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ORAL
MALADOR
-DR AISHWARYA PANDEY
-DEPARTMENT OF PERIODONTOLOGY
-BANARAS HINDU UNIVERSITY
INTRODUCTION
 Breath odor can be defined as the subjective perception after smelling someone’s
breath.
 It can be pleasant, unpleasant, or even disturbing, if not repulsive.
 If unpleasant, the terms breath malodor, halitosis, bad breath, or fetor ex ore can
be applied.
 Breath malodor is a common complaint in the general population.
 Halitosis can lead to personal discomfort and social embarrassment, and it
remains one of the biggest taboos of society.
The three main categories of halitosis are
• genuine halitosis
• pseudo-halitosis
• halitophobia.
• Genuine halitosis is the term that is used when the breath malodor really exists
and can be diagnosed organoleptically or by measurement of the responsible
compounds
• When an obvious breath malodor cannot be perceived but the patient is convinced
that he or she suffers from it, this is called pseudo-halitosis.
• If the patient still believes that bad breath is present after treatment of genuine
halitosis or diagnosis of pseudohalitosis, one considers halitophobia, which is a
recognized psychiatric condition.
Etiology
• In most patients, breath malodor originates from the oral cavity.
• Tongue coating is the predominant cause of oral malodor.
• Furthermore, periodontal diseases (gingivitis and periodontitis) are the second
most important causative factors.
• Extraoral causes were also reported- including ear, nose, and throat (ENT)
disorders, systemic diseases (e.g., diabetes), metabolic or hormonal changes,
hepatic or renal insufficiency, bronchial and pulmonary diseases, or
gastroenterologic disorders.
Intraoral Causes
• Tongue coating, poor oral hygiene, gingivitis, and periodontitis are the
predominant causative factors.
• In these cases the term oral malodor applies.
• It is the result of the degradation of organic substrates by anaerobic bacteria.
• During the process of bacterial putrefaction, peptides and proteins present in
saliva, food debris, gingival crevicular fluid, interdental plaque, shed epithelial
cells, postnasal drip, and blood are hydrolyzed to sulfide-containing and non–
sulfide-containing amino acids, which can be further metabolized.
• The proteolytic degradation of sulfur-containing amino acids (cysteine, cystine
and methionine) by gram-negative bacteria produces sulfurcontaining gases such
as hydrogen sulfide (H2S) and methylmercaptan (CH3SH).
• The most commonly involved bacteria are Porphyromonas gingivalis, Prevotella
intermedia, Prevotella nigrescens, Aggregatibacter actinomycetemcomitans,
Campylobacter rectus, Fusobacterium nucleatum, Peptostreptococcus micros,
Tannerella forsythia, Eubacterium spp., and spirochetes.
• Breath malodor is the result of complex interactions among several bacterial
species
• Thus, for oral malodor, the unpleasant smell of the breath mainly originates from
volatile sulfur compounds (VSCs), especially hydrogen sulfide,
methylmercaptan, and (less significantly) dimethyl sulfide ((CH3)2S), as first
discovered by Tonzetich.
• Other compounds, such as the diamines indole and skatole, the polyamines
putrescine and cadaverine, and the carboxylic acids acetic, butyric, and propionic
acid, are also formed by proteolytic degradation of non–sulfurcontaining amino
acids by oral microorganisms.
Tongue and Tongue Coating
• The dorsal tongue mucosa, with an area of 25 cm3, has a very irregular surface
topography.
• The innumerable depressions in the tongue surface are ideal niches for bacterial
adhesion and growth, sheltered from cleaning actions.
• Moreover, desquamated cells and food remnants also remain trapped in these
retention sites and consequently can be putrefied by the bacteria.
• A fissured tongue (deep fissures on the dorsum, also called scrotal tongue or
lingua plicata) and a hairy tongue (lingua villosa) have an even rougher surface.
(A) to (C) Clinical pictures of heavily coated tongues.
• Accumulated food remnants intermingled with exfoliated cells and bacteria form a
coating on the tongue dorsum.
• The latter cannot be easily removed because of retention by the irregular surface
of the tongue dorsum.
• As such, the two factors essential for putrefaction (bacteria and their nutrients) are
united.
• Several investigators have identified the dorsal posterior surface of the tongue as
the primary source of oral malodor.
Periodontal Infections
• A relationship between periodontitis and oral malodor has been shown.
• However, periodontally healthy patients can suffer from halitosis, not all patients
with gingivitis and/or periodontitis complain about bad breath.
• Several studies have shown that VSC levels in the mouth correlate positively with
the depth of periodontal pockets and that the amount of VSCs in the breath
increases with the number, depth, and bleeding tendency of the periodontal
pockets.
• VSCs aggravate the periodontitis process by increasing the permeability of the
pocket and mucosal epithelium, therefore exposing the underlying connective
tissues of the periodontium to bacterial metabolites.
• Methylmercaptan enhances interstitial collagenase production, interleukin-1 production
by mononuclear cells, and cathepsin B production, thus further mediating connective
tissue breakdown.
• The reaction of hydrogen sulfide with collagen can alter the protein structure, thereby
rendering the periodontal ligament and bone collagen more susceptible to destruction by
proteases.
• These findings suggest that increased production of VSCs may accelerate the progression
of periodontal disease. Toxic VSCs are able to damage the periodontal tissues and create
even more loss of attachment.
• A mutual reinforcement of the loss of periodontal attachment and production of VSCs
occurs, resulting in a vicious cycle.
• Other relevant malodorous pathologic manifestations of the periodontium are
pericoronitis (the soft tissue “cap” being retentive for microorganisms and debris),
major recurrent oral ulcerations, herpetic gingivitis, and necrotizing
gingivitis/periodontitis.
• Microbiologic observations indicate that ulcers infected with gram-negative
anaerobes (i.e., Prevotella and Porphyromonas species) are significantly more
malodorous than noninfected ulcers.
Dental Disorders
• Possible causes within the dentition are deep carious lesions with food impaction
and putrefaction, extraction wounds filled with blood clots, and purulent discharge
leading to important putrefaction.
• Other causes include interdental food impaction in large interdental areas and
crowding of teeth favoring food entrapment and accumulation of debris.
• Acrylic dentures, especially when kept continuously in the mouth at night or not
regularly cleaned, can lead to infections (e.g. candidiasis), which produce a typical
smell.
• The denture surface facing the gingiva is porous and retentive for bacteria, yeasts,
and debris, which are compounds needed for putrefaction.
Dry Mouth
• Saliva has an important cleaning function in the oral cavity.
• Patients with xerostomia often present with large amounts of plaque on teeth and
extensive tongue coating.
• The increased microbial load and the escape of VSCs when salivary flow is
reduced explain the strong breath malodor.
• Other causes of xerostomia are medication, alcohol abuse, Sjögren syndrome (a
common autoimmune rheumatic disease), and diabetes.
Extraoral Causes
• For a minority of patients, extraoral causes can be identified, including ENT disorders,
systemic disease (e.g., diabetes or kidney disease), metabolic or hormonal changes,
hepatic or renal insufficiency, bronchial and pulmonary diseases, or gastroenterologic
disorders.
• Extraoral halitosis can be subdivided into two types: non–bloodborne halitosis and blood-
borne halitosis.
• Non–blood-borne halitosis is uncommon, and most information about it comes from
case reports.
• Non–blood-borne halitosis encompasses, for example, throat infections, nasal infections,
infections of the respiratory system, lung diseases, and stomach disorders.
• Blood-borne halitosis is the result of bad-smelling metabolites that can be formed
or absorbed at any place in the body (e.g., the liver, the gut) and transported by the
bloodstream to the lungs.
• Exhalation of these volatiles in the alveolar air then causes halitosis, at least when
the concentrations of the bad-smelling metabolites are sufficiently high. The
crevicular fluid reflects the circulating molecules in the blood and can thus also
play a relevant role, but due to the small amount, probably not a very dominant
one.
• The extraoral causes are much more difficult to detect, although they can
sometimes be recognized by a typical odor-
• Uncontrolled diabetes mellitus - sweet odor of ketones
• liver disease - sulfur odor
• kidney failure - fishy odor
Pseudo-halitosis or Halitophobia
• If a patient presents with complaints but no objective halitosis can be detected, one speaks
of pseudo-halitosis or imaginary breath odor, which can lead to halitophobia.
• The latter is the case when, even after repeated diagnosis of an absence of bad breath, the
patient cannot accept the absence of halitosis. This condition has been associated with
obsessive-compulsive disorder and hypochondria.
• Well-established personality disorder questionnaires (e.g., Symptom Checklist) allow the
clinician to assess the patient’s tendency for illusional breath malodor.
• Having a psychologist or psychiatrist at the malodor consultation can be especially
helpful for such patients.
• Because of the complexity of this disorder, a malodor consultation is thus preferably
multidisciplinary, combining the knowledge of a periodontologist or dentist, an ENT
specialist, an internist (if necessary), and a psychologist or psychiatrist.
Diagnosis of Malodor
• Preconsultation Approach
• A proper diagnostic approach starts with providing the right information to the patient before the
appointment.
• It is recommended that the patient does not eat garlic, onions, or spices for 2 days before the
consultation because they can cause bad breath and body odor that can last from several hours to 2
days.
• To remove confounding odors, the patient is also instructed to refrain from alcohol, coffee, and
smoking during the 12-hour period before the consultation.
• For the same reason, it is advisable not to use chewing gum, mints, drops, or mouthrinses during
the 8 hours preceding the appointment, both for the patient and for the oral malodor judge.
• The day of the consultation, the use of fragranced shampoo, body lotion, and perfume should also
be avoided, so as not to disturb the organoleptic ratings.
• In most halitosis consultations, the patient is asked not to eat or drink on the morning of the
examination. However, if breakfast is consumed, morning bad breath can be excluded.
Anamnesis
• Each consultation should start with thorough questioning about the breath malodor, eating habits, and medical
and dental history.
• This can be done with a questionnaire that the patient fills out in the waiting room and/or verbally at the
beginning of the consultation, depending on the preference of the examiner and the practical possibilities.
• To start with, the patient should be asked about the frequency of the halitosis (e.g., constantly, every day), the
time of appearance during the day (e.g., after meals can indicate a stomach hernia), when the problem first
appeared, and whether others have identified the problem (to exclude imaginary breath odor).
• In addition, the medical history has to be recorded, with an emphasis on medications and systemic diseases of
the lungs, liver, kidneys, stomach, and pancreas.
• Concerning the ENT history, attention should be paid to the presence of nasal obstruction, mouth breathing,
postnasal drip, allergy, tonsillitis, dysphagia, and previous ENT encounters.
• The dental history includes questions assessing the frequency of dental visits, the use of mouthrinses, the
presence and maintenance of a dental prosthesis, and the frequency of and instruments used for toothbrushing,
interdental cleaning, and tongue brushing and scraping. Finally, the patient is asked about smoking, drinking,
and dietary habits.
Examinations
• After obtaining a thorough anamnesis, the clinician checks whether an unpleasant
odor can be perceived and inspects the mouth to detect possible causes of bad
breath.
• Different ways exist to examine the breath.
• The easiest and least expensive way is to smell the breath.
• However, several devices are on the market that mainly detect VSCs.
Organoleptic Rating
• Gold standard in the examination of breath malodor.
• Easiest and most often used method because it gives a reflection of the everyday
situation when halitosis is noticed.
• In an organoleptic evaluation, a trained and preferably calibrated “judge” sniffs the
expired air and assesses whether it is unpleasant by using an intensity rating.
• Scoring is normally done according to the intensity scale of Rosenberg -
• 0 represents the absence of odor,
• 1 is barely noticeable odor,
• 2 is slight malodor,
• 3 is moderate malodor,
• 4 is strong malodor, and
• 5 is severe malodor.
• In an organoleptic assessment, the judge smells a series of air samples as follows:
1. Nasal breath odor: The subject expires through the nose while keeping the mouth closed.
When the nasal expiration is malodorous yet the air expired through the mouth is not, an ENT
problem can be suspected.
2. Oral cavity odor: The subject opens the mouth and refrains from breathing while the
judge places his or her nose close to the mouth opening (approximately 10 cm from the patient’s
mouth).
3. Oral cavity odor: The patient counts from 1 to 10. This reveals the same as described
earlier, but favors oral malodor because of drying of the palatal and tongue mucosa.
4. Tongue coating: The judge smells a tongue scraping from the posterior part of the tongue,
obtained with an odorless plastic spoon or tongue scraper, at a distance of approximately 5 cm from
his or her nose. This odor resembles that emanating from the tongue dorsum.
(A)
Organoleptic
assessement
of the oral
cavity odor
while the
patients
refrains from
breathing
(B) Assessment of the oral cavity odor when
the patient counts out loud from 1 to 10.
(C) A sample of the tongue coating is
taken to smell afterward.
(d) The
nasal
odor is
rated.
• Although the organoleptic assessment is still the gold standard for diagnosis of
halitosis, the method also has some important drawbacks.
• The assessment can, for example, be influenced by several aspects, such as the
position of the head, hunger, and the experience of the judge.
• Odor judges are also supposed to rest their nose for several minutes interminently
for every testing.
• Abnormalities in the capacity to judge or perceive odors can be caused by a viral
infection of the nasal cavities, a concussion, or smoking.
Fundamentals of Malodor Detection
• The breath of a person contains up to 150 different molecules.
• The characteristics of the expired molecules determine whether we can smell them or not.
• Some gases can cause a striking odor at very low concentrations, whereas others need to
be present in much higher quantities.
• The perception of the molecules depends on the following factors:
1. The odor itself can be pleasant, unpleasant, or even repulsive (olfactory response).
2. Each particular molecule has a specific concentration before it can be detected (threshold concentration).
3. The odor power is the concentration that is necessary to increase the odor score by one unit.
4. The volatility of the compound: Malodorous molecules only express themselves when they become
volatile.
5. The substantivity: The capacity of the molecule to stay present and thus remain the cause of smell.
Portable Volatile Sulfur Monitor The
Halimeter
• It is an electronic device that detects the presence of VSCs
such as hydrogen sulfide and methylmercaptan in breath.
• The instrument cannot discriminate among the different
sulfur compounds.
• The sulfur meter uses a voltametric sensor that generates a signal when exposed to sulfur-
containing gases. Using a recorder or specific software, a graphic presentation can be
obtained, called a haligram which gives the response as a function of time.
• The Halimeter is easy to use as a chair-side test and is relatively inexpensive. Patients are
usually less embarrassed by this examination than by organoleptic assessment.
• An important drawback of the device is that it detects only sulfur compounds and thus is
useful only for intraoral causes of halitosis.
Gas Chromatography
• A gas chromatograph can analyze air, saliva, or crevicular fluid.
• About 100 compounds have been isolated from the headspace
of saliva and tongue coating, including ketones, alkanes, sulfur
containing compounds, and phenyl compounds.
• In the expired air of a person, at least 150 compounds can be found.
• The most important advantage of the technique is that when coupled with mass
spectrometry, it can detect virtually any compound when using adequate materials and
conditions.
• It has very high sensitivity and specificity.
Gas chromatography machinery, including
thermal desorber (Td) to release molecules
trapped in special collectors, gas
chromatograph (GC) for separation of
molecules, and mass spectrometer (Ms) for
identification of molecules
Oral Chroma
• A small, portable “gas chromatograph”
has been introduced, which makes this
technique available for periodontal
clinics.
• More recently, the second generation of
this portable gas chromatograph was
introduced: the OralChroma CHM-2.
• The CHM-2 is a little bit smaller than the
first-generation OralChroma, the
measurements only take half the time,
and it comes with optimized software.
OralChroma
Dark-Field or Phase-Contrast Microscopy
• Oral malodor is typically associated with a higher incidence of motile organisms
and spirochetes, so shifts in their proportions allow monitoring of therapeutic
progress.
• Another advantage of direct microscopy is that the patient becomes aware of
bacteria present in plaque, tongue coating, and saliva.
Oropharyngeal Examination
• The oropharyngeal examination includes inspection of deep carious lesions, interdental
food impaction, wounds, bleeding of the gums, periodontal pockets, tongue coating, dry
mouth, and the tonsils and pharynx (for tonsillitis and pharyngitis).
• The tongue coating can be scored with regard to thickness and surface.
(A) Miyazaki tongue
coating index.
score 0 = none visible,
score 1 = less than one-third
of the tongue dorsum
covered,
score 2 = less than two-
thirds,
score 3 = more than two-
thirds;
here score 2 applies because
less than two-thirds of the
tongue dorsum is covered
(B) Winkel tongue coating
index.
Divide the dorsum of the
tongue into six areas, (i.e.,
three in the posterior and
three in the anterior part of
the tongue).
The tongue coating in each
sextant is scored as
0 = no coating,
1 = light coating,
2 = severe coating.
Self-Examination
• Smelling one’s own breath by expiring into the hands in front of the mouth is not
relevant because the nose becomes used to the odor, and the smell of the skin and
soap used for handwashing may interfere.
• Moreover, studies have shown that self-assessment of oral malodor is notoriously
unreliable, and one should be careful with such information obtained from the
patient.
Treatment of Oral Malodor
• The treatment of oral malodor (with an intraoral origin) should preferably be cause related.
• Because oral malodor is caused by the metabolic degradation of available proteins to malodorous gases by
certain oral microorganisms, the following general treatment strategies can be applied:
• Mechanical reduction of intraoral nutrients (substrates) and microorganisms
• Chemical reduction of oral microbial load
• Rendering malodorous gases nonvolatile
• Masking the malodor
• Treatment should be centered on reducing the bacterial load and micronutrients by effective mechanical oral
hygiene procedures, including tongue scraping.
• Periodontal disease should be treated and controlled, and as an auxiliary aid, oral rinses containing
chlorhexidine and other ingredients may further reduce the oral malodor.
• If breath malodor persists after these approaches, other sources of the malodor, such as the tonsils, lung
disease, gastrointestinal disease, or metabolic abnormalities (e.g., diabetes), should be investigated.
Mechanical Reduction of Intraoral
Nutrients and Microorganisms
• Because of the extensive accumulation of bacteria on the dorsum of the tongue, tongue
cleaning should be emphasized.
• Tongue cleaning reduces both the amount of coating (and thus bacterial nutrients) and the
number of bacteria and thereby improves oral malodor effectively.
• Cleaning of the tongue can be done with a normal toothbrush, but preferably with a
tongue scraper if a coating is established.
• Tongue cleaning using a tongue scraper reduces halitosis levels by 75% after 1 week.
• It is best to clean as far backward as possible; the posterior portion of the tongue has the
most coating.
• Tongue cleaning has the additional benefit of improving taste sensation
• Interdental cleaning and toothbrushing are essential mechanical means of dental plaque
control.
• Both remove residual food particles and organisms that cause putrefaction.
• When chronic oral malodor arises as a consequence of periodontitis, professional
periodontal therapy is needed.
• Chewing gum may control bad breath temporarily because it can stimulate salivary flow.
• The salivary flow itself also has a mechanical cleaning capability.
• Not surprisingly, therefore, subjects with extremely low salivary flow rate have higher
VSC ratings and tongue coating scores than those with normal saliva production.
Chemical Reduction of Oral Microbial
Load
• Together with toothbrushing, mouth rinsing has become a common oral hygiene practice.
• Formulations have been modified to carry antimicrobial and oxidizing agents, impacting the
process of oral malodor formation.
• The active ingredients usually include antimicrobial agents such as chlorhexidine, cetylpyridinium
chloride (CPC), essential oils, chlorine dioxide, triclosan, amine fluoride and stannous fluoride,
hydrogen peroxide, and baking soda.
• Chlorhexidine
• Chlorhexidine is considered the most effective antiplaque and antigingivitis agent. Its antibacterial action can
be explained by disruption of the bacterial cell membrane by the chlorhexidine molecules, thus increasing its
permeability and resulting in cell lysis and death. Because of its strong antibacterial effects and superior
substantivity in the oral cavity, chlorhexidine rinsing provides significant reductions in VSC levels and
organoleptic ratings. Unfortunately, as mentioned in some trials, chlorhexidine at a concentration of 0.2% or
greater also has some disadvantages, such as increased tooth and tongue staining, unpleasant taste, and some
temporary reduction in taste sensation.
• Chlorine Dioxide
• Chlorine dioxide (ClO2) is a powerful oxidizing agent that can eliminate bad breath by oxidation of
hydrogen sulfide, methylmercaptan, and the amino acids methionine and cysteine.
• Two-Phase Oil-Water Rinse
• Rosenberg and colleagues designed a two-phase oil-water rinse containing CPC (Cetylpyridinium
chloride). The efficacy of oil-water-CPC formulations is thought to result from the adhesion of a high
proportion of oral microorganisms to the oil droplets that is further enhanced by the CPC. A twice-daily
rinse with this product (before bedtime and in the morning) showed reductions in both VSC levels and
organoleptic ratings.
• Triclosan
• Triclosan, a broad-spectrum antibacterial agent, has been found to be effective against most oral bacteria
and has good compatibility with other compounds used for oral home care. The anti VSC effect of
triclosan, however, seems strongly dependent on the solubilizing agents. Flavoring oils or anionic
detergents and copolymers are added to increase the oral retention and decrease the rate of release in
toothpaste formulations containing triclosan.
• Amine Fluoride or Stannous Fluoride
• The association of amine fluoride with stannous fluoride resulted in encouraging reductions of morning
breath odor, even when oral hygiene was insufficient.
• Hydrogen Peroxide
• Rinsing with 3% hydrogen peroxide (H2O2) produced impressive reductions (±90%) in sulfur gases that persisted for
8 hours.
• Oxidizing Lozenges
• Sucking a lozenge with oxidizing properties reduced tongue dorsum malodor for 3 hours. This antimalodor effect may
be caused by the activity of dehydroascorbic acid, which is generated by peroxide-mediated oxidation of ascorbate in
the lozenges.
• Baking Soda
• Baking soda dentifrices have been shown to confer a significant odor-reducing benefit for up to 3 hours. The mechanism by
which baking soda produces its inhibition of oral malodor is related to its bactericidal effects.
Conversion of Volatile Sulfur Compounds
Metal Salt Solutions
• Metal ions with an affinity for sulfur are efficient in capturing the sulfur-containing gases.
• Zinc is an ion with two positive charges (Zn++), which will bind to the twice-negatively loaded
sulfur radicals and thus reduce the expression of VSCs.
• The same applies for other metal ions such as stannous, mercury, and copper.
• Clinically, the VSC inhibitory effect was copper chloride > stannous fluoride > zinc chloride
(CuCl2 > SnF2 > ZnCl2).
• Halita, a rinse containing 0.05% chlorhexidine, 0.05% CPC, and 0.14% zinc lactate, has been even
more efficient than a 0.2% chlorhexidine formulation in reducing VSC levels and organoleptic
ratings. The special effect of Halita may result from the VSC conversion ability of Zn++, besides
its antimicrobial action. The combination of Zn++ and chlorhexidine seems to act synergistically.
• Chewing gum can be formulated with antibacterial agents, such as fluoride or
chlorhexidine, helping to reduce oral malodor through both mechanical and chemical
approaches.
• Scientists investigated the beneficial effect of chewing gum containing tea extracts for its
deodorizing mechanism.
• Epigallocatechin is the main deodorizing agent among the tea catechins.
• The chemical reaction between epigallocatechin and methylmercaptan results in a
nonvolatile product.
Masking the Malodor
• Treatment with rinses, mouth sprays, or lozenges containing volatiles with a pleasant odor
has only a short-term effect.
• Typical examples are mint-containing lozenges and the aroma of rinses without
antibacterial components.
• Another pathway is to increase the solubility of malodorous compounds in the saliva by
increasing the secretion of saliva; a larger volume allows the retention of larger volumes
of soluble VSCs. The latter can also be achieved by ensuring proper liquid intake or using
chewing gum; chewing triggers the periodontal-parotid reflex, at least when the lower
(pre)molars are still present.
Conclusion
• Breath malodor has important socioeconomic consequences and can reveal important
diseases.
• A proper diagnosis and determination of the etiology allow initiation of the proper
etiologic treatment.
• Although tongue coating and (less frequently) periodontitis and gingivitis are by far the
most common causes of malodor, a clinician cannot take the risk of overlooking other,
more challenging diseases.
• This can be done with a multidisciplinary consultation or, if this is not feasible, a trial
therapy to deal quickly with intraoral causes (e.g., full-mouth one-stage disinfection,
including the use of proper mouthrinses, tongue scrapers, and toothpastes).

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ORAL MALADOR.pptx

  • 1. ORAL MALADOR -DR AISHWARYA PANDEY -DEPARTMENT OF PERIODONTOLOGY -BANARAS HINDU UNIVERSITY
  • 2. INTRODUCTION  Breath odor can be defined as the subjective perception after smelling someone’s breath.  It can be pleasant, unpleasant, or even disturbing, if not repulsive.  If unpleasant, the terms breath malodor, halitosis, bad breath, or fetor ex ore can be applied.  Breath malodor is a common complaint in the general population.  Halitosis can lead to personal discomfort and social embarrassment, and it remains one of the biggest taboos of society.
  • 3. The three main categories of halitosis are • genuine halitosis • pseudo-halitosis • halitophobia.
  • 4. • Genuine halitosis is the term that is used when the breath malodor really exists and can be diagnosed organoleptically or by measurement of the responsible compounds • When an obvious breath malodor cannot be perceived but the patient is convinced that he or she suffers from it, this is called pseudo-halitosis. • If the patient still believes that bad breath is present after treatment of genuine halitosis or diagnosis of pseudohalitosis, one considers halitophobia, which is a recognized psychiatric condition.
  • 5.
  • 6. Etiology • In most patients, breath malodor originates from the oral cavity. • Tongue coating is the predominant cause of oral malodor. • Furthermore, periodontal diseases (gingivitis and periodontitis) are the second most important causative factors. • Extraoral causes were also reported- including ear, nose, and throat (ENT) disorders, systemic diseases (e.g., diabetes), metabolic or hormonal changes, hepatic or renal insufficiency, bronchial and pulmonary diseases, or gastroenterologic disorders.
  • 7. Intraoral Causes • Tongue coating, poor oral hygiene, gingivitis, and periodontitis are the predominant causative factors. • In these cases the term oral malodor applies. • It is the result of the degradation of organic substrates by anaerobic bacteria. • During the process of bacterial putrefaction, peptides and proteins present in saliva, food debris, gingival crevicular fluid, interdental plaque, shed epithelial cells, postnasal drip, and blood are hydrolyzed to sulfide-containing and non– sulfide-containing amino acids, which can be further metabolized.
  • 8. • The proteolytic degradation of sulfur-containing amino acids (cysteine, cystine and methionine) by gram-negative bacteria produces sulfurcontaining gases such as hydrogen sulfide (H2S) and methylmercaptan (CH3SH). • The most commonly involved bacteria are Porphyromonas gingivalis, Prevotella intermedia, Prevotella nigrescens, Aggregatibacter actinomycetemcomitans, Campylobacter rectus, Fusobacterium nucleatum, Peptostreptococcus micros, Tannerella forsythia, Eubacterium spp., and spirochetes. • Breath malodor is the result of complex interactions among several bacterial species
  • 9. • Thus, for oral malodor, the unpleasant smell of the breath mainly originates from volatile sulfur compounds (VSCs), especially hydrogen sulfide, methylmercaptan, and (less significantly) dimethyl sulfide ((CH3)2S), as first discovered by Tonzetich. • Other compounds, such as the diamines indole and skatole, the polyamines putrescine and cadaverine, and the carboxylic acids acetic, butyric, and propionic acid, are also formed by proteolytic degradation of non–sulfurcontaining amino acids by oral microorganisms.
  • 10. Tongue and Tongue Coating • The dorsal tongue mucosa, with an area of 25 cm3, has a very irregular surface topography. • The innumerable depressions in the tongue surface are ideal niches for bacterial adhesion and growth, sheltered from cleaning actions. • Moreover, desquamated cells and food remnants also remain trapped in these retention sites and consequently can be putrefied by the bacteria. • A fissured tongue (deep fissures on the dorsum, also called scrotal tongue or lingua plicata) and a hairy tongue (lingua villosa) have an even rougher surface.
  • 11. (A) to (C) Clinical pictures of heavily coated tongues.
  • 12. • Accumulated food remnants intermingled with exfoliated cells and bacteria form a coating on the tongue dorsum. • The latter cannot be easily removed because of retention by the irregular surface of the tongue dorsum. • As such, the two factors essential for putrefaction (bacteria and their nutrients) are united. • Several investigators have identified the dorsal posterior surface of the tongue as the primary source of oral malodor.
  • 13. Periodontal Infections • A relationship between periodontitis and oral malodor has been shown. • However, periodontally healthy patients can suffer from halitosis, not all patients with gingivitis and/or periodontitis complain about bad breath. • Several studies have shown that VSC levels in the mouth correlate positively with the depth of periodontal pockets and that the amount of VSCs in the breath increases with the number, depth, and bleeding tendency of the periodontal pockets. • VSCs aggravate the periodontitis process by increasing the permeability of the pocket and mucosal epithelium, therefore exposing the underlying connective tissues of the periodontium to bacterial metabolites.
  • 14. • Methylmercaptan enhances interstitial collagenase production, interleukin-1 production by mononuclear cells, and cathepsin B production, thus further mediating connective tissue breakdown. • The reaction of hydrogen sulfide with collagen can alter the protein structure, thereby rendering the periodontal ligament and bone collagen more susceptible to destruction by proteases. • These findings suggest that increased production of VSCs may accelerate the progression of periodontal disease. Toxic VSCs are able to damage the periodontal tissues and create even more loss of attachment. • A mutual reinforcement of the loss of periodontal attachment and production of VSCs occurs, resulting in a vicious cycle.
  • 15. • Other relevant malodorous pathologic manifestations of the periodontium are pericoronitis (the soft tissue “cap” being retentive for microorganisms and debris), major recurrent oral ulcerations, herpetic gingivitis, and necrotizing gingivitis/periodontitis. • Microbiologic observations indicate that ulcers infected with gram-negative anaerobes (i.e., Prevotella and Porphyromonas species) are significantly more malodorous than noninfected ulcers.
  • 16. Dental Disorders • Possible causes within the dentition are deep carious lesions with food impaction and putrefaction, extraction wounds filled with blood clots, and purulent discharge leading to important putrefaction. • Other causes include interdental food impaction in large interdental areas and crowding of teeth favoring food entrapment and accumulation of debris. • Acrylic dentures, especially when kept continuously in the mouth at night or not regularly cleaned, can lead to infections (e.g. candidiasis), which produce a typical smell. • The denture surface facing the gingiva is porous and retentive for bacteria, yeasts, and debris, which are compounds needed for putrefaction.
  • 17. Dry Mouth • Saliva has an important cleaning function in the oral cavity. • Patients with xerostomia often present with large amounts of plaque on teeth and extensive tongue coating. • The increased microbial load and the escape of VSCs when salivary flow is reduced explain the strong breath malodor. • Other causes of xerostomia are medication, alcohol abuse, Sjögren syndrome (a common autoimmune rheumatic disease), and diabetes.
  • 18. Extraoral Causes • For a minority of patients, extraoral causes can be identified, including ENT disorders, systemic disease (e.g., diabetes or kidney disease), metabolic or hormonal changes, hepatic or renal insufficiency, bronchial and pulmonary diseases, or gastroenterologic disorders. • Extraoral halitosis can be subdivided into two types: non–bloodborne halitosis and blood- borne halitosis. • Non–blood-borne halitosis is uncommon, and most information about it comes from case reports. • Non–blood-borne halitosis encompasses, for example, throat infections, nasal infections, infections of the respiratory system, lung diseases, and stomach disorders.
  • 19. • Blood-borne halitosis is the result of bad-smelling metabolites that can be formed or absorbed at any place in the body (e.g., the liver, the gut) and transported by the bloodstream to the lungs. • Exhalation of these volatiles in the alveolar air then causes halitosis, at least when the concentrations of the bad-smelling metabolites are sufficiently high. The crevicular fluid reflects the circulating molecules in the blood and can thus also play a relevant role, but due to the small amount, probably not a very dominant one. • The extraoral causes are much more difficult to detect, although they can sometimes be recognized by a typical odor- • Uncontrolled diabetes mellitus - sweet odor of ketones • liver disease - sulfur odor • kidney failure - fishy odor
  • 20. Pseudo-halitosis or Halitophobia • If a patient presents with complaints but no objective halitosis can be detected, one speaks of pseudo-halitosis or imaginary breath odor, which can lead to halitophobia. • The latter is the case when, even after repeated diagnosis of an absence of bad breath, the patient cannot accept the absence of halitosis. This condition has been associated with obsessive-compulsive disorder and hypochondria. • Well-established personality disorder questionnaires (e.g., Symptom Checklist) allow the clinician to assess the patient’s tendency for illusional breath malodor. • Having a psychologist or psychiatrist at the malodor consultation can be especially helpful for such patients. • Because of the complexity of this disorder, a malodor consultation is thus preferably multidisciplinary, combining the knowledge of a periodontologist or dentist, an ENT specialist, an internist (if necessary), and a psychologist or psychiatrist.
  • 21. Diagnosis of Malodor • Preconsultation Approach • A proper diagnostic approach starts with providing the right information to the patient before the appointment. • It is recommended that the patient does not eat garlic, onions, or spices for 2 days before the consultation because they can cause bad breath and body odor that can last from several hours to 2 days. • To remove confounding odors, the patient is also instructed to refrain from alcohol, coffee, and smoking during the 12-hour period before the consultation. • For the same reason, it is advisable not to use chewing gum, mints, drops, or mouthrinses during the 8 hours preceding the appointment, both for the patient and for the oral malodor judge. • The day of the consultation, the use of fragranced shampoo, body lotion, and perfume should also be avoided, so as not to disturb the organoleptic ratings. • In most halitosis consultations, the patient is asked not to eat or drink on the morning of the examination. However, if breakfast is consumed, morning bad breath can be excluded.
  • 22. Anamnesis • Each consultation should start with thorough questioning about the breath malodor, eating habits, and medical and dental history. • This can be done with a questionnaire that the patient fills out in the waiting room and/or verbally at the beginning of the consultation, depending on the preference of the examiner and the practical possibilities. • To start with, the patient should be asked about the frequency of the halitosis (e.g., constantly, every day), the time of appearance during the day (e.g., after meals can indicate a stomach hernia), when the problem first appeared, and whether others have identified the problem (to exclude imaginary breath odor). • In addition, the medical history has to be recorded, with an emphasis on medications and systemic diseases of the lungs, liver, kidneys, stomach, and pancreas. • Concerning the ENT history, attention should be paid to the presence of nasal obstruction, mouth breathing, postnasal drip, allergy, tonsillitis, dysphagia, and previous ENT encounters. • The dental history includes questions assessing the frequency of dental visits, the use of mouthrinses, the presence and maintenance of a dental prosthesis, and the frequency of and instruments used for toothbrushing, interdental cleaning, and tongue brushing and scraping. Finally, the patient is asked about smoking, drinking, and dietary habits.
  • 23. Examinations • After obtaining a thorough anamnesis, the clinician checks whether an unpleasant odor can be perceived and inspects the mouth to detect possible causes of bad breath. • Different ways exist to examine the breath. • The easiest and least expensive way is to smell the breath. • However, several devices are on the market that mainly detect VSCs.
  • 24. Organoleptic Rating • Gold standard in the examination of breath malodor. • Easiest and most often used method because it gives a reflection of the everyday situation when halitosis is noticed. • In an organoleptic evaluation, a trained and preferably calibrated “judge” sniffs the expired air and assesses whether it is unpleasant by using an intensity rating. • Scoring is normally done according to the intensity scale of Rosenberg - • 0 represents the absence of odor, • 1 is barely noticeable odor, • 2 is slight malodor, • 3 is moderate malodor, • 4 is strong malodor, and • 5 is severe malodor.
  • 25. • In an organoleptic assessment, the judge smells a series of air samples as follows: 1. Nasal breath odor: The subject expires through the nose while keeping the mouth closed. When the nasal expiration is malodorous yet the air expired through the mouth is not, an ENT problem can be suspected. 2. Oral cavity odor: The subject opens the mouth and refrains from breathing while the judge places his or her nose close to the mouth opening (approximately 10 cm from the patient’s mouth). 3. Oral cavity odor: The patient counts from 1 to 10. This reveals the same as described earlier, but favors oral malodor because of drying of the palatal and tongue mucosa. 4. Tongue coating: The judge smells a tongue scraping from the posterior part of the tongue, obtained with an odorless plastic spoon or tongue scraper, at a distance of approximately 5 cm from his or her nose. This odor resembles that emanating from the tongue dorsum.
  • 26. (A) Organoleptic assessement of the oral cavity odor while the patients refrains from breathing (B) Assessment of the oral cavity odor when the patient counts out loud from 1 to 10. (C) A sample of the tongue coating is taken to smell afterward. (d) The nasal odor is rated.
  • 27. • Although the organoleptic assessment is still the gold standard for diagnosis of halitosis, the method also has some important drawbacks. • The assessment can, for example, be influenced by several aspects, such as the position of the head, hunger, and the experience of the judge. • Odor judges are also supposed to rest their nose for several minutes interminently for every testing. • Abnormalities in the capacity to judge or perceive odors can be caused by a viral infection of the nasal cavities, a concussion, or smoking.
  • 28. Fundamentals of Malodor Detection • The breath of a person contains up to 150 different molecules. • The characteristics of the expired molecules determine whether we can smell them or not. • Some gases can cause a striking odor at very low concentrations, whereas others need to be present in much higher quantities. • The perception of the molecules depends on the following factors: 1. The odor itself can be pleasant, unpleasant, or even repulsive (olfactory response). 2. Each particular molecule has a specific concentration before it can be detected (threshold concentration). 3. The odor power is the concentration that is necessary to increase the odor score by one unit. 4. The volatility of the compound: Malodorous molecules only express themselves when they become volatile. 5. The substantivity: The capacity of the molecule to stay present and thus remain the cause of smell.
  • 29. Portable Volatile Sulfur Monitor The Halimeter • It is an electronic device that detects the presence of VSCs such as hydrogen sulfide and methylmercaptan in breath. • The instrument cannot discriminate among the different sulfur compounds. • The sulfur meter uses a voltametric sensor that generates a signal when exposed to sulfur- containing gases. Using a recorder or specific software, a graphic presentation can be obtained, called a haligram which gives the response as a function of time. • The Halimeter is easy to use as a chair-side test and is relatively inexpensive. Patients are usually less embarrassed by this examination than by organoleptic assessment. • An important drawback of the device is that it detects only sulfur compounds and thus is useful only for intraoral causes of halitosis.
  • 30. Gas Chromatography • A gas chromatograph can analyze air, saliva, or crevicular fluid. • About 100 compounds have been isolated from the headspace of saliva and tongue coating, including ketones, alkanes, sulfur containing compounds, and phenyl compounds. • In the expired air of a person, at least 150 compounds can be found. • The most important advantage of the technique is that when coupled with mass spectrometry, it can detect virtually any compound when using adequate materials and conditions. • It has very high sensitivity and specificity. Gas chromatography machinery, including thermal desorber (Td) to release molecules trapped in special collectors, gas chromatograph (GC) for separation of molecules, and mass spectrometer (Ms) for identification of molecules
  • 31. Oral Chroma • A small, portable “gas chromatograph” has been introduced, which makes this technique available for periodontal clinics. • More recently, the second generation of this portable gas chromatograph was introduced: the OralChroma CHM-2. • The CHM-2 is a little bit smaller than the first-generation OralChroma, the measurements only take half the time, and it comes with optimized software. OralChroma
  • 32. Dark-Field or Phase-Contrast Microscopy • Oral malodor is typically associated with a higher incidence of motile organisms and spirochetes, so shifts in their proportions allow monitoring of therapeutic progress. • Another advantage of direct microscopy is that the patient becomes aware of bacteria present in plaque, tongue coating, and saliva.
  • 33. Oropharyngeal Examination • The oropharyngeal examination includes inspection of deep carious lesions, interdental food impaction, wounds, bleeding of the gums, periodontal pockets, tongue coating, dry mouth, and the tonsils and pharynx (for tonsillitis and pharyngitis). • The tongue coating can be scored with regard to thickness and surface. (A) Miyazaki tongue coating index. score 0 = none visible, score 1 = less than one-third of the tongue dorsum covered, score 2 = less than two- thirds, score 3 = more than two- thirds; here score 2 applies because less than two-thirds of the tongue dorsum is covered (B) Winkel tongue coating index. Divide the dorsum of the tongue into six areas, (i.e., three in the posterior and three in the anterior part of the tongue). The tongue coating in each sextant is scored as 0 = no coating, 1 = light coating, 2 = severe coating.
  • 34. Self-Examination • Smelling one’s own breath by expiring into the hands in front of the mouth is not relevant because the nose becomes used to the odor, and the smell of the skin and soap used for handwashing may interfere. • Moreover, studies have shown that self-assessment of oral malodor is notoriously unreliable, and one should be careful with such information obtained from the patient.
  • 35. Treatment of Oral Malodor • The treatment of oral malodor (with an intraoral origin) should preferably be cause related. • Because oral malodor is caused by the metabolic degradation of available proteins to malodorous gases by certain oral microorganisms, the following general treatment strategies can be applied: • Mechanical reduction of intraoral nutrients (substrates) and microorganisms • Chemical reduction of oral microbial load • Rendering malodorous gases nonvolatile • Masking the malodor • Treatment should be centered on reducing the bacterial load and micronutrients by effective mechanical oral hygiene procedures, including tongue scraping. • Periodontal disease should be treated and controlled, and as an auxiliary aid, oral rinses containing chlorhexidine and other ingredients may further reduce the oral malodor. • If breath malodor persists after these approaches, other sources of the malodor, such as the tonsils, lung disease, gastrointestinal disease, or metabolic abnormalities (e.g., diabetes), should be investigated.
  • 36. Mechanical Reduction of Intraoral Nutrients and Microorganisms • Because of the extensive accumulation of bacteria on the dorsum of the tongue, tongue cleaning should be emphasized. • Tongue cleaning reduces both the amount of coating (and thus bacterial nutrients) and the number of bacteria and thereby improves oral malodor effectively. • Cleaning of the tongue can be done with a normal toothbrush, but preferably with a tongue scraper if a coating is established. • Tongue cleaning using a tongue scraper reduces halitosis levels by 75% after 1 week. • It is best to clean as far backward as possible; the posterior portion of the tongue has the most coating. • Tongue cleaning has the additional benefit of improving taste sensation
  • 37. • Interdental cleaning and toothbrushing are essential mechanical means of dental plaque control. • Both remove residual food particles and organisms that cause putrefaction. • When chronic oral malodor arises as a consequence of periodontitis, professional periodontal therapy is needed. • Chewing gum may control bad breath temporarily because it can stimulate salivary flow. • The salivary flow itself also has a mechanical cleaning capability. • Not surprisingly, therefore, subjects with extremely low salivary flow rate have higher VSC ratings and tongue coating scores than those with normal saliva production.
  • 38. Chemical Reduction of Oral Microbial Load • Together with toothbrushing, mouth rinsing has become a common oral hygiene practice. • Formulations have been modified to carry antimicrobial and oxidizing agents, impacting the process of oral malodor formation. • The active ingredients usually include antimicrobial agents such as chlorhexidine, cetylpyridinium chloride (CPC), essential oils, chlorine dioxide, triclosan, amine fluoride and stannous fluoride, hydrogen peroxide, and baking soda. • Chlorhexidine • Chlorhexidine is considered the most effective antiplaque and antigingivitis agent. Its antibacterial action can be explained by disruption of the bacterial cell membrane by the chlorhexidine molecules, thus increasing its permeability and resulting in cell lysis and death. Because of its strong antibacterial effects and superior substantivity in the oral cavity, chlorhexidine rinsing provides significant reductions in VSC levels and organoleptic ratings. Unfortunately, as mentioned in some trials, chlorhexidine at a concentration of 0.2% or greater also has some disadvantages, such as increased tooth and tongue staining, unpleasant taste, and some temporary reduction in taste sensation.
  • 39. • Chlorine Dioxide • Chlorine dioxide (ClO2) is a powerful oxidizing agent that can eliminate bad breath by oxidation of hydrogen sulfide, methylmercaptan, and the amino acids methionine and cysteine. • Two-Phase Oil-Water Rinse • Rosenberg and colleagues designed a two-phase oil-water rinse containing CPC (Cetylpyridinium chloride). The efficacy of oil-water-CPC formulations is thought to result from the adhesion of a high proportion of oral microorganisms to the oil droplets that is further enhanced by the CPC. A twice-daily rinse with this product (before bedtime and in the morning) showed reductions in both VSC levels and organoleptic ratings. • Triclosan • Triclosan, a broad-spectrum antibacterial agent, has been found to be effective against most oral bacteria and has good compatibility with other compounds used for oral home care. The anti VSC effect of triclosan, however, seems strongly dependent on the solubilizing agents. Flavoring oils or anionic detergents and copolymers are added to increase the oral retention and decrease the rate of release in toothpaste formulations containing triclosan.
  • 40. • Amine Fluoride or Stannous Fluoride • The association of amine fluoride with stannous fluoride resulted in encouraging reductions of morning breath odor, even when oral hygiene was insufficient. • Hydrogen Peroxide • Rinsing with 3% hydrogen peroxide (H2O2) produced impressive reductions (±90%) in sulfur gases that persisted for 8 hours. • Oxidizing Lozenges • Sucking a lozenge with oxidizing properties reduced tongue dorsum malodor for 3 hours. This antimalodor effect may be caused by the activity of dehydroascorbic acid, which is generated by peroxide-mediated oxidation of ascorbate in the lozenges. • Baking Soda • Baking soda dentifrices have been shown to confer a significant odor-reducing benefit for up to 3 hours. The mechanism by which baking soda produces its inhibition of oral malodor is related to its bactericidal effects.
  • 41. Conversion of Volatile Sulfur Compounds Metal Salt Solutions • Metal ions with an affinity for sulfur are efficient in capturing the sulfur-containing gases. • Zinc is an ion with two positive charges (Zn++), which will bind to the twice-negatively loaded sulfur radicals and thus reduce the expression of VSCs. • The same applies for other metal ions such as stannous, mercury, and copper. • Clinically, the VSC inhibitory effect was copper chloride > stannous fluoride > zinc chloride (CuCl2 > SnF2 > ZnCl2). • Halita, a rinse containing 0.05% chlorhexidine, 0.05% CPC, and 0.14% zinc lactate, has been even more efficient than a 0.2% chlorhexidine formulation in reducing VSC levels and organoleptic ratings. The special effect of Halita may result from the VSC conversion ability of Zn++, besides its antimicrobial action. The combination of Zn++ and chlorhexidine seems to act synergistically.
  • 42. • Chewing gum can be formulated with antibacterial agents, such as fluoride or chlorhexidine, helping to reduce oral malodor through both mechanical and chemical approaches. • Scientists investigated the beneficial effect of chewing gum containing tea extracts for its deodorizing mechanism. • Epigallocatechin is the main deodorizing agent among the tea catechins. • The chemical reaction between epigallocatechin and methylmercaptan results in a nonvolatile product.
  • 43. Masking the Malodor • Treatment with rinses, mouth sprays, or lozenges containing volatiles with a pleasant odor has only a short-term effect. • Typical examples are mint-containing lozenges and the aroma of rinses without antibacterial components. • Another pathway is to increase the solubility of malodorous compounds in the saliva by increasing the secretion of saliva; a larger volume allows the retention of larger volumes of soluble VSCs. The latter can also be achieved by ensuring proper liquid intake or using chewing gum; chewing triggers the periodontal-parotid reflex, at least when the lower (pre)molars are still present.
  • 44. Conclusion • Breath malodor has important socioeconomic consequences and can reveal important diseases. • A proper diagnosis and determination of the etiology allow initiation of the proper etiologic treatment. • Although tongue coating and (less frequently) periodontitis and gingivitis are by far the most common causes of malodor, a clinician cannot take the risk of overlooking other, more challenging diseases. • This can be done with a multidisciplinary consultation or, if this is not feasible, a trial therapy to deal quickly with intraoral causes (e.g., full-mouth one-stage disinfection, including the use of proper mouthrinses, tongue scrapers, and toothpastes).