This presentation describes halitosis, its etiology, diagnosis preventive measures and its treatment.

1. ORAL
MALODOUR
D R M A N I S H A
S I N H A
I I N D Y R P G
RAJARAJESWARI DENTAL COLLEGE AND HOSPITAL

2. CONTENTS
 Introduction
 Definitions
 Classification
 Microbiology
 Etiology
 Volatile Sulphur
compounds
 Diagnosis
 Preventive Measures
 Treatment
 Association between
Halitosis and Periodontal
Disease
 Conclusion
 References

3. Halitosis is a medical term, first coined by the
George Lambert in 1921, to describe oral
malodor or bad breath.
Malodor is the
scientific term for bad breath and has its origin from
Latin (“malus,” bad, evil + “odorem, odor,” smell,
scent) and defined as a distinctive smell that is
offensively unpleasant.
INTRODUCTION

4. DEFINITIONS
• Halitosis is also termed
as fetor ex ore or fetor
oris. It is a foul or
offensive odor
emanating from the oral
cavity.
CARRANZA(2003)
Unpleasant odor of the
expired air whatever the
origin may be. Oral
malodour specifically refers
to such odor originating
from the oral cavity itself.
JAN LINDHE(2003)
Halitosis is the general term used to
describe a foul odor emanating from
the oral cavity, in which proteolysis,
metabolic products of the
desquamating cells and bacterial
putrefaction are involved.
MARITA ET AL., 2001

5. SYNONYMS
Bad or foul breath
Breath malodour
Oral malodour
Foetor ex-ore
Foetor oris
Stomato dysodia

6. CLASSIFICATION

7. TEMPORARY
PERMANENT

8. GENUINE:-
Physiologic
halitosis
Pathologic
halitosis

9. PSEUDO-HALITOSIS
HALITOPHOBIA

10. OLFACTORY
REFERENCE
SYNDROME
Olfactory reference syndrome (ORS) is defined as the psychiatric condition characterized by
persistent preoccupation about body odour accompanied by shame, embarrassment,
significant distress, avoidance behaviour and social isolation

11. • When tricyclic antidepressant medication is used, xerostomia can appear, leading to an
increase of halitosis awareness. Patients with symptoms of halitophobia or ORS, should
not be treated by dental practitioners or by ENT specialists, but should be referred to
psychologists or even to psychiatrists.
• Selective Serotonin Reuptake Inhibitor, which increases the concentration of serotonin
in the brain, can help to treat this phenomenon.

12. MICROBIOLOGY OF ORAL HALITOSIS

13. AETIOPATHOGENESIS OF ORAL
MALODOUR

14. • In a recent study of 2000 patients who visited a multidisciplinary bad breath clinic in Leuven,
Belgium, an oral cause was found in nearly 76% of the patients, especially tongue coating
(43%), gingivitis/periodontitis (11%) or a combination of the two (18%). Pseudo-halitosis/
halitophobia was diagnosed in 16% of the cases; and ENT/extra-oral causes were found in 4%
of the patients.

15. • Physiologic
Diet — vegetables such as onions,
garlic,
radishes, turnips
Beverages such as tea and coffee
Alcohol-based wine, brandy,
whisky, liqueurs and beer
Dairy products that contain protein
Dehydration, starvation,
constipation, diarrhea
CAUSES

16. Pathologic
Local oral
Tongue coating (poor oral hygiene)
Gingivitis-ANUG, acute herpetic
gingivostomatitis
Periodontitis
Xerostomia (e.g. from drugs, Sjögren’s
syndrome, radiotherapy, chemotherapy)
Pericoronitis
 Candidiasis
 Oral sepsis
 Oral cancer
 Bone diseases — dry
socket, osteomyelitis,
osteonecrosis
 Debris under dental
appliances (e.g., dentures,
 removable orthodontic
appliances, bridges)

17. EXTRAORAL (NONORAL SYSTEMIC
CONDITIONS)
ENT
Postnasal drip
Tonsillitis, tonsilloliths
Rhinitis, rhinoliths
Sinusitis, antral malignancy
Nasal polyps, carbuncle,
carcinoma
Nasal obstruction/foreign
bodies

18. • Other systemic factors
• Lung — chronic bronchitis,
bronchiectasis, pulmonary abscess,
• tuberculosis, pneumonia, emphysema,
secondary infection,
• bronchial carcinoma, pulmonary infarcts
and its sequelae
• Renal — renal failure, uremia
• Hepatic — cirrhosis, gall bladder
dysfunction, hepatic failure
• Carcinomas (various types) — bronchial
carcinoma
• Diabetic ketoacidosis — acetone breath
of uncontrolled diabetes
 Gastro-intestinal — esophageal refl ux,
pyloric stenosis,
 hiatal hernia, malabsorption syndrome,
enteric infection
 Other systemic conditions – dehydration,
starvation,
 Sjögren’s syndrome, leukemias and other
blood dyscrasias
 Medications —
antihistamines/decongestants,
antidepressants,
anxiolytics, anticholinergics, antipsychotics
etc

19. METABOLIC DISORDERS
Trimethylaminuria - fishy
odour.
• According to Whittle et al., this genetic disease is the
largest cause of undiagnosed body odour.
• is a disorder in which the volatile, fish-smelling compound,
trimethylamine accumulates and is excreted in the urine,
but it is also found in the sweat and breath.
• Because many patients have associated body odours or
halitosis, trimethylaminuria sufferers can meet serious
difficulties in their social context, leading to isolation and
even depression.

20. • Oesophagus. Only in specific cases, this is the origin of malodour. When a Zenker’s
diverticulum is present, a chronic unpleasant odour appears. The incidence of this
phenomenon is less than 0.1% and it is only diagnosed in patients over 65 years of
age. Also bleeding of the oesophagus can cause a musty odour. When severe
regurgitation is determined, halitosis will be present.
• Stomach. Infections with Helicobacter pylori can cause peptic ulcers. There is no 100%
clear correlation found between these ulcers and halitosis. In vitro studies show
significant VSC production by H. pylori.
• Intestines. In cases of intestinal obstruction, a faecal mouth odour may be detectable,
as found in two siblings with extrinsic duodenal obstruction caused by congenital
peritoneal bands.

23. Formation of volatile sulfur compounds:
• VSCs have also been implicated in the progression of periodontal disease. VSCs aggravate
periodontitis by: Disrupting the oral mucosa (pocket epithelium), thereby increasing bacterial
invasion. Impede wound-healing by altering metabolism of fibronectin. Increase the release
of interleukin- 1 and PGE2.
• High VSC concentration might be a predictor of periodontal disease progression.
• Gram-negative, proteolytic bacteria are believed to play an essential role in the formation of VSCs,
although Gram-positive bacteria such as Peptostreptococcus species have also shown ability to
produce VSCs in vitro (McNamara et al. 1972; Persson 1989; Claesson 1990; Persson et al. 1990)
VOLATILE SULPHUR COMPOUNDS

27. General medical questionnaire
 Specific halitosis questionnaire

30. AT THE 1ST EXAMINATION
WRIST LICK TEST
A. SELF ASSESSMENT
Subjects are asked to extend
their tongue and lick their
wrist in a perpendicular
fashion.
The presence of odor is
judged by smelling the wrist
after 5 seconds at a distance
of about 3cm.

32. ORGANOLEPTIC ASSESSMENT
• considered as the “gold standard” to diagnose halitosis in a clinical setting.
• The trained judge or clinician smells a series of different air samples of the patient as
follows: Oral cavity odor is examined on the subject as he is made to refrain from
breathing while the examiner places his nose 10 cm from the oral cavity.
• The judge smells the expired air as the patient counts from 1 to 10 as this is done to
promote drying up of the palate and tongue mucosa, expressing VSCs.

33.  By inserting a translucent tube (2.5 cm diameter, 10 cm length) into the
patient’s mouth and having the person exhale slowly, the breath, undiluted by
room air, can be evaluated and assigned an organoleptic score.
 The tube is inserted through a privacy screen (50cm-70cm) that separates the
examiner and the patient.The use of a privacy screen allows the patient to
believe that they have undergone a specific malodour examination rather than
the direct-sniffing procedure.

34. ORGANOLEPTIC SCORES
1. TONZETICH J ET AL (1976) 2. ORGANOLEPTIC SCORES (0- 5) BY ROSENBERG ,
MULLOCH ET AL 1991
1
0 – absence of odor
1 - detectable
2 – slightly objectionable
3 – slightly to moderately
objectionable
4 – moderately objectionable
5 – moderately to strongly
objectionable
6 – strongly objectionable

35. PORTABLE VOLATILE SULFIDE
MONITOR
• Halimeter analyzes the concentration of hydrogen sulfide and
methylmercaptan, but without discriminating them. The
examination should preferably be done after at least 4 hours
of fasting and after keeping the mouth closed for 3 minutes.
The mouth air is aspirated by inserting a drinking straw fixed
on the flexible tube of the instrument.
• The straw is kept about 2 cm behind the lips, without touching
any surface and while the subject keeps the mouth slightly
open and breathes normally. The sulfide meter uses a
voltametric sensor that generates a signal when exposed to
sulfur-containing gases, especially hydrogen sulfide. Absence
of breath malodor leads to readings of 100 ppb or lower.

36. GAS CHROMATOGRAPHY
• . This device can analyze air, ( incubated) saliva, or crevicular fluid for any volatile
component. About 100 compounds have been isolated from saliva and tongue
coating, with most identified, from ketones to alkanes and sulfur-containing
compounds to phenyl compounds. Elaborate gas chromatography is only available in
specialized centers but is especially useful for identifying nonoral causes.

37. DARK-FIELD OR PHASE-CONTRAST
MICROSCOPY.
• Gingivitis and periodontitis are 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.

38. SALIVA I N C U B A T I O N TEST.
• Reveals VSCs and other compounds such as indole, skatole, lactic acid, methylamine,
diphenylamine, cadaverine, putrescine, urea, ammonia, dodecanol, and tetradecanol
• By adding some proteins, such as lysine or cysteine, the production of respectively cadaverine or
hydrogen sulfide is dramatically increased.
• Organoleptic evaluation (or assessment of the VSCs) of the saliva headspace offers promising
perspectives for monitoring treatment results.

39. ELECTRONIC NOSE.
• A new device that is being developed which has the
capacity of the human nose is referred to as the electric
nose.
• The electronic nose is an intelligent sensing device that
uses an array of gas sensors which are overlapping
selectively along with a pattern reorganization
component.
Merits
• Can identify the specific components of an odor.
• Can analyze the chemical make-up of the compound.
• Smaller.
• Less expensive.
• Easier to use.

40. .
BANA TEST
• It is a chair side, enzyme-based assay, which is used to determine the
proteolytic activity of certain oral anaerobes that contribute to oral malodor and
which are considered as active H2 S producers.

42. PREVENTIVE MEASURES
Visit dentist regularly
Periodical tooth cleaning by dental
professional.
Brushing of teeth twice daily
Use of a tongue scraper
Flossing after brushing to remove food
particles stuck in between the tooth surfaces
Limit intake of strong odour
substance
Limit sugar and caffeine
intake.
Drink plenty of liquids.
Chew sugar free gum for a
minute when mouth feels dry.

43. TREATMENT

45. • Mechanical reduction of intraoral nutrients and microorganisms.
• Chemical reduction of oral microbial load
• Rendering the malodorous gases nonvolatile.
• Masking the malodor

46. • A systemic review by van der Sleen et al., demonstrated that tongue brushing or
tongue scraping have the potential to successfully reduce breath odour and tongue
coating. Due to tongue cleaning, the taste seems to Improve again.
• A/c to a study by Rosenberg M et al, chlorhexidine (CHX): CHX is the most efficient
molecule against plaque. Rosenberg showed that rinsing with 0.2% CHX causes a
reduction of 43% in VSCs and of 50% in the organoleptical scores on a day-long basis.

47. Essential Oils
• Previous studies evaluated the
short-term effect (3 hours) of a
Listerine rinse (which contains
essential oils) compared with a
placebo rinse." '-
• Listerine was found to be only
relatively effective against oral
malodor (±25% reduction vs.
10% for placebo) and caused a
sustained reduction in the levels
of odorigenic bacteria.
C h l o r i n e D i o x i d e
Is a powerful oxidizing agent that
can eliminate bad breath by
oxidation of hydrogen sulfide,
methylmercaptan, and the amino
acids methionine and cysteine.
A study by Frascella J et al,
demonstrated that single use of a
chlorine dioxide– containing oral
rinse slightly reduces mouth odor
by 29% after 4 hrs.
.

48. Two-Phase Oil-
Water Rinse
Rosenberg et al designed
a two-phase oil-water
rinse containing CPC that
was shown to result in
daylong reduction in oral
malodor.
Triclosan
A broad-spectrum antibacterial
Agent, has been found to be
effective against most oral
bacteria and has a good
compatibility with other
compounds. It has
BACTERIOSTATIC action
targets bacteria primarily by
inhibiting fatty acid
synthesis.
Used for oral home care.
An 84% reduction of VSCs
after 3 h is proved in a study

49. Aniine fluoride / Stannous
Fluoride.
The association of
aminefluoride with stannous
fluoride (AmF/Snl 2)
resulted in encouraging
reductions of morning breath
odor, even when oral
hygiene is insufficient.
Hydrogen Peroxide.
Suarez et aL reported that rinsing with 3'%
hydrogen peroxide (H2O,) produced
impressive reductions (±90%) in sulfur
gas that persisted for 8 hours.
O x i d i z i n g Lozenges
Greenstein et al." reported that sucking a
lozenge with oxidizing properties reduces
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 present in
the lozenges.

50. SUBSTANCES CAUSING CONVERSION OF VSCS
1. METAL SALT SOLUTIONS
 Young A. et al (2001) – special effect of
Halita may result from the VSC conversion
ability of Zinc.
Commercially available Zn Salts: Toothpastes –
Trioral, Viadent Advanced care, Aim TC,
Close-up TC, Mentadent Gumcare.
----- Mouthwashes – Lavoris, Listermint
2. TOOTHPASTES :
Brushing the dorso-posterior surface of the
tongue with a dentifrice was more effective
than brushing the teeth in reducing VSCs.
(Tonzetich (1976)
Dentifrices with triclosan have shown to
reduce OL scores significantly. (Gerlach et al
1998, Niles 1999, Hu et al 2003 & Farrell in
2006)
Dentifrices with Baking Soda (Brunette et
al 1998), essential oils (Olshan et al 2003) &
stannous fluoride (Gerlach et al 1998)
seemed to be effective.

51. 3. CHEWING GUM : Tsunoda et al (1996) investigated the
beneficial effects of chewing gum containing tea extracts.
Epigallocatechin (EGCg) is the main deodorizing agent
among tea catechins. The chemical reaction between EGC
& CH3SH results in nonvolatile product.
Waler S.M (1997) compared different concentration of zinc
in a chewing gum and found that 2mg Zn acetate
containing chewing gum remained in the mouth for 5min
resulted in immediate reduction in VSC levels of upto 45%
but long term effect was not mentioned.

52. • Treatment with rinses, mouth sprays and lozenges containing volatiles with a
pleasant odor have only a short term effect. (Reingewirtz N. et al 1999 & Replogle
W.H. in 1996) Eg- Mint – containing lozenges.
• Another pathway is to increase the solubility of malodorous compounds in the
saliva by lowering the Ph of the saliva. (low ph increases the solubility of VSCs)
MASKING THE ORAL
MALODOR

53. VSCs aggravate the periodontitis process by:
increasing the permeability
of the pocket and mucosal
epithelium
Methyl mercaptan enhances
interstitial collagenase
production, interleukin-
1(IL-1) production by
mononuclear cells,
impede wound healing.
Reduction in total protein
synthesis
ASSOCIATION BETWEEN HALITOSIS AND
PERIODONTAL DISEASE

54. • 1981, Pitts et al studied the correlations between odor scores and microbiological findings in crevicular
samples of periodontally healthy subjects. They found that higher levels of crevicular bacteria were associated
with greater odor scores.
• A porcine non-keratinized sublingual mucosa was exposed to hydrogen sulfide and methyl
mercaptan, its permeability increases by 75% and 103%, respectively (Ng & Tonzetich 1984).
• Methyl mercaptan reduces collagen synthesis by 39%, while increases intracellular degradation of
newly synthesized collagen by 62% (Johnson et al. 1996).
• When porcine epithelial tissues were treated with methyl mercaptan, the tissues demonstrated
extensive impaired and dead cells (Johnson et al. 1992a).
These findings suggest that VSC are directly toxic to epithelial tissues and can facilitate bacterial
invasion into underlying connective tissue.

55. TREATMENT & MANAGEMENT
OF HALITOSIS PATIENTS IN
PERIODONTAL DISEASE

56. • Individuals who flossed daily had significantly less odor level than those who did not (Rosenberg
1996). Hence, it is a good motivation tool to have patient smell the floss after each use.
• When the patients’ conventional hygiene is adequate but their oral malodor problem exist, tongue
brushing is also an effective way (Rosenberg & Leib 1995).
• If the patients still suffer from oral malodor after maintaining good oral hygiene, rinsing or gargling
with an effective mouthwash may be advised.
• Quirynen et al. (1998) monitored patients with oral malodor. Patients with srp + mouthrinse showed
significant malodour reduction compared to group with srp alone

57. • Miyazaki et al.(1999) established the recommended examination for halitosis and a classification
of halitosis with corresponding treatment needs.
Accordingly, different treatment needs (TN) have been described for the various diagnostic
categories.
• The responsibility for the treatment of physiologic halitosis (TN-1), oral pathologic halitosis (TN-
1 and TN-2), and pseudo-halitosis (TN-1 and TN-4)
resides on dental practitioners.
• However, extra-oral pathologic halitosis (TN-3) and halitophobia (TN-
5) should be managed by a physician or medical specialist and a psychiatrist or psychological
specialist.

58. Rosenberg M, McCulloch CA. Measurement of oral malodor: Current methods and future prospects. J Periodontol
1992;63:776-82.

59. RECALL THERAPY

60. CONCLUSION

62. REFERENCES
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• Halitosis: Current concepts on etiology, diagnosis and management Uditi Kapoor

63. THANK YOU……