Breath malodor,halitosis ,shazdehahmadi

Introduction
• Halitosis is a general term used to define an
unpleasant or offensive odor emanating from the
breath regardless of whether the odor orginates
from oral or non-oral sources.
• Originates from two latin words:
• Halitus : Breath
• Osis : Disease
Dr.Fardokht Shazdehahmadi

Semantics and Classification
• breath odor can be pleasant, unpleasant, or even disturbing.
• If unpleasant, the terms breath malodor, halitosis, bad
breath, or fetor ex ore can be applied.
• These terms are not synonymous with oral malodor.

There are three main categories of halitosis:
 genuine halitosis
 pseudo-halitosis
 halitophobia

 Genuine halitosis is the term that is used when the breath malodor
really exists and can be diagnose organoleptically or by measurement
of the responsible compounds.
 A distinction should be made between physiologic and a
pathologic halitosis.

Physiologic Halitosis
 The transient disturbing odor caused by food intake (e.g., garlic, onions, and
certain spices), smoking, or medication (e.g., metronidazole) do not reveal a
health problem and are common examples of physiologic halitosis.
The same is true for “morning” bad breath, as
habitually experienced on awakening.
 This malodor is caused by a decreased salivary flow and
increased putrefaction during the night and spontaneously
disappears after breakfast or after oral hygiene measures.

 When an obvious breath malodor cannot be perceived, but the
patient is convinced that he or she suffers from it, this is called
pseudo-halitosis.
 If the patient still believes that there is bad breath after treatment of
genuine halitosis or diagnosis of pseudo-halitosis ,one considers
halitophobia.

imaginary breath odor or halitophobia
• subjects imagine they have breath malodor
• associated with obsessive-compulsive disorders and
hypochondria
• The presence of a psychologist or psychiatrist at the
malodor consultation can be especially helpful for such
patients
• In a recent study of 2000 patients, 16% were diagnosed
with pseudo-halitosis or halitophobia.

• The first one involves an increase of certain metabolites in the blood
circulation (e.g., due to a systemic disease), which will escape via
the alveoli of the lungs during breathing (blood-breath exchange)
and it is commonly referred as “extraoral halitosis.”
• The second pathway (intraoral halitosis) involves an increase of
either the bacterial load or the amount of substrate for these bacteria at
one of the lining surfaces of the oropharyngeal cavity, the respiratory
tract, or the esophagus.
• All types of infections, ulcerations, or tumors at one of the previously
mentioned areas can thus lead to bad breath.

Etiology
• Breath malodor originates from the oral cavity.
• Gingivitis
• Periodontitis
• especially tongue coating
are the predominant causative factors.
• Studies also suggest that oral malodor is associated with the
total bacterial load of anaerobic bacteria in both saliva and
tongue coating.

The most commonly involved bacteria are :
• Porphyromonas gingivalis
• Prevotella intermedia/nigrescens
• Aggregatibacter actinomycetemcomitans
• Campylobacter rectus
• Fusobacterium nucleatum
• Peptostreptococcus micros
• Tannerella forsythia
• Eubacterium spp,
• spirochetes.

Thus, for oral malodor, the unpleasant smell of the breath mainly
originates from
volatile sulfur compounds (VSCs), especially hydrogen sulide,
methylmercaptan, and (less signiicantly) dimethyl sulide
((CH3)2S) Other compounds,
such as the diamines indole and skatole, the polyamines
putrescine and cadaverine, and the carboxylic acids acetic,
butyric, and propionic acid, are also formed by proteolytic
degradation by oral microorganisms

Extraoral causes of halitosis
• Bad-smelling metabolites can be formed/absorbed at
any place in the body (e.g., the liver, the gut) and
transported by the bloodstream to the lungs. Exhalation
of these volatiles in the alveolar air then causes halitosis,
at least when the concentrations of the bad-smelling
metabolites are sufficiently high.

 The extraoral causes are much more difficult to detect,
although they can sometimes be recognized by a typical odor:
 Uncontrolled diabetes mellitus can be associated with a
sweet odor of ketones, which have a sweet smell, like the
odor of rotten apples.
 liver disease can be revealed by a sulfur odor
 kidney failure can be characterized by a fishy odor because
of the presence of dimethylamine and trimethylamine.

Extraoral Causes
 gastro intestinal diseases
 infections or malignancy in respiratory tract
 Chronic sinusitis and tonsillitis
 stomach, intestine, liver or kidney affected by systemic disease
 Hormonal Causes
 Patients with various degrees of hepatocellular failure and/or
portosystemic shunting of blood may acquire a sweet, musty, or even
slightly fecal aroma of the breath, termed fetor hepaticus, which has
been mainly attributed to the accumulation of dimethyl sulfide.

Ozena
• Caused by Klebsiella ozaenae is a rare atrophic condition of the nasal
mucosa, with the appearance of crusts that causes a very strong breath
malodor.

Intraoral Causes

Tongue and Tongue Coating
• The dorsal tongue mucosa, shows a very irregular surface topography . The
posterior part exhibits a number of oval cryptolymphatic units, which roughen
the surface of this area. The anterior part is even rougher because of the
high number of papillae .
• The accumulation of food remnants intermingled with exfoliated cells and
bacteria causes a coating on the tongue dorsum. The latter cannot be easily
removed because of the retention offered by the irregular surface of the
tongue dorsum .

Periodontal Infections
 A relationship between periodontitis and oral malodor has
been shown.
 However, not all patients with gingivitis and/or periodontitis
complain about bad breath, and there is some
disagreement in the literature as to what extent oral
malodor and periodontal disease are related.
 Bacteria associated with gingivitis and periodontitis are
indeed able to produce VSCs.

 Several studies have shown that the VSC levels in the mouth
correlate positively with the depth of periodontal pockets
(the deeper the pocket, the more bacteria, particularly
anaerobic species) and that the amount of VSCs in breath
increases with the number, depth, and bleeding tendency of
the periodontal pockets.

 The prevalence of tongue coating is six times higher in
patients with periodontitis, and the same bacterial
species associated with periodontal disease can also be
found in large numbers on the dorsum of the tongue,
particularly when tongue coating is present.

o Other relevant malodorous pathologic manifestations of
the periodontium are:
o pericoronitis (the soft tissue “cap” being retentive for
microorganisms and debris)
o major recurrent oral ulcerations
o herpetic gingivitis
o necrotizing gingivitis/periodontitis.

Dental Pathologies
 Possible causes within the dentition are deep carious
lesions with food impaction and putrefaction, extraction
wounds filled with a blood clot, and purulent discharge
leading to important putrefaction.
 interdental food impaction in large interdental areas
 crowding of teeth favor food entrapment and
accumulation of debris.
 Acrylic dentures, especially when kept continuously in
the mouth at night or not regularly cleaned, can also
produce a typical smell.

Dry Mouth
• Patients with xerostomia often present with large amounts
of plaque on teeth and an extensive tongue coating.
• The increased microbial load and the escape of VSCs when
saliva is drying up explain the strong breath malodor.
• Other causes of xerostomia are medication, alcohol abuse
,Sjögren syndromeand diabetes.

Fundamentals of Malodor
Detection
• The breath of a person contains up to 150
different molecules.
• The characteristics of the expired molecules
determine whether we can smell them or not.

The perception of the molecules depends on the
following factors:
• The odor itself (olfactory response) can be pleasant, unpleasant, or even
repulsive.
• Each particular molecule has its specific concentration before it can be
detected (threshold concentration).
• The odor power is the extent of concentration that is necessary to increase
the odor score with one unit.
• The volatility of the compound: Malodorous molecules only express
themselves when they become volatile.
• The substantivity: The capacity of the molecule to stay present and thus to
remain the cause of smell.

Diagnosis of Malodor
• start with a thorough questioning about the breath
malodor, eating habits, and medical and dental history.
• This can be done with a questionnaire that the patient fills out.
 ask about the frequency of the halitosis (e.g. constantly, every day),
the time of appearance during the day (e.g. after meals can indicate a
stomach hernia), when the problem first appeared and whether others
have identified the problem (to exclude imaginary breath odor).
 medical history
 Concerning the ENT history.

 The dental history includes questions assessing the frequency
of dental visits, the use of mouth rinses, the presence and
maintenance of a dental prosthesis, and the frequency and
the instruments used for tooth brushing, interdental cleaning,
and tongue brushing and scraping.
 Finally, the patient is asked about his smoking, drinking, and
dietary habits.

Clinical and Laboratory Examination
• Self-Examination:
Licking the wrist and allowing it to dryDr.Fardokht Shazdehahmadi

Oropharyngeal Examination
• The oropharyngeal examination includes inspection of
deep carious lesions, interdental food impaction,
wounds, bleeding of the gums, periodontal pockets,
tongue coating, dry mouth, and the tonsils and pharynx
(for tonsillitis and pharyngitis).

• The tongue coating can be scored with regard to the thickness and surface.
• Several methods have been proposed for the thickness,
• Gross and coworkers proposed an index, ranging from 0 (= no coating) to 3
(= severe coating).
 Miyazaki:assessed the tongue-coating status according to
the area: score 0 = none visible, score 1 = less than one-
third of the tongue dorsum covered, score 2 = less than two-
thirds, and score 3 = more than two-thirds.

• Winkel and coworkers considered both the extension and the thickness of
the tongue coating.
• The dorsum of the tongue is divided into six areas, that is, three in the
posterior and three in the anterior part of the tongue.
• The tongue coating in each sextant is scored as 0 = no coating, 1 = light
coating, and 2 = severe coating. Score 1 is given when the pink color
underneath the coating is still visible; when this is not the case a score 2 is
given.

Organoleptic Rating
• the human nose can smell 10,000 different odors.
• Scoring is normally done according to the intensity scale of
Rosenberg, where 0 represents absence of odor, 1 is given for
barely noticeable odor, 2 for slight malodor, 3 for moderate
malodor, 4 for strong malodor, and 5 for severe malodor.
• In this six-point system, 0 indicates a concentration of odorant
below a threshold, 1 to 4 are increasing occupancy of receptor
binding sites, and 5 is assumed to be close to saturation.

Gas Chromatography
• A gas chromatograph can analyze air, saliva, or crevicular fluid.
• Oral chroma: a small portable gas chromatograph
• It has the capacity to measure the concentration of the three key sulfur componds(hydrogen
sulfide,methylmercaptan,dimethyl sulfide).

Dark-Field or Phase-Contrast Microscopy
 Oral malodor is typically associated with a higher incidence of
motile organisms and spirochetes, so shifts in these
proportions allow monitoring of therapeutic progress.
 Another advantage of direct microscopy is that the patient
becomes aware of bacteria being present in plaque, tongue
coating, and saliva.
 Too often, patients confuse plaque with food remnants.

Portable Volatile Sulfur Monitor
o The portable volatile sulfur monitor (Halimeter, Interscan,
Chatsworth) is an electronic device that detects the presence of
volatile sulfur compounds such as hydrogen sulfide and
methylmercaptan in breath.

Electronic Nose
• Electronic noses identify the specific components of an
odor and analyze its chemical makeup.

the following general treatment strategies can be
applied:
• Masking the malodor
• Mechanical reduction of intraoral nutrients (substrates)
and microorganisms
• Chemical reduction of oral microbial load
• Rendering malodorous gases nonvolatile

Masking the Malodor
• -Rinses
• -Mouth sprays
• -Lozenges containing volatiles
• -Chewing gum
 Another pathway is to increase the solubility of malodorous compounds in
the saliva by increasing the secretion of saliva.

• - Tongue cleaning
• - Tooth brush
• - Inter-dental cleaning
• - Professional periodontal therapy
• - Chewing gum

Chemical Reduction of Oral Microbial
Load
• The active ingredients usually include antimicrobial agents
such as chlorhexidine, cetylpyridinium chloride (CPC),
essential oils, chlorine dioxide, triclosan (TCN), amine
fluoride and stannous fluoride, hydrogen peroxide, and
baking soda.
• Some of these agents have only a temporary effect on the
total number of microorganisms in the oral cavity.

Conversion of Volatile Sulfur
Compounds
o Metal Salt Solutions:
o Metal ions with affinity for sulfur are efficient in capturing
the sulfur-containing gases.
o Zinc is an ionwith two positive charges (Zn++), which will
bind to the twice– negatively loaded sulfur radicals, and
thus can reduce the expression of the VSCs.

Clinically, the VSC inhibitory effect was CuCl2 >
SnF2 > ZnCl2. In vitro, the inhibitory effect was
HgCl2 = CuCl2 = CdCl2 > ZnCl2 > SnF2 > SnCl2 >
PbCl2
Compared with other metal ions, Zn++ is relatively
nontoxic and noncumulative and gives no visible
discoloration. Thus, Zn++ has been one of the most-
studied ingredients for the control of oral malodor.

oHalita
o a solution (0.05% chlorhexidine, 0.05%
CPC, 0.14% zinc lactate, no alcohol),
has been even more efficient than
chlorhexidine alone, suggesting that the
other compounds are also important.
o This is explained by a synergistic effect
between chlorhexidine and CPC on one
hand and by the Zn++ on the other
hand.

Breath malodor,halitosis ,shazdehahmadi

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