2. Extremely common
Majority of adult population has had it at some
point of time
Most of the patients seek help from GPs rather
than a dentist
Dr. Ali Tahir
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: increased
anaerobic activity of pathogens (Traponema
denticola, P. Gingivalis and Bacteroides)
Dr. Ali Tahir
4. Importance
Bad breath can be a sign of undiagnosed disease
Unpleasant condition, can cause huge
embarrassment
Its a big business
Mouthwashes, mints, drops, gums, toothpastes
Dr. Ali Tahir
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. 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. 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. 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. 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. 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
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. History
Onset, duration?
Constant or intermittent, morning, how long
after meals?
Self-report, or reported by others?
Dietary factors, smoking and alcohol use?
Systemic disease and medication
Neurological problems - taste and smell
function?
Currently under stress?
Comprehensive oral examination
Dr. Ali Tahir
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. Strongest odor with lips closed - suggests
nose, sinuses
Strongest odor with nostrils closed - oral or gastric
source
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. 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
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. 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. 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 Zealand
and 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
