All of my Lectures are based on information purposes. It is based on the viva explanation and understanding basis. Basically for 4th BDS Professional Year.

1. Good Afternoon
Folks
Good Afternoon
Folks1

2. Oral Malodour
Dr. Abhishek Gaur
BDS, MDS, (Ph. D.)
Periodontist & Implantologist
R. R. Dental College & Hospital
Umarda, Udaipur (RAJ.)2
Oral Malodour

3. Breath odor can be defined as the subjective perception
after smelling someone’s breath.
• It can be pleasant, unpleasant or even disturbing.
Synonyms:
• Breath malodor
• Halitosis
• Bad breath,
• Fetor ex ore
Carranza (11th edition)
Breath malodor means an unpleasant odor of the expired
air, whatever the origin may be.
Jan Lindhe (4TH edition)3

4. Halitosis is derived from:
• The Latin word “Halitasia” --bad breath
• The Greek word “Osis” -- disease or condition
• Halitosis, also termed fetor ex ore, fetor oris, and
oral malodor, is foul or offensive odor emanating
from the oral cavity.
Carranza (9th edition)
3rd most frequent reason for seeking dental aid,
following tooth decay and periodontal disease.
(Loesche W J et al 2002)
4

5. Classification
ADA classification based on the etiological
pathways involved :
Extrinsic pathways - Tobacco, alcohol and foods
like onions, garlic and certain spices.
Intrinsic pathways – Oral origin (90 %)
– Systemic origin (10 %)
5

6. Classification based on the origin of halitosis:
1. Due to local factors of Pathological origin.
2. Due to local factors of Non-pathological origin
3. Due to systemic factors of Pathological origin
4. Due to systemic factors of Non-pathological
origin
5. Due to systemic administration of Drugs
6. Due to xerostomia.
(Dominic 1982)
6

7. Etiology
90% of breath malodor originates from the oral cavity. Gingivitis ,
periodontitis and special tongue coating are the predominant causative
factors. The remaining 10% has systemic or local causes.
In general, one can identify two pathways for bad breath, the first one
involves an increase of certain metabolites in the blood circulation (due
to the systemic disease), which will escape via the alveoli of the lungs
during breathing.
And, the second pathways involves an increase of either the bacterial
load of the amount of substrates for these bacteria at one of the lining
surfaces of the oropharyngeal cavity, the respiratory tract, or the
oesophagus.
7

8. For oral malodor, the unpleasant smell of the breath mainly
originates from VSCs (volatile sulphur compounds)
especially hydrogen sulphide, methyl mercaptan and less
important dimethyl-sulphide.
-however in certain condition, indole, skatole and volatile
organic acids like butyric or propionic acid.
Most of these compounds results from the proteolytic
degradation by oral micro-organisms of peptides present in
saliva, interdental plaque, postnatal drip, and blood.
For the extra oral cases other than VSCS may be involved,
which has not been identified yet.
8

9. Causes
Intraoral causes-
Physiologic
1. Diet
2. Beverages
3. Alcohol
4. Dairy products that contain protein
5. Dehydration, constipation, salivation, diarrhoea
Pathologic
6. Tongue coating
7. Gingivitis
8. Periodontitis
9. Periocoronitis
10. Xerostomia
11. Oral sepsis
12. Oral cancer
9

10. Extra oral causes:
ENT
1. Postnasal drip
2. Sinusitis
3. rhinitis
4. Tonsilitis
5. Nasal polype, carbuncles
6. Nasal obstruction
Systemic factors:
Lung- chronic bronchitis, bronchitis, lung abscess
Renal- renal failure, uraemia
Hepatic- cirrhosis, gallbladder dysfunction
10

11. Bacteria associated with malodor
11

12. Fundamentals/
Physiology of malodor
detection
Breath of a person contains up to 150 different molecules.
Perception of the molecules depends on the following factors:
1. Olfactory response (odor of molecule)
2. Threshold concentration (conc. at which it can be detected)
3. Odor power (conc. to increase it score by one limit)
4. Volatility (express when they become volatile)
5. Substantivity (capacity to stay present)
12
Fundamentals/
Physiology of malodor
detection

13. Diagnosis of Malodor
1. History taking and medical questionnaire
2. Clinical and Laboratory Examination
3. Self-Examination
4. Oropharyngeal Examination
5. Organoleptic Rating
6. Portable Volatile Sulfur Monitor
7. Gas Chromatography
8. Dark-Field or Phase-Contrast Microscopy
9. Saliva Incubation Test
10.Electronic Nose
11.Chair-Side Test 13
Diagnosis of Malodor

14. MEDICAL HISTORY
•Proper diagnostic approach should starts with
a thorough questioning about the medical
history and about all the relevant pathologies
for breath malodor.
•Patient history should be discretely and
intermittently noted.
14

15. Clinician should ask about the:
1.Frequency (eg.every month).
2.Time of appearance during the day(eg.after meal
indicate the stomach hernia)
3.Time when the problem first appeared.
4.Whether others (non-confidants) have identified the
problems(to exclude imaginary breath odor).
5.Which medications are taken and whether there are
possible contributing factors such as mouth breathing,
dry mouth ,allergies and nasal problems.
15

16. CLINICAL
EXAMINATION
16

17. SELF EXAMINATION
It is done when intra-oral cause has been determined.This can
motivate the patient to continue the oral hygiene instructions.
Following self testing can be used:
•Smelling a metallic or non odorous plastic spoon after
scraping the back of the tongue.
•Smelling a toothpick after introducing it in an interdental
area.
•Smelling saliva spit in a small cup or spoon.
•Licking the wrist and allowing it to dry.
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18. OROPHARNGEAL EXAMINATION
1.Inspection of deep carious lesion.
2.Interdental food impaction.
3.Wounds.
4.Bleeding of gums.
5.Periodontal pockets.
6.Tongue coating.
7.Dry mouth.
8.Tonsils and pharynx for tonsillitis and pharyngitis.
18

19. ORGANOLEPTIC
RATING
“Gold standard” in the examination of breath odor. Easiest
and most often used method assets by judge. In an
organoleptic evaluation ,a trained and preferably calibrated
judge sniffs the expired air and assesses whether it is
unpleasant by using an intensity rating, normally from 0 to 5,
as proposed by Rosenberg and McCulloch.It is thus solely
based on the olfactory organs of the clinician.
19

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21. The judge smells a series of different air samples as follows:
1) Oral cavity odor
2) Breath odor
3) Saliva
4) Tongue coating
5) Nasal breath odor 21

22. The specific character of odor can provide additional information
such as:
The smell of sulphur can be indicated for an intra-oral origin of
halitosis.
The smell of sulphur can however also point out to liver disease
(accumulation of ketones).
The smell of rotten apples has been associated with unbalance
insulin-dependent diabetes, which leads to the accumulation of
ketones.
A “fish odor” can suggest kidney insufficiency characterised by
uraemia and accumulation of di-methylamine and tri-
methylamine.
22

23. Portable Volatile Sulfur Monitor
The portable volatile sulphur monitor (Halimeter) is an electronic device that
analyses the concentration of hydrogen sulphide and methyl mercaptan but
without discriminating them.
• The mouth air is aspirated by inserting a drinking straw fixed on the flexible
tube of the instrument.
• The straw is kept about 2cm behind the lips, without touching any surfaces,
while the subject keeps the mouth slightly open and breathes through the
nose.
• The sulphur meter uses a volta-metric sensor that generates a signal when
exposed to sulphur-containing gases.
• Readings-
• Absence of breath malodor: 150 ppb or less.
• Elevated concentrations of VSCs: 300-400 ppb.
• Using a recorder or specific software, a graphic presentation can be obtained,
called a haligram. 23

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25. Advantages-
• Easy to use as a chair side test.
• Relatively inexpensive.
• Patients are usually less embarrassed.
• Absence of odor in case of halitophobia can be more convincingly
proven.
Drawbacks-
• It detects only sulphur compounds and thus is used only for intra-oral
causes of halitosis.
• It has no specificity and thus cannot discriminate among the different
sulphur compounds.
• The sensitivity for methyl-mercapton is very low (5 times lower than
for hydrogen sulphide) and is almost insensitive to dimethyl sulphide.
• Ethanol and other compounds can disturb the measurement.
25

26. Gas Chromatography
It can analyse air, saliva, or crevicular fluid for different chemical
compounds present in
them.
Advantage-
• It can detect virtually any compound when using adequate materials and
conditions.
• It has a very high sensitivity and specificity.
• Useful for identifying non-oral causes of breath malodor.
Drawbacks-
• Only available in specialised centres.
• Expensive.
• Needs trained personnel. 26

27. 27

28. Oral Chroma (Portable “Gas
Chromatograph”)
It is a recently introduced device for periodontal clinics.
It has a capacity to measure the concentration of 3 key sulphur compounds:-
• Hydrogen sulfide.
• Methyl-mercaptan.
• Dimethyl sulphide.
This can be helpful in differential diagnosis:
• High concentration of methyl-mercaptan compared to hydrogen sulphide-
periodontitis.
• Only hydrogen sulphide is increased- oral hygiene problem.
• Dimethyl sulphide- extra-oral causes.
Drawback- Cannot detect other than sulphur compounds and some intra-oral and
extra-oral causes can thus be overlooked. 28

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30. TreatmentTreatment

31. General treatment strategies
1.Masking malodor.
2.Mechanical reduction of intra-oral nutrients (substrates) and
microorganisms.
3.Chemical reduction of oral microbial load.
4.Rendering malodorous gases non volatile.
Masking malodor
Treatment with rinses, mouth sprays and lozenges containing volatile with a
pleasant odor have only a short term effect.
Examples are:
• Mint containing lozenges.
• Aroma present in rinses. 31

32. Another pathway is to increase
the solubility of malodorous
compounds in saliva by
increasing secretion of saliva
which can be achieved by
chewing gum.
32

33. Mechanical reduction of intra-oral
nutrients and microorganism
• Because of extensive accumulation of bacteria on the dorsum of tongue,
cleaning of tongue should be emphasised.
• Previous investigation demonstrated that tongue cleaning reduces both
amount of coating s well as number of bacteria and thereby improves
oral malodor effectively.
• Cleaning of tongue can be carried out with normal toothbrush but
preferably with a tongue scraper if coating is established.
• Tongue cleaning using tongue scraper reduces halitosis level 75% after1
week.
• It is best to clean as backward as possible as posterior portion has most
coating. 33

34. Chemical reduction of oral
Microbial load
Chlorhexidine
Most effective anti-plaque and anti-gingivitis agents.
Mode Of Action :
•Disruption of bacterial cell membrane
•Increase in permeability
•Cell lysis and then death
Because of its strong antibacterial effect and superior substantivity in oral
cavity, it provides significant reduction VSCs level and organoleptic rating.
But unfortunately, it at concentration greater than 0.2% causes increased tooth
and tongue staining, bad taste and temporary reduction on taste sensation.34

35. Other chemical Methods
are :
•Essential oils
•Chlorine dioxide : Is powerful oxidising agent
•Aminefluoride/stannous fluoride
•Hydrogen peroxide
•Oxidising lozenges
•Baking soda 35

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