2. Oral malodour or Halitosis is a general term denoting
unpleasant breath arising from physiological &
pathological causes from oral & systemic sources
…to describe any disagreeable odour in the exhaled
air of an individual, regardless of whether the odour
originates in the oral cavity or elsewhere from within
the body
8. Putrefactive process within the oral cavity
Not specific to any disease
Self-limiting
Best example is “Morning breath”
9. Oral Halitosis: Halitosis caused by disease, pathological
condition or malfunction of oral tissues.
Halitosis derived from tongue coating, modified by
pathological condition, e.g. periodontal disease, xerostomia.
10. The primary cause of
halitosis -
the release of
odoriferous volatile
sulphur compounds
(VSC).
VSC –
putrefactive
activity of
anaerobic
bacteria
12. the bacteria that
produce the
malodourous
compounds,
the substrates
that the
bacteria utilise
to release the
odour
compounds,
the
malodourous
compounds
themselves.
13. Volatile Sulphur Compounds
• Malodour causing compounds
• Formed by microbial fermentation of
1. Proteins
2. Peptides
3. Mucins found in saliva, blood, postnasal drip, GCF, lysed
neutrophils
4. Desquamated epithelial cells.
14. Many studies have demonstrated that hydrogen sulphide, methyl
mercaptan & to a lesser extent, dimethyl sulphide accounts 90%
of the total volatile sulphur compounds
VSCs found in the mouth air, suggesting that these volatile
sulphur compounds are the chemicals responsible for halitosis
15. Halitosis in 80-90% of the cases originates within
the oral cavity, where anaerobic bacteria degrade
sulphur containing amino acids to foul smelling
VSC’s namely, hydrogen sulphide and methyl
mercaptan.
10-20% of halitosis has non-oral causes.
16. Periodontal pathogens
identified, with BANA
hydrolysis, on the posterior
tongue, contributing to oral
malodor include
Treponema denticola
Porphyromonas gingivalis
Bacteroides forsythus.
Additional periodontal
pathogens, identified as VSC
formers includes
Fusobacterium nucleatum
Bacteroides melanogenicus
17.
18.
19.
20. may result from…hot or spicy food, certain
drinks…alcoholic beverages & coffee.
The most common causes…garlic, onions,
…Tobacco consumption…characteristically mouldy
odour.
Hyposalivation or xerostomia…lead to bad breath,
which can be considered temporary when associated
with reduced salivary flow during the night
21. The superficial layer of oral mucosa consists
of ready-to-be-shed squames,
which are covered with a large number of
anaerobic bacteria.
Covering the microorganisms is a continually
replaced layer of residual saliva
…maintains the surface of the oral mucosa in
a moist state.
…residual saliva layer provides the easily
degradable peptide and protein substrates to
the bacteria
22. Also promotes the process of putrefaction,
…the outer layer of the residual saliva also
restricts the release of odoriferous volatiles into
the mouth air.
…During sleep, due to a reduced flow of saliva,
the resulting thinner residual saliva layer makes it
easier for the odorous volatiles generated in the
mucosal layer to be released into the breath
23. From the tongue coating present on the dorsoposterior surface of the
tongue.
The tongue coating consists of desquamated epithelial cells, blood
cells and VSC-producing anaerobic bacteria.
24. Posterior part exhibits a
number of oral crypto-
lymphatic units, which
roughen the surface, the
anterior part is rougher
because of high no papillae.
These depressions are ideal
niches for bacterial adhesion
& growth…sheltered from
cleaning actions…food
remnants & desquamated
cells…putrified.
25. degree 0 No visible coating
degree 1 < 1/3 covered by easily removable
coating
degree 2 < 2/3 covered by easily removable
coating & < 1/3 covered by not
easily removable coating
degree 3 > 2/3 covered by easily removable
coating
degree 4 > 2/3 covered by not easily
removable plaque
van Steenberghe, 2004
26. The pathogens strongly associated with the etiology of
periodontal disease are also associated in the production of
VSC…
In gingivitis, the bacteria-resistant epithelial seal around the teeth
is lost due to the increased permeability of the gingival sulcus.
VSC produces a similar effect on the gingiva.
27. Hydrogen sulphide-
the permeability of the surface
epithelium…
gingival sulcus -methyl mercaptan
Methyl mercaptan - penetrate into the
deeper gingival tissues & induce
deleterious effects.
Bacterial products could penetrate deeper
into the periodontium …
interleukin-1 beta (IL-1β)
increase the secretion of inflammatory
mediators such as PGE2 and collagenase.
28. Also VSC levels in the mouth correlate +vely with the depth of
the periodontal pockets.
The amount of VSCs in breath increases with the no, depth, &
bleeding tendency of the pdl pockets.
…low O2 tension also results in a low pH & an activation of
decarboxylation of the AAs like lysine, ornithine to cadaverine &
putrescine…2 malodourous diamines.
32. ENT CAUSES: include
Acute pharyngitis
Purulent sinusitis
Post nasal drip chronic sinusitis
regurgitation esophagitis
Ozena
Chronic/purulent tonsillitis
A foreign body in a nasal or sinus cavity…local irritation,
ulceration & putrefaction.
34. GIT: rarely responsible for bad breath…less than 1% of malodor
Zenkers diverticulum
Gastric hernia
Regurgitation esophagitis
Intestinal gas production
35. Liver: Pts with liver insufficiency … cirrhosis, ammonium accumulates
in blood … exhaled…fetor hepaticus
Kidney: Insufficiency … chronic glomerulonephritis … increased uric
acid level in blood … expressed in the expired air …
42. Classification of subjectively perceived halitosis
(Seemann, 2002)
degree 0 From approximately 10cm distance, have the
patient say “A”. No unpleasant smell is
perceived.
degree 1 From approximately 10cm distance, have the
patient say “A”. An unpleasant smell is
perceived.
degree 2 From approximately 30cm distance an
unpleasant smell is perceived during a
conversation.
degree 3 From approximately 1m distance, i.e. during
the anamnesis talk, an obvious bad breath is
perceived.
43. Mechanical reduction
of intraoral nutrients
(substrates) & micro-
organisms
Chemical
reduction
of oral
microbial
load
Rendering mal-
odorous gases non-
volatile
Masking
the
malodor
…is cause related …Strategies
applied
44. Appropriate pdl management is the 1st step.
NUG, gingivitis, chronic & aggressive periodontitis or periodontal
pockets can increase the bacterial load so pdl health has significant
importance in controlling the amount of halitosis caused by bacteria.
45. • …reduces both amount of coating…thus bacterial nutrients & the no of
organisms…improves oral malodor effectively.
Tongue cleaning emphasized
Interdental cleaning & tooth brushing…effective
plaque control
A combination of tooth & tongue brushing or tooth brushing alone has a
beneficial effect on bad breath for upto 1 hr (73% & 30% reduction in VSCs
respectively) - Tonzetich 1976
47. Active ingredients in oral rinses are usually antimicrobial agents
such as chlorhexidine, cetylpyridinium chloride, essential oils,
chlorine dioxide, H2O2, & triclosan….temporary reducing effect on
total no of micro-organisms in oral cavity.
48. Treatment with rinses, mouth sprays, lozenges containing volatiles
have only a short term effect…hence, for temporary halitosis
Also, increasing the pathway of malodorous compound in the saliva by
lowering the pH of saliva or by increasing the secretion of
saliva…lowers malodor.
49. It is crucial for dentists to have an understanding of all types of
halitosis, especially those that arise from the oral cavity.
The available evidence indicates that VSC are not just odoriferous, but
that some of them are deleterious to periodontal health.
Therefore treatment of halitosis can no longer be considered as just a
cosmetic therapy.
Editor's Notes
In 1934, Fair & Wells developed the osmoscope, an instrument for measuring the intensity of odors. Later, this apparatus was used for breath analysis (Brening et al.
1938).
Genuine halitosis -Presence of a malodour that is beyond socially acceptable level.Pseudo-halitosis -Apparently healthy individuals who have no perceivable halitosis, or any halitosis causing local or systemic factors, but persistently claim to have halitosis suffer from a condition called pseudo-halitosis. Halitophobia - is a condition in which the pt has an exaggerated fear of having halitosis; those affected may or may not have a previous history of having genuine halitosis.
and based on the origin of pathological halitosis it is further differentiated into oral and extraoral halitosis. As the name signifies, oral halitosis originates in the oral cavity and extraoral from other parts of the body, such as the nasal cavity and paranasal sinuses, respiratory tract, digestive system and the kidneys.
Neither a specific disease nor a pathological condition that could cause halitosis is found
Putrefactive process within the oral cavity
Not specific to any disease
Self-limiting, usually does not need any therapy
Best example is “Morning breath”
The primary cause of halitosis is due to the release of odoriferous volatile sulphur compounds (VSC) in the exhaled air.
VSC are released following putrefactive activity of anaerobic bacteria present in the oral or nasal cavity.
Extra-oral halitosis: The VSC may also be absorbed by the blood stream from a remote part of the body, such as from a cirrhotic liver, & transferred to the pulmonary alveoli to be exhaled thru the nostrils or mouth as malodorous breath
In the absence of any one of these factors halitosis is unlikely to occur.
This are the comounds formesd by micobial fermentation of proteins
10-20% of halitosis has non-oral causes. These volatile compounds are sulfur compounds, aromatic compounds, nitrogen-containing compounds, amines, short-chain fatty acids, alcohols or phenyl compounds, aliphatic compounds,and ketones
Periodontal pathogens identified, with BANA hydrolysis, on the posterior tongue, contributing to oral malodor include
Treponema denticola, Porphymonas gingivalis Bacteroides forsythus.
Additional periodontal pathogens, identified as VSC formers includes Fusobacterium nucleatum Bacteroides melanogenicus
Exposed tooth pulps
Nonvital tooth with fistula
Dentures/prostheses
Various causes like
Tobacco consumption may leave a characteristically (Kleinberg & Westbay, 1992).
Morning breath disappears soon after intake of food or fluid. This may be explained by the increased saliva flow and the resulting thickening of the residual saliva layer over the oral mucosa, restricting the release of foul smelling VSC. In addition, the movement of the tongue and cheek during mastication and the increased salivary flow removes food debris, desquamated epithelial cells and free-floating bacteria.
physiological halitosis is mainly…
Even in healthy subjects with no oral lesions, the tongue coating is believed to be the primary source of oral malodour
The presence & extent of coating indicates the load of micro-organisms and debris that are harbored by the tongue
van Steenberghe, 2004
The pathogens strongly associated with the etiology of periodontal disease are also associated in the production of VSC…
In gingivitis, the bacteria-resistant epithelial seal around the teeth is lost due to the increased permeability of the gingival sulcus.
VSC produces a similar effect on the gingiva.
Unlike in the mouth air where hydrogen sulphide is present in greater concentration…Hydrogen sulphide increases the permeability of the surface epithelium…facilitating increased penetration of Lipopolysaccharide into the gingival tissues the gingival sulcus has methyl mercaptan as the predominant compound Methyl mercaptan has also been shown to be toxic in low concentrations to gingival fibroblastsMethyl mercaptan has been shown to penetrate into the deeper gingival tissues & induce deleterious effectsAs a consequence, bacterial products could penetrate deeper into the periodontium …depending upon the host response, the disease process may progress In addition methyl mercaptan induces secretion of interleukin-1 beta (IL-1β), acts synergistically with LPS & IL-1β to increase the secretion of inflammatory mediators such as PGE2 and collagenaseThese studies show that VSC are not just odour-causing compounds but that they might actually participate in initiating gingivitis.
Deeper the pocket the more B particularly anaerobic species
all detrimental to the maintenance or regeneration of mineralised tissues such as the alveolar bone
Pericoronitis: cap retentive for microorganisms & debris, herpetic gingivitis, major recurrent oral ulcerations, necrotizing gingivitis & periodontitis
G-ve anaerobes- prevotella & porphyromonas species)
Nasal
Paranasal
Laryngeal regions
Pulmonary tract
Digestive tract
Systemic diseases
Ozena-rare atrophic condition of the nasal mucosa with the appearance of crusts & causing strong malodour
Tonsillitis-the deep crypts of the tonsils accumulate debri & B, especially periopathogens, resulting in putrefaction
Bronchiectasis-Infection of standing mucus secretion in cystic dilations through walls of bronchioles
Hernia in esophageal wall allowing food accumulation & hence putrefaction. Not separated from oral cavity by any sphincter, so significant malodor
Fundus of stomach protrudes thru diaphragm with relative sphincter insufficiency allowing gases to escape or contents 2 flow back in esophagus
Ulceration of mucosal lining of esophagus by acidic stomach contents flowing back bcoz of sphincter dysfn
Some gases – dimethyl sulphide are absorbed but not metabolised by intestinal endothelium thus transported by blood – exhaled through lungs
Systemic metabolic disorders
Type 1 diabetes… accumulation of ketones… lack of glucose leads to break down of fat and proteins … ketone bodies such as acetoacetate and hydroxybutyrate.
Trimethylaminuria – hereditary metabolic disorder leads to fishy odor of breathe, urine, sweat, expired air, and other bodily secretions. Enzamatic defect that prevents the transformation of trimethylamine to trimethylamine oxide resulting in abnormal amounts of this molecule
Hormonal causes: With increased progestrone level during menstrual cycles bad breathe can develop.
Enzamatic defect that prevents the transformation of trimethylamine to trimethylamine oxide resulting in abnormal amounts of this molecule
Medications Drugs such as metronidazole … patients perception of metallic taste …. MalodorEucalyptus containing medications … melon like odor.Arsenic … rotten onions.Others …amphetamines, chloral hydrate, cytotoxic agents, dimethyl sulphoxide, disulfiram, nitrates and nitrites, phenothiazines
The patient takes breathe deeply by inspiring the air by nostrils and holding awhile, then expiring by the mouth directly or via a pipette, while the examiner sniffs the odor at a distance of 20 cm
article-Diag to management
Yaegeki, murata
From every patient, different samples are analysed:
MOUTH ODOUR (smelled at 10 cm form the oral cavity: while the patient normally breaths and while the patient counts loudly to 10)
SALIVA ODOUR (measured by the wrist-lick test: the patient licks at the wrist, and after 10 s of drying, a score is given to this sample)
TONGUE COATING (a score is given to debris, scraped from the dorsum of the tongue with a periodontal probe)
’ interdental floss (after flossing with dental tape, the odour of the floss is scored)
NASAL ODOUR (while the patient is breathing through the nose (mouth closed), a score is given to the exhaled air.
(if the patient wears a partial or full removable denture, scoring of the odour of this prosthetic is noted).
Gold standard
Bcoz malodor is caused by metabolic degradation of available proteins 2 malodorous gases by certain microorganisms,
Halitosis can be treated if its etiology can be detected
properly. Therefore, The most important issue for treatment of halitosis is detecting of etiology or determining of its source by detailed clinical examination.
Because of extensive accumulation of B on dorsum of tongue…tooth brush, tongue scraper
Both remove residual food particles & organisms that cause putrefaction.
Pg 339
Low pH increases solubility of VSCs & larger volume of saliva allows larger retention of soluble VSCs
