Department of periodontics

1. Halitosis
T.Hudson Jonathan
1st yr MDS

2. Contents
• Introduction
• Classification of halitosis
• Etiology of halitosis
• Factors influencing odor production
• Diagnosis of halitosis
Organoleptic measurement
Gas chromatography
Dark field
Saliva incubation test

3. Contents
• Treatment needs of halitosis
 Masking the malodor
 Mechanical reduction of intra oral nutrients
 Chemical reduction of oral microbial load
 Rendering malodorous gases non volatile
• conclusion

4. 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 feter ex ore can be
applied.(carranza 12ed)

5. • Halitosis is a technical term for bad breath and
orginates from the latin word ‘Halitus’ meaning
breath and the greek word ‘osis’ meaning
abnormal or diseased.
• Breath malodor should not be confused with the
momentarily disturbing odor caused by food
intake or smoking because these odor do not
reveal a health problem.

6. • Same way morning bad breath which is habitually
experienced on awakening and mainly caused by a
decreased salivary flow and increased putrefaction
during night which generally disappears after
breakfast or brushing.

7. Classification of halitosis
• There are three main categories of halitosis.
Halitosis
Genuine halitosis Pseudo halitosis Halitophobia
physiologic pathologic
Intra oral Extra oral

8. Genuine halitosis:
• It is the termed used when the breath malodor really
exists and can be diagnosed organoleptically or by
measurements of the responsible compounds.
Physiologic halitosis:
• Malodour arises through putrefactive process within the
oral cavity ,neither specific disease nor pathologic
condition that could cause halitosis is found.
• Origin is mostly the dorsoposterior region of the tongue.
eg:food intake (garlic,onion) smoking, medications

9. Pathologic halitosis:
• A persistent breath odour, by definition does reflect
some pathology.
Intra oral:
• Halitosis caused by disease, pathologic condition or
malfunction of oral tissues.
• Halitosis derived from tongue coating (eg: periodontal
disease, xerostomia) is included in this subdivision.

10. Extra oral:
• Malodor orginates from nasal, paranasal or laryngeal
regions, pulmonary tract or upper digestive tract.
• Includes disoders anywhere in the body where the
odour is blood borne and emitted via the lungs
(eg:diabetes mellitus,hepatic cirrhosis, uremia,internal
bleeding).
Pseudo halitosis:
• Obvious malodor is not preceived by others, although
the patient stubbornly complains of its existence.

11. • Condition is improved by counselling(using literature
support and education)and simple oral hygiene
measures.
Halitophobia:
• After treatment of genuine halitosis, or pseudo halitosis,
the patient persists in believing that he/she has
halitosis.
• No physical or social evidence exists to suggest that
halitosis is present.

12. Due to local factors of pathologic origin:
• Food impaction
• Excessive smoking
• Healing extraction wounds
• Necrotic tissue from ulceration
• Hairy or coated tongue
• Chronic periodontal disease
• Chronic sinusitis
• Abscess
• Tonsilitis
• Pharyngitis

13. Due to local factors of non-pathologic origin:
• Stagnation of saliva
• Young children between 2-5yrs exhibit malodor due to
tonsil crypts,lodging food and debris.
• Denture breath: due to its porous nature encourages
accumulation of food.
Due to systemic factors of pathologic origin:
• Diabetes due to accumulation of ketones in blood
excreted through respiratory system.

14. • Von willebrand disease, thrombocytopenia- due to
decomposed blood from spontaneous bleeding in oral
cavity.
• Vit-c deficiency: have typical foul breath of fuso
spirochetal infections.
Due to systemic factors of non-pathologic origin:
• Vegetarians have less tendency of halitosis fewer
degraded waste byproducts of protienaceous substances.
• Meat-contains fat & volatile fatty acids produced in GIT
absorbed into blood excreted in breath.

15. • Garlic,onion,alcohol-absorbed into circulatory system and
exhaled through lungs.
• Excessive alcohol intake-alteration in microbial flora
causes proliferation of odour fermenting organisms.
• Halitosis cannot orginate from gastric content expect in
blenching and vomiting since the odour & gas cannot
escape when oesophagus is in normal closed condition.
• Hunger odour:due to putrefaction of pancreatic juices in
the stomach.

16. Drugs associated with halitosis

17. Factors influencing odor production
• Prinz 1930 suggested that more than 90./. Of all cases
of objectional breath orginate from sources within the
oral cavity.
• In contrast (Crohn et al 1942) deemed oral malodor of
importance only in small percentage of halitosis cases.
• The oral malodor is manifested because of the
production of volatile compounds namely Hydrogen
Sulphide(H2S), Methylmercaptan(CH3 CH), Dimethyl
Sulphide(CH3 2S).

18. (Law D.B.et al 1943)
• These volatile compounds are produced through the putrefactive
action of micro-organisms on exogenous and endogenous
protinaceous substrates,namely exfoliated oral epithelium,
salivary corpuscles,food debris,saliva and blood (Massler et al
1951).
Proteins
Proteolysis
Further degraded
Highly volatile compounds
Peptides + amino acids

19. • This manifestation occurs in mouths of all individuals.However it
is especially accentuated in tissue degenerative conditions such
as gingivitis, periodontitis, and acute ulcerative gingivo-
stomatitis.(Spouge et al 1964)
• The proteolytic activity in the mouth has been associated with
the bacteria namely Staphylococcus,B.subtilis,B.proteus,colon
bacilli,B.melaninogenicus,clostridia,B.sporogenes,B.histolyticum,
& T.mucosum.(Law.D.B.et al 1943)
• Numerous micro organisms indigenous to saliva, dental
plaque,gingival crevice, and tongue possess marked odor
producing potential.

20. • Berg and Fosdick 1946,demonstrated that most of
the 17 strains of micro organisms isolated from
saliva,when added to raw saliva containing normal
flora,exhibited the potential to stimulate varying
amounts of odor from salivary substrates.
• While it has been clearly demonstrated that micro
organisms are essential for odor production,(Berg et
al 1946) no single organism has been implicated as
the primary cause of oral malodor.

21. Diagnosis of halitosis
• An investigative protocol as given by (Gaurav et al
2016) for a patient who presents to primary care
practioner.
Patient with chief complaint of oral malodor
A through medical history including diet/
medication intake
Halitosis history
Periodontal screening
(Rule out transient
halitosis /physiological
halitosis)

22. Breath sampling through Organoleptic test
in clinical setting
Halitosis present Halitosis absent
Advanced diagnostic tests like Gas
chromatography,BANA test
(To rule Out
Intraoral
causes) Dental referral
Positive(Signifies
Halitosis induced
observed By
intraoral cause)
Negative
(Halitosis present)
(Halitosis still not)
Consider Delusional
Halitosis

23. Chest X ray
ENT consultation to rule
out Upper RTI/lower RTI
Positive (Signifies halitosis due
to various respiratory factors) Negative
Gastroenterologist
referral to rule out GIT
causes
(Endoscopy)
Negative Positive
Complete blood
count/urinanalysis to rule
out diabetes mellitus,
renal, liver and blood
dyscaraias
findings
Enzymatic analysis to rule
out metabolic
disorders like
trimethylaminuria,
maple syrup disease

24. Organoleptic measurement
• Organoleptic measurement can be carried out simply
by sniffing the patients breath and scoring the level of
oral malodor.
• By inserting a translucent tube (2.5cm 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 in a organoleptic score.

25. Organoleptic scoring scale (Miyazaki H et al 1999)

26. • However to prevent the patient from seeing the examiner
sniffing from the tube , a privacy screen is often used.The
tube is (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.
• For reliable diagnosis,the oral malodor assessment should
preferably be carried out on two or three different days, if
possible.This is especially important when either
pseudohalitosis or halitophobia is suspected.

27. • Patient are instructed to abstain from taking antibiotics
for three weeks before the assessment,from eating
garlic,onion & spicy foods for 48hrs before assessment
and to avoid using scented cosmetics for 24hrs before
assessment.
• They are also instructed to abstain from their usual oral
hygiene practices,oral rinse,breath freshners and to
abstain from smoking for 12hrs before assessment.
• The examiner who should have a normal sense of smell ,is
required to refrain from drinking juice,coffee,tea,smoking
and using scented cosmetics before the assessment.

28. Gas chromatography
• In the 1970s, the late Joseph Tonzetich and colleagues
used a gas chromatograph equipped with a selective
flame detector to demonstrate that volatile sulfur
compounds, primarily H2S and CH3SH, were the major
cause of physiological putrefactive oral malodor
(Tonzetich J 1977).
• A gas chromatography can analyse air,saliva,or crevicular
fluid.About 100 compounds have been isolated from the
headspace of saliva and tongue coating,from ketones to
alkanes, and sulphur containing compounds to phenyl
compounds.

29. • In the expired air of a person
approximately 150 compounds
can be found. The most
important advantage of this
technique is that when coupled
with mass spectrometry, it can
detect virtually any compound
when using adequate materials
& conditions. Moreover it has a
very high sensitivity &
specificity.

30. Dark field
• Oral malodor is typically associated with a higher
incidence of motile organisms and spirochetes,so shifts
in these proportions allow monitoring of therapeutic
progress.
• Another advantage of direct microscopy is that the
patient becomes aware of bacteria being present in
plaque, tongue coating and saliva.

31. Saliva incubation test
• The analysis of the headspace earlier incubated saliva
by gas chromatography reveals VSCs and other
compounds such as indole, skatole, lactic acid,
methylamine, diphenylamine and tetradecanol.
• By adding some proteins such as lysine or cysteine,the
production of respectively cadaverine or hydrogen
sulphide is dramatically increased.

32. Electronic nose
• Electronic noses identify the specific components of an
odor and analyze its chemical makeup.
• They consists of a mechanism for chemical detection
such as an array of electronic sensors,and a mechanism
for pattern recognition
• They are smaller, less expensive and easier to use than
gas chromatography but can only be developed for
specific applications if the important metabolites are
already known .

33. Chair side methods
• Gas chromatography is a laboratory- based procedure that
cannot be easily implemented at chairside, so that there was
no transference of this method to the clinic.
• This changed in the early 1990s, when Rosenberg et al.
showed that a portable instrument developed to monitor
sulfides in the workplace could be adapted for chairside use
to measure volatile sulfur compounds in exhaled air.
• The instrument, eventually modified for oral usage and sold
under the trade name of Halimeter was shown to significantly
correlate with organoleptic scores

34. • These correlations indicated
that the volatile sulfur
compounds measured by the
Halimeter account for only 18%
to 41% of the organoleptic
score, indicating that other
important odorants, such as
volatile fatty acids and
cadaverine, are contributing to
the organoleptic score but are
not detected by the Halimeter.

35. • This explains the anomalous finding that sometimes
malodor can be detected by the examiner, but the
volatile sulfur compounds levels are in the low range
(Schmidt NF,1978).
• The Halimeter apparently has never been validated
by gas chromatography in regard to the specificity of
the sulfur compounds detected (Tonzetich J et al
1995).

36. • Despite these limitations, the availability of the Halimeter
has led to an unprecedented increase in oral malodor
research and to treatment clinics that monitor clinical
improvements with this instrument and has encouraged
the development of second generation sensors.
• Sensors for volatile sulfur compounds have been integrated
into periodontal probes and paddles, which can be placed
directly into the pocket or onto the tongue, again yielding
significant correlations with organoleptic scores (Diamond
Probe,) (Morita M,et al 2001).

37. • A volatile sulfur compound monitor, which uses a
zinc-oxide thin-film semiconductor sensor, correlated
significantly with gas chromatographic readings of
exhaled air (Shimura M et al 1996), and with
organoleptic scores (Shimura M et al 1997).
• As such, this monitor accounted for about 67% of the
odor being detected by the organoleptic scores,
suggesting that it could be a useful substitute for the
‘‘nose’’ in clinical studies.

38. • Three species associated with periodontal disease
Treponema denticola, Porphyromonas gingivalis and
Bacteroides forsythus,Produce volatile sulphur compounds
and volatile fatty acids such as butyrate and propionate ,so
that their detection in plaque and /or tongue samples
might provide additional information concerning factors
contributing to the individual malodor(Persson et al 1990)
• These organisms can be detected in plaque sample by the
presence of an enzyme that degrades Benzoyl-DL-arginine-
∝ -naphthylamide(BANA), a synthetic trypsin substrate
forming a colored compound(Bretz W A et al 1990)

39. • We have adapted this enzyme assay to a 5- to 10-
minute chairside test(BANA Test,) that detects the
presence of this enzyme in plaque and tongue samples
(De Boever EH et al 1994).
• Kozlovsky et al.1994 found that the BANA Test
correlated significantly with the organoleptic scores
obtained from the whole mouth, tongue and saliva,
but not with the volatile sulfur compounds.

40. • When multiple-regression analyses were performed
with the organoleptic scores as the dependent
variable, both peak volatile sulfur compounds and the
BANA scores factored into the regression, yielding
highly significant associations (P<0.001).
• These findings suggest that the BANA Test was
associated with malodorous compounds other than
volatile sulfur compounds.

41. Treatment needs
• Treatment needs (TN)
for halitosis in dental
practice have been
categorized into five
classes to provide
guidelines for clinicians
in treating halitosis
patients.(Miyazaki H et
al 1999)

42. • Managed by dental practioner:
I. Pysiologic halitosis(TN-1)
II. Oral pathologic halitosis(TN-1 & TN-2)
III. Pseudo halitosis (TN-1 & TN-4)
• Extra oral pathologic halitosis (TN-3)- By physician or
medical specialist
• Halitophobia (TN-5)- by physician,psychiatrist or
psychological specialist.

43. • The available bacteriological data cannot identify any
specific organisms as responsible for tongue odor,other
than an overgrowth of many bacterial types,especially
proteolytic species.
• Treatment thus aimed at the reduction or elimination
of oral malodor will require an antimicrobial
component directed against this overgrowth.
• This should include a debridement component, such as
tongue brushing,possibly in combination with an anti
microbial mouth rinse.(Perio 2000 vol 28)

44. • Since malodor is caused by the metabolic degradation
of available proteins to malodorous gases by certain
oral micro organisms,the following general treatment
strategies can be applied.
I. Masking the malodor
II. Mechanical reduction of intra oral nutrients
(substrates and micro organisms)
III. Chemical reduction of oral microbial load
IV. Rendering malodorous gases non volatile

45. Masking the malodor:
• Treatment with rinses,mouth sprays and lozenges
containing volatiles with a pleasant odor have only a
short term effect.
• Typical examples are mint-containing lozenges and the
aroma present in 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.

46. • The latter can also be achieved by ensuring a proper
liquid intake or by using a chewing gums;chewing triggers
the periodontal-parotid reflex,atleast when the lower
pre-molars are still present.
Mechanical reduction of intra oral nutrients and micro
oragnisms:
• Saliva enters the mouth essentially sterile from the
parotid,submandibular and lingual glands but
expectorated saliva contains over 100,000,000 cultivable
colony forming units per ml (Perio 2000 vol-28)

47. • This means that large numbers of bacteria are
constantly being shed into the saliva from the oral
surfaces.
• It is possible that subjects with malodor have higher
peptide, protein,or glycoprotein levels per ml of saliva
compared with subjects without malodor due to
increased seepage of blood and serum into the saliva
from periodontal disease and tongue inflammation.

48. • A fissured tongue is associated with
oral malodor permusably because it
provides an increased surface area of
bacteria to colonize (De boever EH et
al 1995)
• Due to excessive accumulation of
bacteria on the dorsum of the tongue,
tongue cleaning should be emphasized.
• Cleaning of tongue can be carried out
with a normal toothbrush , but
preferably by a tongue scraper if a
coating is established.

49. • Tongue cleaning using a tongue
scraper reduces halitosis levels
75./.after 1 wk. This should be gentle
cleaning to avoid soft tissue damage.
• Interdental cleaning and tooth
brushing are essential as they remove
food particles and organisms that
cause putrefaction.
• When chronic oral malodor arises as
a consequence of the presence of
periodontitis,professional periodontal
therapy is needed.

50. Chemical reduction of oral microbial load:
• Together with toothbrusing ,mouth rinsing has become a
common oral hygiene practice.Formulations has been
modified to carry antimicrobial and oxidizing agents with
impact in the process of oral malodor formation.
• The active ingredients usually includes anti microbial
agents such as chlorhexidine, cetylpyridinium
chloride(CPC), essential oils, chlorine dioxide,
Triclosan(TCN), amine fluoride and stannous fluoride,
hydrogen peroxide and baking soda.

51. Chlorhexidine:
• It is considered as the most effective anti
plaque and anti gingivitis agent.Its
antibacterial action can be explained by
disruption of the bacterial cell membrane
by the chlorhexidine molecules,increasing
its permeability and resulting in cell lysis
and death.
• Due to its strong antibacterial effects and
superior substantivity in the oral
cavity,chlorhexidine rinsing provides
significant reduction in VSC levels and
organoleptic ratings.

52. Essential oils:
• Previous studies evaluated the short
term effect of a listerine rinse compared
with a placebo rinse.
• Listerine was found to be only
moderately effective against oral
malodor(±25./. Reduction vs 10./. for
placebo of VSCs after 30min)and caused
a sustained reduction in the levels of
odorigenic bacteria.similar VSC
reduction were found after rinsing for 4
days.

53. Chlorine dioxide:
• Chlorine dioxide (ClO2) is a powerful oxidizing agent
that can eliminate bad breath by oxidation of hydrogen
sulphide, methylmercaptan, and the amino acids,
methionine and cysteine.
• Studies demonstrated that a single use of a ClO2
containing oral rinse slightly reduces mouth odor.

54. Triclosan:
• Triclosan a broad spectrum anti bacterial agent has
been found to be effective against most oral bacteria
and has a good compatibility with other compounds
used for oral home care.
• A pilot study demonstrated that an experimental
mouth rinse containing 0.15./.triclosan and 0.84./. Zinc
produced a stronger and more prolonged reduction in
mouth odor than an listerine rinse.

55. Aminefluoride/Stannous fluoride:
• The association of aminefluoride with stannous
fluoride (AmF/SnF2) resulted in encouraging reductions
of morning breath odor even when oral hygiene was
insufficient.
• Recently new evidence supporting the use of AmF/SnF2
rinse became available.The formulation showed not
only short term but also long term effect on malodor
indicators in patients with obvious malodor.

56. Oxidizing lozenges:
• Greenstein et al reported that sucking a lozenge with
oxidizing properties reduces tongue dorsum malodor
for 3hrs.
• This antimalodor effect may be caused by the activity
of dehydroascorbic acid, which is generated by
peroxide-mediated oxidation of ascorbate present in
the lozenges.

57. Baking soda:
• Baking soda dentifrices have been shown to confer a
significant odor- reducing benefit for time periods
upto 3hrs.
• The mechanisms by which baking soda produces its
inhibition of oral malodor is related to its bactericidal
effects.

58. Hydrogen peroxide:
• Suarez et al reported that rinsing with 3./. Hydrogen
peroxide produced impressive reductions (±90./.) in
sulphur gases that persist for 8 hrs.

59. Conclusion
• Clinical dentistry has responded to the publics demand for
treatment of oral malodor with the establishment of bad
breath clinics (Nieders M et al 1999) and multidiscipline
breath odor clinics (Delanghe G et al 1999) in which the
source of the oral malodor is determined and often
definitive treatment are provided.
• Because halitosis treatments are successful in cases of
physiologic or pathologic halitosis but unsuccessful in cases
of halitophobia,evalution of the psychological condition of
the halitosis patients is important.A questionnarie can be
useful for identifying patients with a psychological condition.

60. References
 Carranza .Clinical periodontology- 12th edition.
 Loesche W,Kazor C. Microbiology and treatment of
halitosis. Periodontology 2000 vol 28,2002.
 Kapoor U, Sharma G, Juneja M, Nagpal A. Halitosis
current concept on etiology, diagnosis and
management. European J of dentistry 2016 june vol
10 issue 2.
 R.Jaiganesh. Textbook of periodontics 1st edition

61. References
 Yaegaki k ,Jeffrey M. Examination, classification and
treatment of halitosis;clinical perspective. J of canadian
dental association march 2000 vol 66.
 Tonzetich J. Production and origin of oral malodor:A
review of mechanisms and method of analysis. J of
periodontol january 1977 vol 48
 Moharamzadeh K. Disease and condition in dentistry
:An evidence based reference,1st edition.

62. Thank you