet, bacteria, epithelial cells

Peptides/proteins

Amino acids

Pathogenesis of oral malodor:

CORRELATION BETWEEN THE PRESENCE OF A PATHOGENIC MICROFLORA IN THE SUBGINGIVAL MICROBIOTA AND HALITOSIS:

• In 1981, Pitts et al studied the correlations between odor

scores and microbiological findings in crevicular samples of

periodontally healthy subjects. They found that odor scores

were significantly correlated with the concentration of

overall bacterial populations and that higher levels of

crevicular bacteria were associated with greater odor scores.

• In patients with periodontitis, more sulfur-containing protein substrate is available through increased exfoliation of epithelial cells and crevicular effusion of leukocytes.

• Sato and colleagues found that the number of leukocytes increased in the saliva of patients with periodontitis and that the level of methyl mercaptan produced correlated with bleeding on probing, pocket depth and gingival exudate

Diagnosis

Self assessment tests

Whole mouth malodor (Cupped breath)

The subjects are instructed to smell the odor emanating

from their entire mouth by cupping their hands over their

mouth and breathing through the nose. The presence or

absence of malodor can be evaluated by the patient

himself/herself.

Wrist lick test

Subjects are asked to extend their tongue and lick their

wrist in a perpendicular fashion. The presence of odor is

judged by smelling the wrist after 5 seconds at a distance

of about 3 cm.

Spoon test

Plastic spoon is used to scrape and scoop material from the

back region of the tongue. The odor is judged by smelling

the spoon after 5 seconds at a distance of about 5 cm

organoleptically.

Dental floss test

Unwaxed floss is passed through interproximal contacts.

Saliva odor test

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

saliva into a petridish. The dish is covered immediately,

incubated at 370 C for five minutes and then presented for

odor evaluation at a distance of 4 cm from the examiner’s

nose.

OBJECTIVE TESTS

• Organoleptic measurement

• Gas chromatography (GC)

• Sulphide monitoring

Organoleptic measurement (sniff test)

• Organoleptic measurement is a sensory test scored on the basis of the

examiner’s perception of a subject’s oral malodor.

• Organoleptic measurement can be carried out simply by sniffing the

patient’s breath and scoring the level of oral malodor.

• By inserting a translucent tube (2.5 cm diameter, 10 cm length) into the

patient’s mouth and having the person exhale slowly, the breath, undiluted

by room air, can be evaluated and assigned an organoleptic score.

• The tube is inserted through a privacy screen (50cm-70cm) that separates

the examiner and the patient. The use of a privacy screen allows the patient

to believe that they have undergone a specific malodor examination rather

than the direct-sniffing procedure.

• Organoleptic Scores (0- 5) By Rosenberg , Mulloch Et Al 1991.

• 0 - No appreciable odor

• 1 - Barely noticeable odor

• 2 - Slight but noticeable odor

• 3 - Moderate odor

• 4 - Strong odor

• 5 - Extremely foul odor

Yaegaki & coil 2000

VOLATILE SULFIDE MONITOR:

• This electronic (Haiimeter, InterScan, Chatsworth, Calif) analyzes concentration of hydrogen sulfide and methyl-mercaptan , but without discriminating between them.

Gas Chromatography (GC):

• GC, performed with apparatus equipped with a flame

photometric detector, is specific for detecting sulphur in mouth

air.

• It measures directly the three VSC methyl mercaptan,

hydrogen sulfide and dimethyl sulfide.

• GC is considered the gold standard for measuring oral malodor.

• This device can analyze air, saliva, crevicular fluid for a volatile

component.

Diamond probe:

Ninhydrin method of detecting amine compounds:

• Iwanicka et al (2005) showed that amine levels were higher in the saliva of subjects suffering from halitosis and lower in healthy controls.

Electronic nose:

..

Tanaka M et al used these electronic noses to clinically assess oral malodor and examined the association between oral malodor strength and oral health status.

Halitox System:

Quick and simple

Detects VSCs and poly amines

TOPAS:

It detects both VSC and polyamines in the sample.

The absorbent point given with the kit is inserted into the

pocket.

Left in place for 1 minute.

Submerge the absorbent point tip in the toxin reagent .

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

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

toxins in the sample.

BANA test:

Used to determine the proteolytic activity of certain oral anaerobes that contribute to oral malodor.

PREVENTIVE MEASURES:

Preventive measures rather than curative aspects are highly recommended.

– Visit dentist regularly

– Periodical tooth cleaning by dental professional.

– Brushing of teeth twice daily with appropriate brushing techniques and

for a duration of 2-3 mins.

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

in the tongue surface.

– Flossing after brushing to remove food particles stuck in

between the tooth surfaces.

– Limit intake of strong odour species.

– Limit sugar and caffeine intake.

– Drink plenty of liquids.

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

– Eat fresh fibrous vegetables such as carrots.

MANAGEMENT:

• Treatment needs (TN) for halitosis have been categorized into 5 classes

in order to provide guidelines for clinicians in treating halitosis patients:

• Treatment of physiologic halitosis (TN-1),

• Oral pathologic halitosis (TN-1 and TN-2), and

• Pseudo-halitosis (TN-1 and TN-4) should be the responsibility of a

dentist,

• However, treatment of extra-oral pathologic halitosis (TN-3) or

halitophobia (TN-5) should be undertaken by a physician or medical

specialist such as a psychiatrist or psychologist.

(i) Mechanical reduction of intraoral nutrients and micro-

organisms

(ii)Chemical reduction of oral microbial load

(iii) Rendering malodorous gases nonvolatile

(iv) Masking the malodor.

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

- Tooth brush

- Inter-dental cleaning

- Professional periodontal therapy

- Chewing gum

2. Chemical reduction of oral microbial load- Chlorhexidine

- Essential oils

- Chlorine dioxide

- Two-phase oil- water rinse

- Triclosan

- Aminefluoride/ Stannous fluoride

- Hydrogen peroxide

- Oxidising lozenges -Roldan S 2005,2004,2003 scully 2006

3.Conversion of volatile sulfide compounds- Metal salt solutions

- Toothpastes

- Chewing gum

4. Masking the malodor-Rinses

-Mouth sprays

-Lozenges containing volatiles

-Chewing gum

Herbal treatment:

Herbs and essential oils can be made into very effective mouthwash

remedies to sweeten breath and help keep gums and teeth healthy  fennel 

not only improves digestion, but also can reduce bad breath and body odor

that originates in the intestines.

Give raw carrots as a midday treat to help scour teeth of bacteria-laden

plaque, a common cause of bad breath. 

Cardamom tea contains cineole, a potent antiseptic that kills bad-breath

bacteria and sweetens breath.

Thymol, one of the constituents of thyme, is contained

in antiseptic mouthwashes. 

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

fight plaque and gingivitis when mixed with astringent herb

powders and/or baking soda.

A few drops of Tea tree oil , lemon or peppermint essential oils

can be added to warm water for an effective mouth

rinse to freshen breath

Conclusion:

• It’s a common complaint that may periodically affect most of the adult population. Oral maldor, which is commonly noticed by patients, is an important clinical sign and symptom that has many etiologies which include local and systemic factors. It is often difficult for the clinician to find the underlying pathologies.

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

References:

Newman ,Takei, Carranza. Clinical periodontology ; 10th and 11th edition J lindhe. Clinical periodontology and implant dentistry; vol 1: 5th edition S Settineri, C Mento. Self-reported halitosis and emotional state:impact on

oral conditions and treatments: Health and Quality of Life Outcomes 2010, 8:34.

C Scully, J Greenman. Halitosis: Periodontology 2000, 2008;48:66–75. S R Porter, C Scully. Halitosis-clinical review ; BMJ 2006;333:632–635. British Dental Association, Bad Breath FactFile. April 2008. Yaegaki K, Sanada K. Volatile sulphur compounds in mouth air from

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

W J Loesche, C Kazor. Microbiology and treatment of halitosis. Periodontology 2000, Vol. 28, 2002, 256–279.

Velde Van den S, Quirynen M, Van Hee P, Van Steenberghe D: Halitosis associated volatiles in breath of healthy subjects. Journal of Chromatography B 2007, 853:54-61.

G Campisi, A Musciotto. Halitosis: could it be more than mere bad breath?; Intern Emerg Med (2011) 6:315–319.

Tangerman A, Winkel EG. Intra- and extra-oral halitosis:finding of a new form of extra-oral blood-borne halitosis caused by dimethyl sulphide. J Clin Periodontol 2007 34(9):748–755.

Yaegaki K, Coil JM. Genuine halitosis, pseudo-halitosis and halitophobia: classification, diagnosis, and treatment. Compend Cont Educ Dent 2000; 21(10A):880–886.

Thank u..,