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  1. 1. Dr. Ali Tahir
  2. 2.  Extremely common Majority of adult population has had it at somepoint of time Most of the patients seek help from GPs ratherthan a dentist Dr. Ali Tahir
  3. 3.  Bacterial putrifaction of food debris, cells, saliva &bloodProteolysis of proteins  peptides  amino acids free thiol groups and volatile sulphides Can result from any form of sepsis: increasedanaerobic activity of pathogens (Traponemadenticola, P. Gingivalis and Bacteroides) Dr. Ali Tahir
  4. 4. Importance Bad breath can be a sign of undiagnosed disease Unpleasant condition, can cause hugeembarrassment Its a big business  Mouthwashes, mints, drops, gums, toothpastes Dr. Ali Tahir
  5. 5. Compounds commonly produced by mouth bacteria Volatile sulphur compounds  Hydrogen Sulphide – rotten egg  Methyl mecaptan (CH3SH) – Natural gas Skatole Cadaverine  Di-amino acid – spoiled meat Putrescine Oragnic acids  Isovaleric acid, acetic acid, propionic acid, butyric acid Dr. Ali Tahir
  6. 6.  Sleep.  Poor dental hygiene; gingivitis, periodontitis, dentu Food res.(onions, garlic, Broccoli, Cauliflower).  PN drip, sinusitis, nasal polyps, adenoids, foreign Drugs: ISDN, disulfaram. bodies, tonsillitis & tonsilliths. Xerostomia  Ketones (acetone)(anxiety, pyrexia, anticholiner  Trimethylamine (fishy odor)gics, antihistamines, TCA’s, Sjögren’s Syndrome)
  7. 7.  Association with H.Pylori Pharyngeal pouch Gastric outlet probs  Delusional halitosis Severe Reflux  Hallucinatory feature of DKA psychotic illness Renal dysfunction Hepatic dysfunction  Temporal Lobe Epilepsy Respiratory disease  Trimethylaminuria
  8. 8.  About 90% of halitosis originates in the mouth The other 10%  Systemic disease  Diabetes - ketoacidosis - acetone smell  Cirrhosis, liver failure - "mousy", "musty" smells  Renal failure - fishy smell  Leukemia - "decaying blood" smell  Carcinoma Dr. Ali Tahir
  9. 9.  Respiratory system  Exhalation of volatile food compounds  Volatile medications - amyl nitrate  Nasal/sinus/lung infections  Tonsils and tonsiloliths (may not contribute to mouth odor) Dr. Ali Tahir
  10. 10.  Gastrointestinal system (considered rare)  Reflux  Carcinoma  Helicobacter pylori infection (gastric ulcers) Genetic disorders (enzyme deficiencies)  Trimethylaminuria (fishy odor) - autosomal recessive  Cystinuria, cystathionuria heterozygotes  Recessive defects in cysteine metabolism  Very high VSC levels (gut bacteria) Dr. Ali Tahir
  11. 11.  Frustrating to diagnose and treat - expensive Iatrogenic odors  Gauze pad left behind after cleft palate surgery Foreign objects  Inserted up the nose  Young children and developmentally disabled  If undetected, may lead to odor in adults Idiopathic odors  Detectable by others, no apparent oral or non-oral cause  Cause presumed rare, not yet defined Dr. Ali Tahir
  12. 12.  Detectable only by patient - no apparent cause Patients often refuse to accept objective findings Associated with anxiety or depression Can be confused with genetic disorders  Patients may show abnormalities by gas chromatography  Trimethylaminuria heterozygotes  May be more common than once thought  Saliva TMA detectable by patient, but not others Dr. Ali Tahir
  13. 13.  Posterior dorsum of tongue  Depends on tongue coating, deep fissures, worsens with dry mouth Periodontal pockets in periodontal diseases  VSC can be measured in fluid from deep pockets  Mouth odor/VSC proposed as early sign of periodontitis  Not all periodontal patients have mouth odor Other oral lesions  Abcesses, impactions Oral candidiasis  Sweet fruity smell Dr. Ali Tahir
  14. 14. Dr. Ali Tahir
  15. 15.  Tongue bacteria  Streptococcus salivarius - a sign of “health”?  May be dominant in persons w/o halitosis (n = 5)  Gram-negative, proteolytic anaerobes  May predispose towards halitosis  Many novel species (n = 6)  Digest nasal discharges, food debris, saliva components, sloughed cells  Produce VSC, cadaverine  BANA hydrolysis test (Perioscan®) used for detection Periodontal pathogens Dr. Ali Tahir
  16. 16.  History Onset, duration? Constant or intermittent, morning, how longafter meals? Self-report, or reported by others? Dietary factors, smoking and alcohol use? Systemic disease and medication Neurological problems - taste and smellfunction? Currently under stress? Comprehensive oral examination Dr. Ali Tahir
  17. 17. Instruments for odor detection Gas chromatography of breath samples  Most informative  Extremely sensitive and precise  Expensive and cumbersome  Limited to research centers Portable sulfide meter (the Halimeter®)  Can be used in a dental office  Detects only VSC  Must be calibrated regularly to maintain accuracy Dr. Ali Tahir
  18. 18.  Strongest odor with lips closed - suggestsnose, sinuses Strongest odor with nostrils closed - oral or gastricsource Tongue sample to confirm oral origin Odor equally strong from nose or mouth - systemic No discernible odor - verify with others(spouse, friend) Dr. Ali Tahir
  19. 19.  Non-oral etiologies - appropriate referral Oral etiologies  Treat all existing conditions  Attempt to improve hygiene, flossing  Encourage posterior tongue hygiene  Commercial tongue scrapers  Many designs on the market  The gag reflex is a barrier to compliance Dr. Ali Tahir
  20. 20. Dr. Ali Tahir
  21. 21.  Masking fragrances  Mouth rinses, drops, gums, mints, etc. Chemicals that interact with VSC  Oxidizing agents - products based on chlorine dioxide  Only two published studies - short-term  Zinc reacts with VSC  Safe when not used in excess  More published evidence  Reduces VSC levels short-term Dr. Ali Tahir
  22. 22.  Antibacterial products  Should reduce bacterial odors, depending on efficacy Chlorhexidine is considered the gold standard  High substantivity - remains on oral tissues for a long time  Problems with taste and staining Others with published evidence for odor reduction  Two-phase oil-water mouthrinse (cetylpyridinium chloride)  Sulfides lower after 6 weeks of use  More effective than Listerine (essential oils)  Currently available in Israel and Great Britain  Toothpaste with substantive triclosan copolymers - short term Dr. Ali Tahir
  23. 23.  The probiotic concept  Replace “bad” bacteria with “good” bacteria  Lots of ongoing research  FDA approves human trial of probiotic S. mutans  Genetically engineered to be non-cariogenic  Lots of safeguards required Probiotic treatment of bad breath in New Zealandand Australia  S. salivarius strain K12  Indigenous strain that produces antibacterial peptides (BLIS)  Step 1: Use chlorhexidine to knock down tongue flora  Step 2: Replace tongue flora with K12 Dr. Ali Tahir