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  • The dorsum of the tongue provides a suitable environment
    for the growth of these anaerobic organisms,as favourable redox potentials are found in the deep crypts of the tongue associated with the structure of the papilla
  • halitosis.ppt

    1. 1. A seminar on Halitosis By, Dr. Dandu Sivasai prasad I Year M.D.S Department of periodontics  Mamata dental college
    2. 2. 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
    3. 3. 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
    4. 4. 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.
    5. 5. Synonyms • Bad or foul breath • Breath malodour • Oral malodour • Foetor ex-ore • Foetor oris • Stomato dysodia
    6. 6. 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)
    7. 7. 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
    8. 8. 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.
    9. 9. 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.
    10. 10. 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
    11. 11. 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.
    12. 12. • 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).
    13. 13. • 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 .
    14. 14. Classification • Genuine halitosis • Physiologic halitosis • Pathologic halitosis • Pseudo halitosis • Halitophobia.
    15. 15. 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.
    16. 16. • 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.
    17. 17. • 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
    18. 18. • 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
    19. 19. 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
    20. 20. • Pseudo halitosis – Apparently healthy individuals • Haltophobia – exaggerated fear of having halitosis – also referred as delusional halitosis – considered variant of monosymptomatic hypochondrial psychosis.
    21. 21. 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
    22. 22. 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
    23. 23. 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
    24. 24. Etiology (Contd.) B. Respiratory disease • Sinusitis • Tonsillitis • Malignancy • Bronchiectasis C. Volatile foodstuffs • Garlic • Onions • Spiced foods
    25. 25. 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
    26. 26. 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.
    27. 27. • 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.
    28. 28. Putrefaction products Oral malodor Diet, bacteria, epithelial cells Peptides/prot eins Amino acids Pathogenesis of oral malodor:
    29. 29. 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.
    30. 30. • 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
    31. 31. 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.
    32. 32. 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.
    33. 33. 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.
    34. 34. Dental floss test Unwaxed floss is passed through interproximal contacts.
    35. 35. 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.
    36. 36. OBJECTIVE TESTS • Organoleptic measurement • Gas chromatography (GC) • Sulphide monitoring
    37. 37. 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.
    38. 38. • 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.
    39. 39. • 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
    40. 40. Yaegaki & coil 2000
    41. 41. VOLATILE SULFIDE MONITOR: • This electronic (Haiimeter, InterScan, Chatsworth, Calif) analyzes concentration of hydrogen sulfide and methyl- mercaptan , but without discriminating between them.
    42. 42. 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.
    43. 43. Diamond probe:
    44. 44. 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.
    45. 45. 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.
    46. 46. HalitoxSystem: Quick and simple Detects VSCs and poly amines
    47. 47. 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.
    48. 48. BANA test: Used to determine the proteolytic activity of certain oral anaerobes that contribute to oral malodor.
    49. 49. 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.
    50. 50. – 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.
    51. 51. 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.
    52. 52. (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.
    53. 53. 1. Mechanical reduction of intraoral nutrients and micro-organisms - Tongue cleaning - Tooth brush - Inter-dental cleaning - Professional periodontal therapy - Chewing gum
    54. 54. 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
    55. 55. 3.Conversion of volatile sulfide compounds - Metal salt solutions - Toothpastes - Chewing gum
    56. 56. 4. Masking the malodor -Rinses -Mouth sprays -Lozenges containing volatiles -Chewing gum
    57. 57. 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.
    58. 58.  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
    59. 59. 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
    60. 60. 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.
    61. 61.  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.
    62. 62. Thank u..,