Halitosis Copyright (c) Department of Periodontology University of Dental Medicine, Yangon (Retyped version: Please check correct spelling)

1. 19 September 2018
Halitosis
Department of Periodontology
University of Dental Medicine,
Yangon

2. Definition
❖ Halitosis is derived from Latin.
❖ It means breath and osis, an abnormal or diseased
conditions.
❖ Unpleasant foul offensive odour; bad breath; malodour;
fetor ex oris (ore)

3. Causes / Etiology
❖ The primary cause of halitosis is the uncontrolled growth
of gram negative anaerobic bacteria.

4. ❖ Oral microbes are known to produce volatile sulphur
compounds, namely methly mercaptan (CH3SH),
hydrogen sulphide (H2S) and dimethyl sulfide (CH3)2S.
❖ The most commonly involved bacteria are
Porphyromonas gingivalis, Prevotella intermedia /
nigrescens, Aggregatibacter actinomycetemcomitans,
Campylobacter rectus, Fusobacterium nucleatum,
Peptostreptococcus micros, Tannerella forsythia,
Eubacterium spp, and spirochetes.

5. ❖ These volatile sulphur compounds are the primary
components of oral malodour.
❖ These are formed through the putrefactive action of oral
microbes on sulphur containing amino acids, peptones or
proteins found in the mouth.

6. Production of volatile sulfur compounds causing
halitosis
Proteins in diet
Proteins in
GCF
Proteins in
saliva
Peptid
esBacteria
proteases
Host proteases Sulfur containing
amino acids
Volatile sulfur
compounds
Halitosis
Other amino
acids
Anaerobic
gram
negative
bacteria

7. ❖ Many components besides sulfide components (e.g.,
diamines) in the GCF and saliva can be malodourous.
❖ First, pH has to be above the neutrality (i.e. basic) to
cause halitosis.
❖ Conversely, an acidic pH is inhibitory to the proliferation
of gram negative, anaerobic bacteria and consequently
low pH leads to reduction of malodour.

8. ❖ Second, reduced flow of saliva allows colonization of
bacteria on the teeth and soft tissue, thereby promoting
the production of odorous gases.
❖ Other related important factors are age, genders, habits
and diurnal variation.

9. A. Local causes (Oral Origins
90%)
❖ Poor oral hygiene
❖ Periodontal diseases are strongly associated with bad
breath. The concentration of volatile sulphur compounds
increases with severity of periodontal diseases.
❖ Carious lesions (especially with food particles)
❖ Tongue coating
❖ Food impaction
❖ Poor dental prothesis hygiene

10. ❖ Surgical or extraction sites
❖ Oral infections or abscess
❖ Soft tissue lesion with ulcerations, bleeding or necrosis
❖ Ingestion of highly flavored food and beverages
❖ Heavy smoking
❖ Xerostomia
❖ Allergic conditions
❖ Oral carcinoma

11. B. Systemic causes (Non-oral
origins)
❖ Upper and lower respiratory tract diseases (e.g.,
bronchitis, bronchiectasis)
❖ Gastro-intestinal tract diseases (e.g., gastric hernia)
❖ Pathologic conditions of peri-oral structures (e.g.,
purulent sinusitis, chronic pharyngitis, post-nasal drip or
discharges)
❖ Stress or nervous tension is a major enhance of bad
breath. One major effect of stress is drying of the mouth.

12. ❖ Onset of menstruation
❖ Other systemic causes of breath malodour includes renal
(uremia / fishy), pancreatic (acetone) and liver
(ammonium)

13. C. Psychological or
psychiatric causes

14. Classification
There are three main categories of halitosis:
❖ Genuine halitosis
❖ Pseudo-halitosis
❖ Halitophobia

15. Genuine halitosis
❖ Genuine halitosis is the term that is used when the
breath malodour really exists and can be diagnosed
organoleptically or by measurement of the responsible
compounds.

16. Psedo-halitosis
❖ When an obvious breath malodour cannot be perceived,
but the patient is convinced that he is she suffers from it,
this is called pseudo-halitosis.

17. Halitophobia
❖ If the patient still believes that there is bad breath after
treatment of genuine halitosis or diagnosis of pseudo-
halitosis, one considers halitophobia, which is a
recognized psychiatric condition.

18. Management

19. A. Diagnosis
i. Patient history
❖ There is a saying “Listening to the patient and he will tell
you the diagnosis”

20. ❖ The common questions are about the frequency of odor,
the time of appearance within the day, the time of
appearance within the day, whether others have
identified the problems, what kind of medications are
taken and whether dryness of the mouth noticed.

21. ii. Clinical and Laboratory
exmination
1. Gas chromatography or combined with mass
spectroscopy
2. Sulphide monitor system (Helimeter)
3. Organoleptic measurement

22. B. Treatment
❖ Local measures
❖ Systemic measures - specific treatment of systemic
cause if present
❖ Psychotherapy (if needed)

23. Classification of halitosis on Treatment
need (TN)
No Classification Treatment Needs
I Genuine halitosis
A. Physiologic halitosis TN 1
B. Pathologic halitosis
a. Oral Pathologic halitosis TN-1 and TN-2
b. Extra Oral Pathologic halitosis TN-1 and TN-3
II Pseudo halitosis TN-1 and TN-4
III Halitophobia TN-1 and TN-5

24. Treatment Needs (TN) for
breath odor
Category Description
TN-1
Explanation of halitosis and instructions for oral hygiene
(Support and reinforcement of patient’s own self care for further
improvement in their oral hygiene)
TN-2
Oral prophylaxis, professional cleaning and treatments for oral
diseases
TN-3 Referral to a physician or medical specialist
TN-4
Explanation of examination date, further professional instruction,
education and reassurance
TN-5
Referral to a clinical psychologist or other psychological
specialists

25. Local measures
❖ An etiologic treatment is to be preferred.
❖ The treatment of oral malodour consists of the elimination of the local
pathology / cause present.
❖ If underlying disease is suspected, the patient should be referred to
the respective specialists.
❖ Thorough plaque control to remove plaque and food particle is a
daily necessity.
❖ Regular check up to correct problems areas; common oral diseases,
faulty restorations, leaking crowns, all of which causes food trap is a
must.

26. ❖ Instructions on proper oral hygiene be reinforced and
professional oral prophylaxis are essential.
❖ Inter-proximal cleaning is relatively more important
because toothbrush bristles do not gain access to inter-
proximal areas.
❖ Further, the tongue is probably some of the important
reservoirs of bacteria involved in halitosis and tongue
scraping should be an important component of the
treatment.

27. ❖ Mouth rinses are valuable adjuncts but do not provide the best
sole treatment.
❖ Chlorhexidine is the mouth rinse that demonstrates
considerable reduction of malodour.
❖ It is well established that zinc containing mouth rinses have the
property of the complex the divalent sulphur radicals, reducing
the important cause of malodour.
❖ (Zinc can block the biologic effects of volatile sulphur
compounds on protein synthesis)
❖ The use of hydrogen peroxide rinse also offers positive
perspectives, mouth rinses are best used before bed time.

28. ❖ Any treatment that promotes increased level of saliva
and tongue action will be of help to reduce malodour
especially when oral dryness is at stage.
❖ This can mean a proper fluid intake or the use of
sugarless chewing gum, candy or the fibrous vegetables.
❖ Vit C deficiency may be a cofactor on bad breath.
❖ Smokers especially should take regular supplements of
Vit C since the nicotine in the cigarettes destroys Vit C.