This document provides an overview of halitosis (bad breath). It begins with definitions and classifications of halitosis. It then discusses the history, epidemiology, etiology and pathogenesis of halitosis, focusing on the role of volatile sulfur compounds from bacteria. Causes of halitosis are categorized as intraoral (e.g. periodontal disease, tongue coating) or extraoral (e.g. respiratory, gastrointestinal issues). Diagnostic tools and treatments are also summarized, including mechanical cleaning and use of antimicrobial agents to reduce oral bacteria.

1. Halitosis
Dept of Periodontics

2.  Introduction
 History
 Epidermology
 Classification
 Etiology
 Valatile sulphur compounds in the pathogenesis of halitosis
 Association between halitosis and periodontal disease

3.  Correlation between the presence of a pathogrnic
microflora in subgengival microbiota and halitosis
 Diagnosis of malodor
 Preventive measures
 Threatment
 Conclusion
 references

4.  Halitosis is a general term used to define an unpleasant or
offensive odour emanating from the breath regardless of
whether the odour originates from oral or non-oral sources.
 It is originates from 2 Latin words
- Halitus Breath
-Osis Disease

5.  It was described as a clinical entity by HOWE ( 1874)
 Halitosis should not be confused with the generally temporary
oral odour caused by intake of certain foods, tobacco or
medications

6.  Bad or foul breath
 Breath malodour
 Oral malodour
 Foetor ex-ore
 Foetor oris
 Stomato dysodia

7.  Halitosis is the general term used to describe a foul odour
emanating from the oral cavity, in which proteolysis, metabolic
products of the desquamating cells and bacterial putrefactions
are involved. -Marita et al., 2001
 Halitosis is the general term used to described any
disagreeable odour in expired air, regardless of whether the
odorous substances originate from oral or non-oral sources.
-Tangerman (2002)
 Halitosis is also termed as fetor ex ore or fetor oris. It is a foul
or offensive odour emanating from the oral cavity
-Carranza (2003)

8.  Unpleasant odour of the expired air weather the origin may be,
oral malodour specifically refers to such odour originating from
the oral cavity itself. - Jan Lindhe (2003)
 Breath malodour, defined as foul or offensive odour of expired
air, may be caused by a number of factors, both intra-oral
(gingivitis, periodontitis, sinus tract opening in oral cavity) &
extra-oral (nasal inflammation, chronic sinusitis, diabetes
mellitus, liver insufficiency etc.,) & can be linked to more
serious underlying medical problems including primary bleary
cirrhosis, uraemia, lung carcinoma, decompensate liver
cirrhosis & trimethylaminuria.
Quirynen Zhao, Avontroodl et al., (2003)

9.  Odours are essential clue in the creation & conservation of
social bonds, as they are located with cultural values.

 The problem of halitosis has been reported for many years.
 References were found in papyrus manuscripts dating back to
1550 BC.
 During Christianity, the devil’s supreme malignant odour smelled
of sulphur & it was presumed that sins produced a more or less
bad smell.

10.  A treaty in Islamic literature from the year 850 BC, talked about
dentistry, referring to the treatment of fetid breath the use of
Siwak when breath had changed or at any time when getting
out of bed.
 Buddhist monks in Japan also recommended teeth brushing &
tongue scraping before the first morning prayers.
 The Hindus consider the mouth as the body’s entry door and
therefore, insist that it be kept clean, mainly before prayers.
The ritual is not limited is not teeth brushing, but including
scraping the tongue with a special instrument and using mouth
wash. -Anand Choudhary (2012)

11.  Bad breath has been a common problem for thousands of
years.
 It is a considerable social problem.
 It is incidence remains poorly documented in most countries.
 In vast majority- the cause is originated from the oral cavity, i.e.
gingivitis, periodontitis, and tongue coating.

12.  Japan study 2,672 individuals , 6 - 23% of subjects had oral
malodour (VSC) as in expired air at some period during the
day -Miyazaki (1996).
 Another study in the United States involving individuals older
than 60 years found 24% oral malodour.
-Rosenberg (1996).
 The prevalence of persistence oral malodour in a Brazilian
study was reported to be 15% was nearly 3 times higher in
men than in women ( regardless of age ) and the risk was
slightly more than 3 times jigger in people over 20 years of age
compared with those aged 20 years or under, controlling for
gender.

13. Physiologic halitosis
1. Genuine halitosis
Pathologic halitosis
2. Pseudo halitosis.
3. Halitophobia.

14. PHYSIOLOGIC HALITOSIS : Cases
 morning breathe odour
 Tobacco
 Smoking
 Certain foods
 Medications
PATHOLOGICAL HALITOSIS :
 90% of the patients are common.
 It is cased by bacteria, volatile sulphur compounds.
- it is 2 types
A. Intra oral origin
B. Extra oral origin

15. A. INTRA ORAL ORIGIN :
• Poor oral hygiene, dental caries, periodontal
diseases in particular NUG, NUP, periodontitis,
dry socket, other oral infections, tongue coating
& oral carcinoma.
• The role of the tongue coating in the aetiology of oral
malodour has been extensively documented.
• Tongue coatings include desquamated epithelial cells, food
debries, bacteria and salivary proteins and provide an ideal
environment for the generation of VSCs and other
compounds that contribute to malodour.

16. B. EXTRA ORAL ORIGIN :
•It is 10-20%
•It is related to
 Gastro-intestinal diseases
Infections of malignancy in respiratory tract
Chronic sinusitis and tonsillitis
Systemic diseases like- liver , kidney, stomach & intestine

18. Systemic condition characteristic odous
 Diabetes mellitus Acetone, sweet fruity
 Renal failure Urine or ammonia
 Liver failure Fresh cadaver
 Tuberculosis or Foul, putrefactive
lung abscess
 Internal haemorrhage / Decomposed blood
 Blood disorders
 Fever, dehydration Odour due to xerostomia
and poor oral hygiene.

19. 2. PSEUDO HALITOSIS :
 It is common in apparently healthy individuals.
3. HALITOPHOBIA :
 It is also referred as delusional halitosis
 It is exaggerated fear of having halitosis.
 It is considered variant of nonsymptomatic hypochondrial
psychosis.

20.  Halitosis generally arises as a result of the bacterial
decomposition of food particles, cells, blood and some
chemical compounds of the saliva.
-Moss (1988)
 They are mainly ,
 Volatile sulphur compounds
 Hydrogen sulphide [H2S]
 Dimethy sulphide [(CH3)2S]
 Methyl mercaptan [(CH3)SH]

21.  Non sulphur compounds:
Diamines
Putrescence
Acetone and Acetaldehyde

22.  Common causes of halitosis, There 2 types
1.Local causes
A. Oral disease
B. Respiratory disease
C. Volatile foodstuffs
2. Systemic causes

23. A. ORAL DISEASE:
 Food impaction
 Acute necrotising ulcerative gingivitis
 Acute gingivitis
 Adult and aggressive periodontitis
 Pericoronitis
 Dry socket
 Xerostomia

24.  Oral ulceration
 Oral malignancy
B. RESPIRATORY DISEASE:
 Sinusitis
 Tonsillitis
 Malignancy
 Bronchietasis

25. C. VOLOTILE FOODSTUFFS:
 Garlic
 Onions
 Spiced foods

26. 2. Systemic causes:
 Acute febrile illness
 Leukaemia's
 Upper respiratory tract infections
 Helicobacter pylori infection
 Pharyngo-oesophageal diverticulum
 Gastro-oesophageal reflux disease

27.  Pyloric stenosis or duodenal obstruction
 Hepatic failure ( fetor hepaticus)
 Renal failure ( end stage)
 Trimethylaminiuria
 Hyper methioninaemia
 Menstruation ( minstrel breath).

28.  Major compounds of halitosis
 VSC’s- mrethyl mercaptan, hydrogen sulfide, dimethyl
sulfide, & dimethyl disulfide.
 Polyamides – putrescein , cadaverine, skatole, indole
 Short chain fatty acids – butyric acid, proionic acid,
valeric acid, isovaleric acid .
 Others – acetone, acetaldehyde and ethanol diacyl

29.  It increase the permeability of mucosa and crevicular
epithelium.
 It impair oxygen utilization by host cells, and reacts with
cellular proteins and interferes with collagen maturation.
 It also increases thee collagen solubility.
 It decrease the DNA synthesis.
 It increases the secretion of collagenases, prostaglandins
from fibroblasts.
 VSC reduce the intracellular pH, inhibit cell growth and
periodontal cell migration.

30. Diet
Bacteria
Epithelial cells
Peptides/ proteins
Amino acids
Putrefaction products
Oral malodour

31.  In 1981, Pitts et al studied the correaltions between odour scores
and microbiological findings in crevicular samples of
periodontally healthy subjects. They found that odours scores
were significantly correlated with the concentration of overall
bacterial populations and that higher levels of crevicular
bacteria were associated with greater odour scores.
 In patients with periodontitis, more sulphur-containing protein
substrate is available through increased exfoliation of epithelial
cell and crevicular effusion of leukocytes.
 Sato and colleagues found that the number of leukocytes
increased in the saliva of patients with perodontitis and that
the level of methyl mercaptan produced correlated with
bleeding on probing, pocket depth and gingival exudate.

32. SELF ASSESSMENT TESTS :
1. Whole mouth malodour ( cupped breath) :
The subjects are instructed to smell the odour
emanating from their entire mouth by cupping their
hands over their mouth and breathing through the
nose.
The presence or absence of malodour can be evaluated
by the patient himself/ herself.

33. 2. Wrist lick test :
Subjects are asked to extend their tongue
and lick their wrist in a perpendicular
fashion.
The presence of odour is judged by smelling the
wrist after 5 seconds at a distance of about 3
cm.

34. •3. Spoon test :
•Plastic spoon is used to scoop and scrape
material from the back region of the tongue.
•The odour is judged by smelling the spoon
after 5 seconds at a distance of about 5 cm
organoleptically.

35. •Dental floss test :
• Unwaxed floss is passed
through interproximal contacts.

37. •Saliva odour test :
•Involves having the subject expectorate
approx 1-2 ml of saliva into a petridish.
•The dish is covered immediately, incubated at 37◦c for 5
minutes and then prevented for odour evaluation at a distance
of 4 cm from the examiner’s nose.

38. 1. Orgaoleptic measurement
2. Gas chromatography (GC)
3. Sulphide monitoring
1.

39. Orgaoleptic measurement :
• Organoleptic measurement is a sensory test scored on the
basis of the examiner’s perception of a subject’s oral
malodour.
• Organoleptic measurement can be carried out simply by
sniffing the patient’s breath and scoring the level of
malodour.
• By measuring 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

40.  The tube is inserted through a privacy screen ( 50 cm-
70 cm) that separates the examiner and the patient.
The use of privacy screen allows the patient to believe
that they have undergone a specific malodour
examination rather than the direct-sniffing procedure.

41. Organoleptic Score (0-5) by Rosenberg, Mulloch et
al -1991.
 0- no appreciable odour
 1- barely noticeable odour
 2- Slight but noticeable odour
 3- moderate odour
 4- strong odour
 5- extremely foul odour.

43. VALATILE SULFIDE MONITOR :
This electronic ( Halimeter, InterScan, Chatsworth, Calif)
analyzes concentration of hydrogen sulphide and methyl
mercaptan, but without discriminating between them

44. Diamond probe :

45.  GAS CHROMATOGRAPHY :
 Gas chromatography performed with apparatus equipped
with a flame photometric detector, is specific for detecting
sulphur in mouth air.
 It measures directly the 3 valasal sulphur compounds-
methyl mercaptan, hydrogen sulfide and dimethyl sulfide.
 Gas chromatography is considered the gold standard for
measuring oral malodour.
 This device can analyze air, saliva, crevicular fluid for a
volatile component.
 Photo


46. Electronic nose :
•Tanaka M et al used these electronic
noses to clinically assess oral malodour
and examined the association between oral
malodour strength and oral health status.
photo

47. Halitox system :
• It is quick and simple
• It is detects VSCs and poly
amines

48. Ninhydrin method of detecting amine
compounds :
Iwanicka et al -2005 , showed
that level were higher in the
saliva of subjected suffering from
halitosis and lower in healthy
controls

49. BANA TEST:
Used to determine the proteolytic
activity of certain oral anaerobes that
contribute to oral malodour.

50.  TOPAS :
 it detects both VSCs and polyamines in the sample.
 It is directly proportional to the level of toxins in sample.
Procedure
The absorbent point is inserted into the pocket.
Left in place for 1 min
Submaerge the absorbent point tip in the toxin reagent
Wait for 5 minutes
See for yellow colour in the specimen on the scale of 0-5.

51.  PREVENTIVE MEASURES :
 Preventive measures rather than curative aspects are highly
recommended.
 Visit dentist regularly .
 Periodical tooth cleaning by dental professional.
 Brushing of teeth twice daily with appropriate brushing
techniques and for a duration of 2-3 mins.
 use of a tongue scraper to get rid of the lurking odour
causing bacteria in the tongue surface.
 Flossing after brushing to remove food particles stuck in
between to tooth surfaces.

52.  Limit intake of strong odour species.
 Limit suger and caffeine intake.
 Drink plenty of liquieds.
 Chew suger free gum for a minute when mouth feels dry.
 Eat fresh fibrous vegetables such as carrots.

53.  Treatment needs (TN) for halitosis have been
categorized into 5 classes in order to provide
guidelines for clinicians in treating halitosis patients:
 Treatment of physiologic halitosis (TN-1)
 Oral pathologic halitosis (TN-1 and TN-2 )
 Pseudo – halitosis ( TN-1 and TN-4) should be the
responsibility of a dentist
 However, treatment of extra-oral pathologic halitosis
(TN-3) or halitophobia (TN-5) should be undertaken
by a physician or medical specialist such as a
psychiatrist or psychologist.

55. 1. Chemical reduction of oral microbial load.
2. Rendering malodours gases non-volatile.
3. Masking the malodour.
4. Mechanical reduction of intraoral nutrients and
micro-organisms.

56. 1. Mechanical reduction of intra-oral nutrients
and micro-organisms:
• Tongue cleaning
• Tooth brush
• Inter-dental cleaning
• Professional periodontal
therapy
• Chewing gum.

57. 2. chemical reduction of oral microbial load :
• Chlorhexidine.
• Essential oils.
• Chlorine dioxide.
•Two – phase oil- water rinse.
•Triclosan.
•Aminefluoride /Stannous fluoride
•Hydrogen peroxide.
•Oxidising lozenges.

58. 3. Conversion of volatile compounds :
• Metal salt solution
• Tooth pastes
• Chewing gums

59. 4. Masking the malodour :
•Rinses
•Mouth sprays.
•Lozenges containing volatiles.
•Chewing gums

60. HERBAL TREATMENT:
• Herbals and essential oils can be
made into very effective mouthwash
remedies to sweeten breath and help
keep gums and teeth healthy fennel not
only improve digestion, but also can
reduce bad breath and body odour that
originates in the intestines.
• Cardamom tea contains circle, a
potent antiseptic that kills bad breath
bacteria and sweetens breath.

61. • Thymol – one of the constituents
of thyme, is contained in antiseptic
mouthwashes.
• Neem leaf powder – it can be
used as an effective tooth powder to
fight plaque and gingivitis when
mixed with astringent herb powders
and / or backing soda.
• A few drops of Tea tree oil, lemon
or peppermint essential oils can be
added to warm water for an effective
mouth rinse to fresh breath

62.  It is a common complaint that may periodically affect
most of the adult population.
 Oral malodour, which is commonly noticed by
patients, is an iportant clinical sign and symptom that
has many etiologics which include local and systemic
factors. It is often difficult for the clinician to find the
underlying pathologies.
 Although consultation and treatment may result in
dramatic reduction in bad breath, patients may find it
difficult to sense the improvement themselves.

63.  Carranza’s – 11th edition.
 Jan Lindhe – 6th edition .