Halitosis, a common complaint, is very general term which is used to describe any king of unpleasant odor emitted from the mouth regardless of the source of this odor i.e whether it is form an oral source or non-oral sources like the nasal passages or lungs. Halitosis caused by a variety of reasons including periodontal disease, bacterial coating of tongue, systemic disorders and different types of food. Regardless of the cause, affecting 50 to 65% of the world’s population Oral malodor is a generic description term for foul smell emanating from the mouth. The term does not imply any source or causation, perse. It is an aid to diagnosis Halitosis may lead to significant personal discomfort and social embarrassment. Halitosis is an extremely unappealing characteristic of sociocultural interactions and may have long‑term detrimental aftereffects on psychosocial relationships. With proper diagnosis, identification of the etiology, and timely referrals when needed, steps can be taken to create a successful individualized therapeutic approach for each patient seeking assistance. It is significant to highlight the necessity of an interdisciplinary method for the treatment of halitosis to prevent misdiagnosis or unnecessary treatment. The literature on halitosis, especially with randomized clinical trials, is scarce and additional studies are required. Since halitosis is a recognizable common complaint among the general population, the primary healthcare clinician should be prepared to diagnose, classify, and manage patients that suffer from this socially debilitating condition. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

1. Good morning
1

2. HALITOSIS
Guided by :
Dr. Vineeta Gupta
Dr. Sangita Agarwal
Dr. Vaibhav Tiwari
Dr. Shirish Kujur
Dr. Jyoti Wasti
Dr. Supriya Mishra
Dr. Varsha Goswami
Presented by
Dr. Neha Sahu
P.G. 1ST YEAR

3. CONTENTS:
1.Introduction
2. synonyms
3.Definition
4.Epidemiology
5.Classification
6.Etiology
7.Source of volatile compound
8.Role of VSC in pathogenesis
9.Causes of halitosis
10.Relationship of periodontal disease and oral
malodour
11.Ph and malodour
12.Bacteria and malodour
13.Assessment of halitosis
14.Management
15.Conclusion
16.References

4.  Halitosis, a common complaint, is very general term which is used to
describe any king of unpleasant odor emitted from the mouth regardless of
the source of this odor i.e whether it is form an oral source or non-oral
sources like the nasal passages or lungs.
 Halitosis caused by a variety of reasons including periodontal disease,
bacterial coating of tongue, systemic disorders and different types of food.
 Regardless of the cause, affecting 50 to 65% of the world’s population
 Oral malodor is a generic description term for foul smell emanating
from the mouth. The term does not imply any source or causation,
perse. It is an aid to diagnosis
 Halitosis may lead to significant personal discomfort and social
embarrassment.
INTRODUCTION

5. Halitosis is also called as
a. Bad breath
b. Fetor ex ore
c. Fetor oris (Glossary of Periodontal Terms – 2001)
d. offensive breath
e. oral malodor
f. Ozostomia (greek, ozo– to smell, and stoma – the mouth)
g. Stomatodysodia (greek, stoma – the mouth and disodia – bad
odor)
SYNONYMS

6.  Halitosis is derived from the Latin word ‘Halatasia’
meaning bad breath and the Greek word ‘osis’
meaning disease or condition
 According to Marita H et al (2001) 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
DEFINITION

7.  According to Carranza (2003) halitosis is also termed as fetor ex ore
or fetor oris. It is a foul or offensive odor emanating from the oral
cavity.
 According to Jan Lindhe (2003) breadth malodor means an unpleasant
odor of the expired air whatever the origin may be. Oral malodor
specifically refers to such odor originating from the oral cavity itself.

8. EPIDEMIOLOGY

9.  They indicate that moderate chronic halitosis affects
approximately one third of the groups,
 whereas severe halitosis may involve less than 5% of the
population.
 It is clear that halitosis is a prevalent problem, and that the
dental profession needs to take its responsibility in managing
it.

10. CLASSIFICATION OF
HALITOSIS

11. Classification of Halitosis (Miyazaki et
al.,1999):
1.• Halitophobia.
2.• Pseudo-phobia.
3. • Genuine halitosis.
A. Pathologic halitosis.
Oral Extra-oral
B Physiologic halitosis

12. Classification of Halitosis (Tangerman
et al., 2010): •
1.Intra-oral
2. Extra- oral.
A. Blood borne.
B. Non-blood borne

13. Type 0: Physiologic Halitosis-It is present in health.
Type 1: Oral Halitosis: It is of oral origin. The most common causes for oral halitosis are: • Poor
oral hygiene. • Plaque stagnation areas. • Gingivitis, tongue coating. Other possible origins of oral
halitosis include: • Periodontal disease. • Acute necrotizing ulcerative gingivitis, • Osteoradionecrosis. •
Large carious cavities. • Blood/thrombi (e.g. extraction sockets). • Ulceration • Interdental food packing.
• Oral prostheses (dentures, orthodontic appliances, bridges).
Type 2: Airway Halitosis- This halitosis originates from the respiratory tract itself (rhinosinusitis,
tonsillitis, pharyngitis, laryngitis, bronchitis, pneumonia), anywhere from nose to alveoli.
Type 3: Gastroesophageal Halitosis. It is caused by leakage of odorant volatiles from the stomach
via the esophagus to the mouth and nose.
Type 4: Blood-borne Halitosis. This type of halitosis is where volatile chemicals in the systemic
circulation can transfer to exhaled breath during alveolar gas exchange and cause halitosis.
Type 5: Subjective Halitosis- Subjective halitosis is a halitosis complaint without objective
confirmation of halitosis by others or halitometer readings.
Classification of Halitosis (Aydin & Harvey
Woodworth., 2014):

14.  Multiple contributing factors in the same patient are
classified as a combination of the different types. Eg: Type
1+4+5.
 The authors claim that this classification is representative of
the multifactorial etiology of halitosis
 It is mechanistic, logical, understandable, memorable,
flexible, clear, concise and precise than the old
classifications.

15. Kapoor U, Sharma G, Juneja M, Nagpal A. Halitosis: Current concepts
on etiology, diagnosis and management. Eur J Dent. 2016 Apr-
Jun;10(2):292-300.

16.  Term used when breath malodour really exists and can be
diagnosed by organoleptically or by measurement of the
responsible compound.
 Genuine halitosis can be physiological or pathological in
nature. Pathological halitosis can arise from local (intraoral)
causes or systemic (extraoral) causes
Genuine halitosis

17. Genuine halitosis
Physiological
and
Transient
Causes
Morning breath-associated malodor is transient in nature and is due to
the overnight activity of bacteria on oral debris, which is increased due
to hyposalivation.
Other physiological causes of halitosis are starvation and menstruation,
which influence the production of VSCs.
It is transient and caused by food intake,smoking or medication
Oral malodor can also occur postoperatively, following third molar
surgery.
Patients undergoing fixed orthodontic treatment have a high degree of
predisposition to oral malodor, indicating the need to observe more
stringent oral hygiene protocols.

18.  Is an “Olfactory Reference Syndrome” which is a variant of
Monosymptomatic Hypochondrial Psychosis in which the patients suffer
from an olfactory delusion that they are emitting a foul smell form the
mouth or elsewhere in the body.
 Some of these person who take his very seriously may actually become very
depressed to the extent of thoughts of suicide.
 Gustatory and olfactory hallucinations can also occur in patients with
schizophrenia, Temporal lobe epilepsy or organic brain diseases such as
cerebral tumor.
Delusional Halitosis

19. Pseudohalitosis refers to a condition
in which the patient reports with a
complaint of bad breath but does not
actually have it. This group of patients can
be convinced that they do not suffer from
halitosis with counseling and by explaining
the results of the examination.
Halitophobia is the fear of having bad breath.
Patients with halitophobia generally suffer from
some form of psychiatric syndrome that is linked to
social phobia. Patients with halitophobia are never
convinced by the clinician’s claim that the halitosis
does not exist and require psychiatric consultation.
Halitophobia - characterized by patient persistent belief
that he/she has halitosis ,despite reassurance ,treatment and
counseling

20. ETIOLOGY OF HALITOSIS
 The condition is multifactorial in etiology and may involve both oral (80-90%) and
non-oral (10-20%) conditions.
 localized factors play the most important role in the majority of cases, and 90% of oral
odor originates from the oral cavity as a result of microbial metabolism on the tongue
dorsum, in the saliva, and in the periodontal pockets.
 Volatile sulphur compounds (VSC), namely hydrogen sulphide (H2S) and methyl
mercaptan (CH3SH) are the main cause of oral malodor.
 These substances are by-products of the action of bacteria on proteins.
 Gram-positive bacteria produce little or no malodor; most Gram-negative bacteria are
potent producers of odoriferous compounds. (Niles and Gaffar;1995)

22. sulfur
compounds
aromatic
compounds
nitrogen-
containing
compounds
amines
short-chain
fatty acids
alcohols or
phenyl
compounds
aliphatic
compounds
ketones
SOURCE OF VOLATILE
COMPOUND

23. Family group Compound name
Volatile sulfur compounds (VSCs) Hydrogen sulfide
Methyl mercaptan
Dimethyl sulfide
Volatile aromatic compounds and amines Indole, Skatole ,Pyridine ,Picoline, Urea,
Ammonia, Methylamine, Dimethylamine,
Trimethylamine, Putrescine, Cadaverine
Short/medium-chain fatty acids or
organic acids
Propionic acid, Butyric acid ,Acetic acid,
Valeric acid ,Isovaleric acid, Esanoic acid
Alcohols Methanol, Ethanol ,Propanol
Volatile aliphatic compounds Cyclopropane, Cyclobutane ,Pentane
Aldehydes and ketones Acetaldehyde ,Acetone ,Benzophenone,
Acetophenone

24.  Volatile sulfur compounds (VSCs) are mainly responsible for intra-oral
halitosis.
 They produce by bacteria by enzymatic reactions of sulfur-containing amino
acids which are L-cysteine and L-methionine
 VSC are all thiols, containing SH group which is formed when the oxygen atom
in the hydroxyl group is replaced by sulphur.
 VSC are byproducts of gram-negative bacterial metabolism of sulphur
containing amino acids. This metabolism is of putrefactive in nature and leads
to oxygen depletion.

25. ENZYMATIC WAY OF THE HYDROGEN SULFIDE AND METHYL MERCAPTAN production
Proteinogenic amino acids Enzyme Products
L-Cysteine L-cysteine desulfhydrase Pyruvate + ammonia +
hydrogen sulfide
L-Methionine L-methionine α-deamino-γ-
mercaptomethane-lyase
α-Ketobutyrate + ammonia +
methyl mercaptan

26. Role of VSCs in the pathogenesis
Increases the permeability of oral mucosa and crevicular epithelium
VSCs break the disulphide bond linkage between proteoglycans and
glycoproteins in the extracellualr matrix
These compounds impairs oxygen utilization by host cells, and reacts with
cellular proteins, and interfere with collagen maturation .It also increases
collagen solubility.
Decreases DNA synthesis and proline transport reduction of total protein
content and collagen synthesis of fibroblasts
Increases the secretion of collagenases, prostaglandins from fibroblasts,
ultimately leading to conversion of mature collagen to a product
susceptible for enzymatic degradation.
Reduce the intracellular pH inhibit cell growth and periodontal cell
migration

27.  The volatile sulfur components reach high levels, several hours after food
intake and increases with age, tongue coating and periodontal inflammation
(VSC normal limit for social acceptance, 75 ppb).
 VSCs can diffuse and penetrate deeply into tissues, damage the epithelium, basement
membrane and underlying lamina propria. It can be toxic to periodontal tissues even at
low concentrations.
 Decreasing the concentration of VSCs could be a significant adjunct to periodontal
therapy and prevention of periodontal disease.
 Apart from VSCs, certain non-sulfur containing compounds such as
cadaverine, putrescine, indole and skatole have also been implicated in the
foul smell of oral malodor, but their contribution is thought to be limited.

28.  some of the bacteria produce hydrogen sulfide and methyl mercaptan
from serum
 The bacteria which are the most active VSC producers are

29.  The other VSC is dimethyl sulfide which mainly responsible for
extra-oral or blood-borne halitosis but it can be a contributor
to oral malodor.
 Ketones such as acetone, benzophenone, and acetophenone
are present in both alveolar (lung) and mouth air;
 indole and dimethyl selenide are present in alveolar air.
 These compounds are also factors for Halitosis occurrence
and it may be simply classified their origins into three
categories;
1. oral causes
2. non-oral causes
3. the other causes.

30. CAUSES OF HALITOSIS
Poor oral hygiene
Food impaction
Tongue coating
Periodontal pockets
Acute necrotizing
ulcerative gingivitis
Gingivitis
Adult and aggressive
periodontitis
Pericoronitis
Vincent’s disease
Drysocket
Xerostomia
Oral ulceration
Oral malignancy
Exposed tooth pulps
Nonvital tooth with
fistula
Dentures/prostheses
REASONS OF HALITOSIS
WHICH IS ORIGINATED
FROM ORAL CAVITY

31.  Oral conditions may provide a suitable environment for bacterial
growth.
 The number of bacterial species, which are found in oral cavity, are over
500 and most of them are capable to produce odorous compounds
which can cause halitosis.
 In these conditions, poor oral hygiene plays a key factor for
multiplication of halitosis causative bacteria and causes an increase in
halitosis.
 These bacteria include especially Gr-negative species and proteolytic
obligate anaerobes and they mainly retained in tongue coating and
periodontal pockets.
 Among healthy individuals, with no history of halitosis and no
periodontal diseases, some show halitosis because of retention of
bacteria on the tongue surface.
 These bacteria degrade organic substrates (such as glucose, mucins,
peptides, and proteins present in saliva, crevicular fluid, oral soft tissues,
and retained debris) and produce odorous compounds.

32. RELATIONSHIP OF PERIODONTAL
DISEASE TO ORAL MALODOR
Patients with chronic peridontitis and pocket formation frequently suffer from unpleasant mouth odor
associated with accumulated debris and an increased rate of putrefaction.
The fetid odor is characteristic of acute necrotizing ulcerative gingivitis is an extreme example of
malodor from periodontal pathogens.
Periodontal conditions that favor the bacterial growth and retention of debris contribute to oral
malodor.
Interproximal spaces and periodontal pockets are conducive to anaerobic growth and
microenvironments for production of VSCs. These subgingival and inter proximal periodontal malodors
make a significant contribution to overall malodor.

33. In an evaluation
of oral malodor
in healthy
subjects and
patients with
periodontal
disease, Yaegaki
and Sanada
found that
bleeding on
probing and
periodontal
pocket depth is
positively
correlated with
the production of
VSCs.
Several studies
done by
Tonzetich et al in
1977 suggested
that periodontitis
increase the
severity of oral
malodor and
possible reason
for this is the
increased amount
of substrate
available to be
metabolized.
In patients with
periodontitis,
more sulfur-
containing
protein substrate
is available
through
increased
exfoliation of
epithelial cells
and crevicular
effusion of
leukocytes.
In addition to
being major
contribution to
oral malodor,
VSCs have been
implicated in the
disruption of oral
mucosa and may
contribute the
progression of
periodontal
disease

34. Respiratory disease Foreign body (nose/lung)
Sinusitis
Tonsillitis
Tonsilloliths
Malignancy (e.g., antral, pharyngeal)
Bronchiectasis
Subphrenic abscess
Gastrointestinal and hepatic disease
Pharyngeal pouch
Zenker diverticulum
Pyloric stenosis or duodenal obstruction
Aorto-enteric anastomosis
Gastroesophageal reflux disease
and Helicobacter pylori infection Hepatic failure (foetorhepaticus)
Hematological Leukemias
Renal disease Renal failure (usually end-stage renal failure)
Endocrine Diabetic ketoacidosis Menstruation (menstrual breath)
Metabolic Trimethylaminuria Hypermethioninemia
Non-oral cause of halitosis

35. RESPIRATORY DISEASE AND HALITOSIS
 Respiratory system problems can be
divided into upper and lower
respiratory tract problems.
 Bacterial activity in this pathology
causes halitosis which leads to
putrefaction of the tissues or causes
tissue necrosis and ulcerations and
production of malodorous gases,
which are expired causing halitosis.
sinusitis
antral
malignancy
cleft palate
foreign
bodies in
the nose or
lung
nasal
malignancy
subphrenic
abscess
nasal
sepsis
tonsilloliths
tonsillitis
pharyngeal
malignancy
lung infections
bronchitis
bronchiectasis
lung
malignancy

36.  Gastrointestinal diseases causing halitosis may cause excessive flatulence
or Helicobacter pylori infection causes gastric ulcers and VSC levels
increase in oral breath.
 Levels of VCS’s in oral breath may be higher in patients with erosive than
nonerosive oesophagogastro-duodenal mucosal disease although VSC
levels are not influenced by the degree of mucosal damage
 Moshkowitz et al found a strong association between the occurrence and
severity of halitosis and GERD.
GIT AND HALITOSIS
Pyloric
stenosis
duodenal
obstruction
aorto-enteric
anastomosis
pharyngeal
pouches
zenker’s
diverticulum
hiatal hernia
cause food
retention
Reflux
esophagitis

37. Volatile food
stuffs
Garlic
Onions
Spiced foods
Drugs
Alcohol
Tobacco
Betel
Solvent abuse
Chloral hydrate
Nitrites and
nitrates
Dimethyl
sulfoxide
Disulphiram
Phenothiazines
Amphetamines
Suplatast tosilate
Paraldehyde
OTHER CAUSES
OF HALITOSIS

38. pH and oral malodor
 Fresh collected saliva form healthy individuals has a pleasant smell but upon incubation, the pH of
the collection turns towards alkalinity and results in putrid odor.
 McNamara et al (1972) incubated saliva for 24 hours at 37C in tubes containing:
1. Brain heart infusion broth
2. Buffer at pH either at 6.5 or 7.5
3. Whole saliva
 There was no odor in the tubes incubated at pH 6.5, but at pH 7.5 the odor was strong and putrid.
 When fresh broth at pH 6.5 and 7.2 were cross-inoculated with material from the above two broths,
the putrid odor was noted only in tubes at pH 7.2.

39. When glucose was
added to the tubes
containing whole
saliva and then
incubated for 24 hours
at 37C to make the
pH acidic, there was
no malodor formation.
If no glucose was
added or if the level of
the glucose was kept
low so as to be
insufficient to make
the samples acidic,
substantial malodor
resulted.
It was clear form these
experiments that a pH
above neutrality was
essential for the
formation of malodor

40. Relationship between gram-negative bacteria and oral malodor was demonstrated by the
experiments of McNamara et al (1973) who showed that:
1. Rise in odor in whole saliva incubated with no sugar corresponded with the rise the
ratio of gram-positive to gram-negative organisms.
2. If glucose is added at a concentration of 20mM to make the pH acidic, the decrease in
odor formation is matched by emergence of a flora of mainly gram-positive organisms.
3. If glucose is added at minimal concentration of 2mM, a concentrate, which is too low to
prevent the saliva form being alkaline, odor formation once more occurs and also there
is shift in favor of gram-negative members of oral flora.
Bacteria and oral malodor:

41. The gram-positive bacteria in the mouth depend largely upon CHO
group, as their main energy source for growth, which they can get
readily form carbohydrates in the diet.
 On the other hand gram-negative bacteria derive energy form both
carbohydrates and proteins.
 Thus it is evident that gram negative bacteria would be selected and
this results in odor formation, when no or only insufficient glucose
or other fermentable carbohydrates are added to incubated saliva
whereas with more carbohydrate addition one would expect gram
positive bacteria to be selected.

42. Sweet smell:
o Fruity smell of acetone/ decomposing apples - is associated
with uncontrolled diabetes/ diabetic ketoacidosis.
o Fruity alcoholic smell – Use of alcohol.
o Fruity – pear-like, acrid smell – chloral hydrate, paraldehyde.
o Penetrating wintergreen odour – Methyl salicylate
o Aromatic, pungent odour - Ethchlorvynol
Characterstics breath odour

43. 43
 Fishy smell:
o Fishy odour - Due to high levels of trimethylamine due to lack of trimethylamine
oxidase in the liver.
o Fishy, rancid butter or boiled cabbage odour – Hypermethioninemia.
 Musty smell:
o Musty fish, raw liver/feculent – Fetor hepaticus – Hepatic failure (mercaptans,
dimethyl sulphide)
 Feculent smell/ foul odor – Intestinal obstruction, oesophageal diverticulum
 Urine-like/ ammoniacal smell – Uremia (ammonia)
 Foul/ putrid smell – Lung abscess, Emphysema, Intranasal foreign body

44. • Severe, bad breath – Trench mouth (Vincent’s angina), Amphetamines
• Sweaty feet/ cheesy smell – Isovaleric academia (odour of sweaty feet
syndrome)
• Bitter almond smell – Cyanide
• Burned rope – Marijuana
• Camphor – Naphthalene
• Coal gas/ stove gas – Carbon monoxide
• Disinfectant – Phenol, Creosote
• Garlic – Phosphorus, Arsenic, Tellurium, Parathion, Malathion

45.  Self assessment
 Subjective measurement – organoleptic assessment
 Objective instrumental analysis
a. Halimeter
b. Diamond probe
c. Gas chromatography
d. Mass spectrometry
e. BANA test
f. β-Galactosidase test
g. Salivary incubation test
h. Ninhydrin method
i. Chemical sensor
ASSESSMENT OF HALITOSIS

46. SELF ASSESSMENT
The following self assessement tests can be done-:
1. Whole mouth malodor (cupped breath test)
2. Wrist lick test
3. Spoon test
4. Dental floss test
5. Salivary odor test
Before their first visit to the office, patients are
instructed to abstain from
 Food, breath fresheners, and oral hygiene for 6
hours;
 Smoking for 12 hours;
 Scented cosmetics for 24 hours;
 Onions, garlic, and spicy foods for 48 hours

47. Whole mouth malodor (Cupped breath):
The subjects are instructed to smell the
odor emanating from their entire mouth by
cupping their hands over their mouth and
breathing through the nose. The presence or
absence of malodor can be evaluated by the
patient himself/herself.
Wrist lick test:
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 3 cm.

48.  Spoon test:
Assesses the odor emanating from the dorsum of the posterior
tongue;
A plastic spoon is used to scrape and scoop material from the back
region of the tongue.
The odor is judged by smelling the spoon after 5 seconds at a
distance of about 5 cm organoleptically.
 Dental floss test:
Dental floss odor test is used to determine the presence of interdental
plaque odor.
Unwaxed floss is passed through interproximal contacts of the
posterior teeth
Examiner assesses the odor by smelling the floss at a distance of
approx. 3 cm.
 Saliva odor test:
Involves having the subject expectorate approx. 1-2 ml of saliva into
a petridish.
The dish is covered immediately, incubated at 370 C for five minutes
Presented for odor evaluation at a distance of 4 cm from the
examiner’s nose.

49. The oldest way for unpleasant odor detection is by smelling with
the nose.
This measurement is considered to be the gold standard for
measuring and assessing bad breath
Measurement of unpleasant odors by smelling the exhaled air of
the mouth and nose is called organoleptic measurement.
It is the simple way for the detection of halitosis.
 The measurement method is the organoleptic test; 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 (the purpose
of using a pipette is to lessen the intensity of expiring air)
the severity of odor is classified into various scales, such as a 0-
to 5-point scale
SUBJECTIVE MEASUREMENT
ORGANOLEPTIC ASSESSMENT

50. OrganolepticScores
Tonzetich et al (1976)
0-Absence of odor
1-Detectable odor
2-Slightly objectionable
3-Slightly to moderately objectionable
4-Moderately objectionable
5-Moderately to strongly objectionable
6-Strongly Objectionable

51. 0: Absence of odor – Odor cannot be detected
1: Questionable odor – Odor is detectable, although the examiner
could not recognize it as malodor
2: Slight malodor – Odor is deemed to exceed the threshold of
malodor recognition
3: Moderate malodor – Malodor is definitely detected
4: Strong malodor – Strong malodor is detected, but can be
tolerated by examiner.
5: Severe malodor – Overwhelming malodor is detected and
cannot be tolerated by the examiner (Examiner instinctively
averts the nose)
Fixed distance odor intensity scale
(Rosenberg and mcculloch 1992)

52. Grade 0 – No malodor detected
Grade 1 – Malodor is clearly detected, if the observer
approached to a distance of about 10cm to the mouth of
the patient.
Grade 2 - Malodor is clearly detected, if the observer
approached to a distance of about 30cm to the mouth of
the patient.
Grade 3 - Malodor is clearly detected, if the observer
approached to a distance of about 100 cm to the mouth of
the patient
Distance malodor scale:

53.  An organoleptic assessment at the first appointment should always be
performed separately for oral and nasal air.
 This will help to differentiate intra-oral halitosis from extra-oral halitosis.
 It should be performed in the morning and patient should be instructed to
refrain from following procedures to get the most reliable measurement
A. No cosmetic products like fragrances, after-shave, scented lip-stick or other
masking products for 24 hours
B. No smoking for 12 hours before assessment.
C. No antibiotic treatment for atleast 3 weeks (better 6-8 weeks) before the
examination.
D. No drinking coffee, tea or juice or eating in the morning prior to the oral
examination.
E. Avoid eating strong foods for atleast 48 hours before assessment.
F. No tongue cleaning for 24 hours before the first breath assessment.

54. HALIMETER/SULPHUR
MONITERING
 Halimeter (Interscan, Chatsworth, USA) which is used chairside and
provides both the patient and the professional an idea of the breath
situation.
 A halimeter score of ≥ 75 ppb is recognized as clearly detected halitosis.
 It is important to understand that VSC assessment, as well as other breath
diagnostic tools are subjected to great variation, especially between
different hours of the day, and are strongly affected by confounders.

55.  portable sulfide monitor used to test for levels of sulfur
emissions (to be specific, hydrogen sulfide) in the mouth air.
 When used properly, this device can be very effective at
determining levels of certain VSC-producing bacteria.
 drawbacks :
1. other common sulfides (such as mercaptan) are not
recorded as easily and can be misrepresented in test results.
2. Certain foods such as garlic and onions produce sulfur in the
breath for as long as 48 hours and can result in false
readings.
3. The Halimeter is also very sensitive to alcohol, so one
should avoid drinking alcohol or using alcohol-containing
mouthwashes for at least 12 hours prior to being tested.
4. This analog machine loses sensitivity over time and requires
periodic recalibration to remain accurate.

56.  This technology is specifically designed to digitally measure
molecular levels of the three major VSCs in a sample of mouth
air (hydrogen sulfide, methyl mercaptan, and dimethyl
sulfide).
 It is accurate in measuring the sulfur components of the
breath and produces visual results in graph form via computer
interface.
 It is an excellent means of accurately determining the
levels of specific compounds.
 It is so precise that it can be used to measure minute
differences in VSC levels before and after mouth rinses or
other oral hygiene procedures.
 It separates and analyzes compounds that can be vaporized
without decomposition; samples are collected from saliva,
tongue coating, or expired breath.
Gas Chromatography

57.  In this method, measurements are performed and equipped with a flame
photometric detector or by producing mass spectra.
 The concentration of each VSC (ng/10 mL mouth air) was determined based
on a standard of hydrogen sulfide and methyl mercaptan gas prepared with a
permeater.
In the gas chromatography
method, the patient close
the mouth and hold air 30 s,
then mouth air (10 mL) is
aspirated using a gas-tight
syringe.
After collections of samples,
it is injected into the gas
chromatograph column at
70°C.
 The results are precise and reliable, but this method takes a long time to run
 the results of the gas chromatography method show high correlation to
organoleptic measurements but gas chromatography has high sensitivity and it can
detect low concentration molecules

58.  The OralChroma™ (CHM-1, Abimedical, Kawasaki, Japan) is a chairside
instrument bases on a gas chromatograph, which detects and discriminates the
three most important VSCs .
 This information can be included in the diagnosis. For example, a high
concentration of CH3SH compared to H2S may indicate periodontitis, and an
increased H2S level may indicate a problem with oral hygiene.
 Further, increased levels of [CH3]2sh may indicate extra-oral halitosis .
 The measurements are more reproducible and reliable than organoleptic
measurements, and even extremely low gas concentrations can be detected.
 But the device is expensive and the results are not shown in real time; it takes
8 min before the results are shown.
 Recently, a new model has been introduced (CHM-2) with a reduced analysis
time (4 min).

60. DIAMOND PROBE/CHEMICAL SENSOR
 Sensors are integrated into the periodontal probe.
 Probe is placed directly into the periodontal pocket or
tongue.
 It has an electrical control unit and a disposable
sensor tip that combines a standard Michigan 0 styled
dental probe with a sulphide sensor which responds to
the sulfides present in the periodontal pocket.
 Through the sulfide-sensing probe, sulfide compounds
generate an electrochemical voltage and this voltage is
measured by an electronic unit. The measurement is
shown on device’s screen as a digital score.

61.  Using the new chemical sensors, ammonia and methyl
mercaptan compounds can be measured from breath
air and some new types of sensors measure each
volatile sulfur-containing compounds separately.
 The sensitivity is similar to gas chromatography and
results of the measures are highly close to organoleptic
scores so chemical sensors are called the electronic
nose.
ELECTRONIC NOSE Error. Please try
again
No odour
Slight odour
Moderate odour
Strong odour

62.  The BANA test is practical for chair-side usage.
 It is a test strip which composed of N-benzoyl-DL-arginine-2-
naphthylamide and detects short-chain fatty acids and
proteolytic obligate gram-negative anaerobes, which hydrolyze
the synthetic trypsin substrate and cause halitosis.
 It detects especially Treponema denticola, P. gingivalis, and T.
forsythensis that associated with periodontal disease.
 By using the BANA test, we can detect not only halitosis, but
also periodontal risk assessment.
BANA TEST

63.  To detect halitosis, the tongue is wiped with a cotton
swab. For periodontal risk assessment, the subgingival
plaque is obtained with a curette.
To evaluate, the samples are placed on the BANA test
strip, which is then inserted into a slot on a small
toaster-sized incubator.
The incubator automatically heats the sample to 55°
for 5 min.
If T. denticola, P. gingivalis, or B. forsythus are
present, the test strip turns blue or the bluer.
Deepening of the blue color shows existence of the
higher the concentration and the greater the number
of organisms.

64. Quantifying β-galactosidase activity
 Deglycosylation is the removed link of glycosyl groups from glycoproteins.
Deglycosylation of glycoproteins are the initial step in oral malodor
production.
 By deglycosylation of glycoproteins, proteolytic bacteria degrade proteins
which are especially salivary glycoproteins and cause halitosis.
 Proteolysis of glycoprotein depends on the initial removal of the carbohydrate
side-chains which are O- and N-linked carbohydrates.
 β-Galactosidase is one of the important enzymes which are responsible for the
removal of both O- and N-linked carbohydrate sidechains.

65.  β-Galactosidase activity can be easily determined by the use
of chromogenic substrates absorbed onto a chromatography
paper disc.
 In order to measure β-galactosidase activity, saliva was taken
in a paper disc and discoloring of the paper disc changes based
on β-galactosidase activity and these changes are recorded; no
color: 0, faint blue color: 1, moderate to dark blue color: 2.
Sterer et al. found a positive correlation between organoleptic
scores and β-galactosidase.

66.  The salivary incubation is one of the assessment methods to measure
halitosis indirectly.
 First time, Marc Quirynen et al. (2003) carried out a study to evaluate
salivary incubation and halitosis.
 To measure halitosis with the salivary incubation test, saliva was
collected in a glass tube and then incubating the tube at 37°C in an
anaerobic chamber under an atmosphere of 80% nitrogen, 10%
carbon dioxide, and 10% hydrogen for 3-6 h.
 After incubation, an examiner evaluates the odor.
 The most important advantage is that the salivary incubation test has
much less influenced by external parameters such as smoking,
drinking coffee, eating garlic, onion, spicy food, and scented
cosmetics.
Salivary incubation test

67. Ninhydrin method
 Gases which are components of halitosis were produced from the breakdown of peptides and
glycopeptides by bacterial putrefaction in the oral cavity.
 During this process, peptides are hydrolyzed to amino acids which further are metabolized to
amines or polyamines.
 These molecules cannot measured by sulfide monitoring. Hence, the ninhydrin method was used
for examination of amino acids and low-molecular-weight amines.
 Levels of low-molecular-weight amines may give information for halitosis caused from
bacterial putrefaction of low-molecular-weight amines.
 The ninhydrin method is simple, rapid, and inexpensive.

68.  This method is a kind of colorimetric reaction. The collected saliva is
mixed with isopropanol and centrifuged.
 The supernatant is diluted with isopropanol, buffer solution (pH 5),
and ninhydrin reagent.
 The mixture was refluxed in a water bath for 30 min, cooled to 21 °C,
and diluted with isopropanol.
 Light absorbance readings were determined using a spectrometer.
The results of ninhydrin methods show a significant correlation with
organoleptic scores and sulfide monitor measurements

69. Treatment options include:
Usage of masking products (counter-actives).
Mechanical reduction of microbes and their substrates.
Chemical reduction of microbes.
Chemical neutralization of odorous compounds including VSCs.
Patient with non-oral halitosis should be referred to
otorhinolaryngologist or internal medicine for appropriate
treatment.
TREATMENT

70. Masking products:
• It is just a transient relief measure.
• Commercial products like mints, toothpastes, mouth rinses, sprays and chewing
gums with pleasant flavors and fragrances.
• Menthol and other active ingredients are usually active only for few hours after
use.
Some chewing gums contain special anti-odor ingredients. Chewing fennel seeds,
cinnamon sticks, mastic gum, or fresh parsley are common folk remedies.

71. It can be achieved by a solid breakfast, improving hyposalivation, using chewing gums, brushing the teeth, flossing,
using toothpicks, tongue cleaning and professional oral health care.
Passage of solid food like hard, dry bread over the tongue surface could remove the coating. 60% reduction in
hydrogen sulphide and 83% reduction in methyl mercaptan levels were observed 1 hour after breakfast.
Salivary levels could reduce physiologically at the night, lowered by mouth breathing or snoring. It could be
treated by salivary stimulation.
Chewing gums can mechanically stimulate salivary flow and cleans the tooth surfaces. But without active
ingredients, they have a modest decrease.
Brushing the teeth exclusively was not very effective in reducing VSCs in morning breath or oral malodour
scores.
Mechanical reduction of microbes and their
substrates:

72. Tongue cleaning: It should be carried out gently with low force to avoid unnecessary
tissue trauma. Forcible cleaning can induce plasma membrane disruption and induce
micro-bleeding, which can be detected by hemoglobin in saliva.
Various instruments can be applied with gentle pressure to scrape off the tongue coating.
1. • Brushing the tongue with a tooth paste was more effective. Studies reveal that VSCs
could be reduced for atleast one hour by brushing the teeth, tongue and mouth rinse
with water.
2. • Mechanical cleaning the posterior parts of the tongue is uncomfortable due to gag
reflex.
3. • There is a visible reduction in organoleptic scores and levels of VSCs with brushing
than scraping the tongue.
4. • Thus, tongue cleaning can reduce the substrates for putrefaction rather than the
bacterial load.

73. Chair side in-office dental care consists of:
A)Oral prophylaxis
B) Tissue conditioning with sustained delivery antimicrobials.
C) Surgical intervention if required
D)Appropriate restorations as per requirement
E) Reduction of all plaque retentive areas or ‘Plaque Traps’
F) Regualr monitoring on the ‘Halimeter’ to control VSC levels.
.

74. Home care regimen primarily consists of:
A)Tooth brushing with Triclosan dentifrice at least twice daily.
B)Tongue brushing with an aernating with Triclosan.
A)Tooth brushing with Triclosan dentifrice at least twice daily.
B)Tongue brushing with an antibacterial
C)Adequate flossing
D)Mouth rinsing with Chlorhexindine alternating with Triclosan.

75.  Teeth cleaning using hand scalers, electric toothbrush and interdental brush,
cleaning dentures and oral mucosa with sponge brush significantly reduced
methyl mercaptan levels.
 Full-mouth disinfection with scaling, root planing and chlorhexidine
application resulted in a faster and prolonged reduction of organoleptic
scores, even after 2 months.
 Oral prophylactic procedures such as supra and sub gingival scaling and
elimination of periodontal pockets should be undertaken (Miyazaki et al,
1999; Porter & Scully, 2006).
 Carious teeth have to be restored. Teeth with periapical pathology should
be endodontically treated.
 Abscesses of acute nature should be managed by using appropriate
antibiotics.
Professional oral care:

76.  Toothpastes and mouthrinses with antimicrobials could reduce the
microorganisms chemically.
 It includes chlorhexidine, triclosan, essential oils and cetylpyridinium
chloride. Other agents include L-trifluoromethionine and
Dehydroascorbic acid.
 0.2% Chlorhexidine and zinc formulations could reduce the VSCs in
breath odour and organoleptic scores.
 Better results were observed with chlorhexidine in combination with
teeth and tongue brushing.
 0.2 – 0.3% Triclosan could be beneficial in reducing the hydrogen
sulphide producing bacteria and reducing organoleptic scores.
 A formulation of triclosan/copolymer/ sodium fluoride in 3 weeks
randomized double blind trial by Hu et al. 2005 seemed to be particularly
effective in reducing VSC, oral bacteria, and halitosis.
Chemical reduction of micro-
organisms:

77.  Quarternary ammonium compounds like benzalkonium chloride and 0.2%
cetylpyridinium chloride inhibit bacterial growth; can reduce hydrogen
sulphide and methyl mercaptan levels.
 A systematic review, published by Cochrane, compared the effectiveness of
mouth rinses in controlling halitosis. The researchers concluded that mouth
rinses containing CHX and CPC could inhibit production of VSCs while mouth
rinses containing chlorine dioxide and zinc may neutralize the sulfur
compounds producing halitosis. (Nasser M et al 2008)
 Combined effects of zinc and CHX were studied in a study conducted in 10
participants, Zinc (0.3%) and CHX (0.025%) in low concentration led to 0.16%
drop in H2 S levels after 1 h, 0.4% drop after 2 h and 0.75% drop after 3 h
showing a synergistic effect of the two. (Thrane PS et al 2007)
 L-trifluouromethionine can inhibit mercaptan production by bacteria and
reduce halitosis.
 Full-strength oxidizing lozenges can reduce malodor by peroxide-mediated
oxidation of ascorbate into dehydroascorbic acid. But formulations are rare due
to instability of Vitamin C derivative.

78.  Toothpastes, mouthrinses, lozenges and other products can
reduce halitosis by chemically neutralizing odorous
compounds like VSCs.
 It includes metal ions like zinc, sodium, tin and magnesium
that interact with sulphur and form insoluble sulphides.
 The proposed mechanism is that the metal ions oxidize thiol
groups in VSCs.
 Oxidizing agents change the environment needed to
metabolize sulphur-containing aminoacids into VSCs.
Chemical neutralization of
odorous compounds:

79. Sorbitol lozenges with zinc gluconate (0.1%, 0.2% and 0.5%) could be used. These
lozenges can be added with aspartame and Vitamin C/ Ascorbate to improve the bitter taste
caused by high concentration of zinc.
Zinc containing mouth washes are also available. The addition of 2mg zinc acetate in
mouth washes resulted in significant reduction of VSCs.
Sodium bicarbonate or baking soda can reduce VSCs. It may have a bactericidal effect or
transform VSCs into a non-malodorous form.
In rare instances, Epsom salt (Magnesium sulphate) and Stannous fluoride could be used
for reducing halitosis.
Mouthrinse with 3% hydrogen peroxide caused upto 90% reduction in VSCs for 8 hours.

80. Chlorine dioxide can oxidize methionine and cysteine, which are the
precursors for VSCs. A mouthwash containing 1% sodium chlorite was more
effective in cysteine challenge testing
Iminium is a non-metal oxidation catalyst. It can neutralize cysteine,
hydrogen sulphide and methyl mercaptan. It is present in sanguinarine.
Oral antibiotic rinses with metronidazole and nystatin could be used for
short term reduction of halitosis.
Newer preparations containing enzymes are claimed to freshen breath. It
includes proteases like papain and lipases like glycoamylase.
Synthetic mouthwashes contain ethyl alcohol. The alcohol acts as a
disinfectant and can eliminate oral malodor by eliminating oral bacteria
involved in production of VSCs

81. Chlorhexidine and zinc – as a mouthrinse was effective
for atleast 9 hours.
Cetylpyridinium chloride and zinc – synergistic effect on
levels of VSCs.
Chlorhexidine, Cetylpyridinium chloride and zinc lactate
was efficient.
Sodium bicarbonate with 2% zinc, Zinc chloride with
sodium chlorite and zinc with sanguinarine were also
found to be effective.
Some of the effective combinations to
reduce halitosis include:

82. Role of botanical extracts:
 Eugenol is widely used in various mouthwashes. It is derived from clove oil,
cinnamon and basil. Eugenol acetate inhibits oral malodor. It is in use for
over 2000 years. It is potent against gram positive, gram negative and
acid-fast bacteria. Its refreshing effect can neutralize the malodor related
to tobacco smoking. It is also used in treatment of halitosis-related to dry
socket.
 Tannins have antibacterial effect and reduce bacterial load in the oral
cavity. It is non-toxic and does not cause dessication or inflammation. They
can be used for patients with diabetes or xerostomia, when alcohol based
mouthwashes could not be administered.
 The volatility of CH3N could be reduced by betel leaves. Allylpyrocatechol
derived from Piper betel leaves or inflorescences is used to remove
halitosis. It is a form of betel quid chewing and used with tobacco, areca
fruit and slaked lime in many countries. The compounds in betel quid
induce pre-cancerous lesions on frequent usage. But, the non-toxic
allylpyrocatechol can be used to control halitosis and reduce obligate
anaerobes.

83. Other phenolic compounds which inhibit oral microbes and reduce bad
breath are catechin and resveratrol extracted from licorice (Glycyrrhiza
spp.), Camellia spp., Acacia catechu, Polygonum spp., Areca catechu,
Potentilla fragarioides, Rheum, Prunus, Ginkgo biloba, Machilus, Elaeagnus,
Apocynum and Geranium including phytic acid, Echinacea angustifolia,
Pestacia lentiscus, lavender (Lavendula angustifolia) and sage (Salvia
officinalis) extracts.
Essential oils like mint oils, oils of anise, fennel, basil and juniper berry have
both masking and antibacterial effects in controlling malodor. Other oils
include eucalyptol, thymol, menthol, tea tree oil are used with methyl
acetate and methyl lactate. Bay, bergamot, caraway, cedar, cinnamon,
citronella, clove, coriander, laurel, lavender, lemon, marjoram, mustard,
orange, orris, parley, pimento, pine, rosemary, sage, sassafras, terpentine,
thyme and witch hazel oils were used in several dosage forms to reduce
oral malodour.

84. Regular use of probiotics can help to control halitosis. Kang et al reported
reduction of VSCs levels by F.nucleatum after taking Weissella cibaria. It
could be due to hydrogen peroxide producting by W.cibaria that inhibits
bacteria.
Reduction of anaerobes by increasing the proportion of acidogenic
microbes could reduce malodour. End products of carbohydrate
metabolism by acidogenic streptococci can inhibit the growth of
anaerobes.
Fermentable alternatives to sucrose like Inulin that is fermented to acid
that are less cariogenic. Similarly, S.salivarius also suppresses VSCs by
competing for colonization with pathogenic bacteria. It could be used as a
probiotic with intention of colonization of the throat and control of local
infection.
Role of Probiotics in halitosis:

85. There are very little reports about management of non-
oral etiologies.
Tonsillectomy to remove the foci of malodor bacteria on
crypts of tonsils.
Eradication of H. pylori infection. Usually, omeprazole
and amoxicillin reduce sulphide levels and organoleptic
scores in such dyspeptic patients.
A study by Han et al showed 640% greater odds of
having dimethyl sulphide defined halitosis in patients with
Hepatitis-B infection
Non-oral management:

88. Halitosis is an extremely unappealing characteristic of sociocultural
interactions and may have long-term detrimental aftereffects on
psychosocial relationships.
With proper diagnosis, identification of the etiology, and timely
referrals when needed, steps can be taken to create a successful
individualized therapeutic approach for each patient seeking
assistance.
It is significant to highlight the necessity of an interdisciplinary
method for the treatment of halitosis to prevent misdiagnosis or
unnecessary treatment. The literature on halitosis, especially with
randomized clinical trials, is scarce and additional studies are
required.
Since halitosis is a recognizable common complaint among the
general population, the primary healthcare clinician should be
prepared to diagnose, classify, and manage patients that suffer from
this socially debilitating condition. Financial support and
sponsorship Nil. Conflicts of interest There are no conflicts of
interest.
CONCLUSION:

89.  Carranza 10th edition
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 Rösing CK, Loesche W. Halitosis: an overview of epidemiology, etiology and
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 Porter SR, Scully C. Oral malodour (halitosis). BMJ. 2006 Sep
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 Mokeem SA. Halitosis: a review of the etiologic factors and association with
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