Oral Malodor - Periodontics Prepared by : Dr. MOHAMMED SHALIK Al-Azhar Dental College

4.  Breath odour can be defined as the subjective
perception after smelling someone’s breath.
 It can be pleasant, unpleasant, or disturbing.
 If unpleasant, the terms
Breath malodor
Halitosis
Bad breath can be applied.
INTRODUCTION

5.  Breath malodor should not be confused with the
momentarily disturbing odour caused by food intake
or smoking because these odour do not reveal a
health problem.
 A persistent breath malodor by definition does
reflect some pathology.
Oral malodor can be defined as foul or
offensive odour emanating from oral cavity.

6. CLASSIFICATION
BASED ON ETIOLOGY.
1. Local factors of pathologic origin,
EG: Poor oral hygiene
Extensive caries
Periodontal diseases
Cyst and tumor of oral and pharyngeal cavity.
2. Local factors of non pathologic origin,
EG: Stagnation of saliva associated with food
debris, denture and excessive smoking.

7. 4) Systemic factors of non pathologic origin,
EG: Diet like garlic, onion, meet and meet
products.
Excessive alcohol consumption.
5) Xerostomia
3) Systemic factors of pathologic origin,
EG: Diabetis mellitus
Liver failure
Lung abcess,
Tuberculosis.

8. BASED ON PATIENT CRITERIA
1) Genuine halitosis : The term used when the breath
malodour really exist and can be diagnosed organo-
leptically or by measurement of the responsible
compound.
2) Pseudo-halitosis : When an obvious breath malodor
cannot be perceived
but the patient is convinced that he or she suffer from
it. This is called pseudo-halitosis.

9. 3) Halitophobia : If the patient still believes that there is a
bad breath after treatment of genuine halitosis diagnosis
is psedo-halitosis, one considers halitophobia which is
recognised psychiatric condition.

10.  In the vast majority (85%) the cause originated from
the oral cavity. Such as Gingivitis, periodontitis, and
tongue coating were the predominant causative
factors.
 Age = 5 to over 80 yrs.
 No gender predominance.

11.  The unpleasant smell of breath mainly originates from
volatile sulfide compounds [VSCs], especially Hydrogen
sulfide (H2S), Methyl mercaptan (CH3SH) and Dimethyl
sulfide.
 Other compounds in mouth air may also be offensive
such as Diamines (Putrescine, Cadaverine), Indole,
Skatole and Butyric or Propionic acid.
 Most of these compounds result from the proteolytic
degradation of peptides present in the saliva by oral
micro-organisms.

12. DENTITION
 Deep carious lesions with food impaction and
putrefaction.
 Extraction wound filled with a blood clot and purulent
discharge leading to putrefaction.
INTRA ORAL CAUSES
 Interdental food impaction
in large interdental areas.
 Crowding of teeth favor
food entrapment and
accumulation of debris.

13.  Acrylic dentures when kept in the mouth at night or not
regularly cleaned can also produce a typical smell
associated with candidiasis.
 The denture surface facing the gingiva is porous and
retentive for bacteria,yeast,debris and all factors that
cause putrefaction.

14. PERIODONTAL INFECTIONS:
 Bacteria associated with gingivitis and periodontitis are
almost all gram negative (Porphyromonas gingivalis,
Prevotella intermedia, Actinobacillus
actinomycetemcomitans, Fusobacterium nucleatum,
Peptostreptococcus micros, Eubacterium species,
Spirochetes)

15. and are known to produce VSCs. It is thus understandable
that the VSC levels in the mouth correlate positively with
the depth of periodontal pockets.
 VSCs increase the permeability of pocket and mucosal
epithelium and therefore expose the underlying
connective tissues of the periodontium to bacterial
metabolites.
 The low oxygen tension in deep periodontal pockets
also results in a low pH and an activation of the
decarboxylation of the amino acids to Cadaverine
and Putrescine, two malodorous diamines.

16.  Other relevant malodorous pathologic manifestations of
the periodontium are Pericoronitis (the soft tissue cap
being retentive for microorganisms and debris)
 Recurrent oral ulcerations
 Herpetic gingivitis
 Necrotizing gingivitis and periodontitis.

17. DRY MOUTH:
 Patients with Xerostomia often present with large
amounts of plaque on teeth, prosthesis and tongue
dorsum.
 The increased microbial load and the escape of VSCs as
gases when saliva is drying up explain the strong breath
malodor.

18. TONGUE AND TONGUE COATING:
 The innumerable depressions in the tongue surface
are ideal niches for bacterial adhesion and growth,
sheltered from cleaning actions.

19.  Desquamated cells and food remnants remain trapped
in the retention sites and consequently can be putrefied
by bacteria.
 A fissured tongue and a hairy tongue have an even
rougher surface.

20.  The accumulation of food remnants intermingled with
exfoliated cells and bacteria causes a coating on the
tongue dorsum.
 The dorsum of the tongue has been considered as a
primary source of oral malodor

21. EAR-NOSE-THROAT:
 The ENT causes include Acute pharyngitis, Purulent
sinusitis and Post nasal drip.
 Post nasal drip is often associated with chronic sinusitis
or regurgitation esophagitis, in which the acidic content
of the stomach reaches the nasopharynx and causes
mucositis.
EXTRA ORAL CAUSES

22. BRONCHI AND LUNG:
 pulmonary causes include chronic bronchitis,
bronchiectasis,and bronchial carcinoma.
GASTROINTESTINAL TRACT:
 The following pathologies might be responsible for less
than 1% of malodor cases:-
1.ZENKERS DIVERTICULUM:(hernia in esophageal wall
allowing accumulation of food and debris and thus
putrifaction)can cause a significant breath odor.
2.GASTRIC HERNIA can cause reflux of gastric contents
up to the oropharynx.

23. 3.REGURGITATION ESOPHAGITIS: Ulceration of
mucosal lining of esophagus by acidic stomach
contents flowing back because of improper function
of sphincter.
4.INTESTINAL GAS PRODUCTION: Some gases like
dimethyl sulfide are not metabolized by intestinal
endothelium and are exhaled through the lungs.

24. KIDNEY:
 kidney insufficiency caused by chronic
glomerulonephritis will lead to increased uric acid
level in the blood,which is expressed in the expired
air with a typical ammonium like breath.
LIVER:
 In patients with cirrhosis ,ammonium will
accumulate in the blood and will be exhaled.

25. SYSTEMIC METABOLIC DISORDERS:
 Type 1 diabetes can result in the accumulation of
ketones.
TRIMETHYL AMINURIA:
 This hereditary metabolic disorder lead to a typical
fishy odor of breath,urine,sweat,expired air, and
other bodily secretions.

26. HORMONAL CAUSES:
 with increased progesterone levels during the
menstrual cycle, a typical breath odor can develop.
MEDICATIONS:
 Metronidazole can cause breath malodor.
 Eucalyptus containing medications impart melon like
odor.
 Arsenic smells of rotten onions.

27. DIAGNOSIS OF MALODOR
MEDICAL HISTORY: The clinician should ask
about;
 the frequency
 time of appearance within a day
 what medication are taken
 whether the patient has dryness of the mouth
or other symptoms

28. CLINICAL AND LABORATORY EXAMINATION
SELF EXAMINATION: the following self testing
can be used:-
 Smelling a metallic or no 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.

29. :
In organoleptic evaluation, a trained judge
sniffs the expired air and assess whether or not this
is unpleasant using an intensity rating, normally
from 0 to 5 as proposed by Rosenberg and
McCulloch.
0- No odour
1- Barely noticeable odour
2- Slight but clearly noticeable odour
3- Moderate odour
4- Strong offensive odour
5- Extremely foul odour

30.  The judge smells a series of different air samples
as follows:-
1.ORAL CAVITY ODOUR: the subject opens the
mouth and refrains from breathing while the judge
places his or her nose close to the mouth opening.
2. BREATH ODOUR: The subject expires through the
mouth while the judge smells both at the beginning
and at the end of the expiration.

31. 3. TONGUE COATING: The judge smells a tongue
scraping. This is to evaluate whether the smell is
similar to the experienced malodor
4. NASAL BREATHE ODOUR: The subject expires
through the nose keeping the mouth closed. When
the nasal expiration is malodorous, where as the air
expired through the mouth is not, nasal/para nasal
cause can be suspected.

33. SPECIFIC CHARACTER OF BREATH
ODOUR
A rotten eggs smell is indicative of VSC’s.
A sweet odour - liver insufficiency; besides VSCs,
aliphatic acids (butyric, isobutyric, propionic acid)
accumulate.
A smell of rotten apples - unbalanced insulin
dependent diabetes, which leads to the
accumulation of ketone bodies.
A fish odour can suggest kidney insufficiency
characterized by uremia and accumulation of
dimethylamine and trimethylamine.

34. PORTABLE VOLATILE SULFIDE MONITOR
 This electronic device (halimeter, interscan, chatsworth,
calif) analyzes the concentration of hydrogen sulfide
and methyl mercaptan, but without discriminating
them.
 The examination should preferably be done after
atleast 4 hours of fasting and after keeping the mouth
closed for 3mins.
 The mouth air is aspirated by inserting a drinking straw
fixed on the flexible tube of the instrument.

35.  The sulfide meter uses a voltametric sensor that
generates a signal when exposed to sulfur
containing gases, especially hydrogen sulfide.
 Absence of breath malodor leads to readings of
100ppb or lower.
 Patients with elevated concentrations of VSCs easily
reached 300-400ppb. This device can only reveal
sulfur containing gases.

36. GAS CHROMATOGRAPHY
 This device can analyze air, saliva, or crevicular fluid
for any volatile component.
 About 100 compounds have been isolated from
saliva and tongue coating.
 Elaborate gas chromatography is only available in
specialized centers but is especially useful for
identifying non oral causes.

37.  It has capacity to measure the concentration of three
key sulfides separately.

38. DARK FIELD OR PHASE CONTRAST
MICROGRAPHY
 Gingivitis and periodontitis are typically associated
with 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. High proportions
of spirochetes in plaque have been associated with a
specific acidic malodor.

40. SALIVA INCUBATION TEST
 For clinical practice 0.5ml of unstimulated saliva is
collected in a glass tube(diameter 1.5cm) and the
tube is flushed with CO₂ and sealed.
 The sealing prevents inflow from outside air and the
glass prevents the smell of the hardware.
 It is incubated at 37℃ in an anaerobic chamber under
an atmosphere of 80% nitrogen, 12% CO₂ and 10%
hydrogen over 3hours.
ELECTRONIC NOSE
 Artificial nose that has the same capacities as the
human nose would be ideal.

41. TREATMENT OF ORAL MALODOR
 The treatment of oral malodor should preferably be
cause related. They are;
 Mechanical reduction of intraoral nutrients
and microorganisms.
 Chemical reduction of oral microbial load.
 Rendering nonvolatile malodorous gases.
 Masking the malodor.

42. MECHANICAL REDUCTION OF INTRAORAL
NUTRIENTS AND MICROORGANISMS
 Because of the extensive accumulation of bacteria on
the dorsum of the tongue, tongue cleaning has been
emphasized.
 Cleansing of the tongue can be carried out with a normal
tooth brush but preferably with a tongue scrapper if a
coating is established.
 This should be gentle cleaning to prevent soft tissue
damage.
 The posterior portion of the tongue has the most
coating.
 Tongue cleaning has the additional benefit of improving
taste sensation.

43.  Interdental cleaning and tooth brushing are essential
mechanical means of dental plaque control. Both
remove residual food particles and organisms that cause
putrifaction.
 Because periodontitis causes chronic oral malodor,
professional periodontal therapeutics needed.
 A one stage full mouth disinfection, combining scaling
and root plaining with the application of chlorhexidine,
reduced the organoleptic malodor levels upto 90%.
 Chewing may control bad breath temporarily because it
can stimulate salivary flow. The salivary flow has a
cleaning capability.

44. CHEMICAL REDUCTION OF ORAL MICROBIAL
LOAD
 ‘Mouth rinsing’ has become a common practice in
patients with oral malodor. The active ingredients in
oral rinses are usually antimicrobial agents such as
Chlorhexidine, Cetylpyridimium chloride(CPC), Essential
oil, Chlorine dioxide, H₂O₂, Triclosan.
CHLORHEXIDINE: it is considered as the most effective
antiplaque and antigingivitis agent. Because of its
strong antibacterial effects and superior substantivity in
the oral cavity chlorhexidine rinsing provides significant
reduction in VSC levels and organoleptic rating.

45.  Rosenberg et al showed that a 0.2% chlorhexidine
regimen produced a 43% reduction in VSC values and a
greater than 50% reduction in organoleptic mouth odor
ratings.
ESSENTIAL OILS: Previous studies evaluated the short time
effect (3 hours) of a Listerine rinse(which contains
essential oils) compared with a placebo rinse.
CHLORINE DIOXIDE: ClO₂ is a powerful oxidising agent that
can eliminate bad breath by oxidation of H₂S,
methylmercaptan, and amino acids, methionine and
cysteine.

46. TWO-PHASE OIL-WATER RINSING: Rosenberg et al
designed a two-phase oil-water rinse containing
CPC that was shown to result in day long
reduction in oral malodor.
TRICLOSAN: Triclosan, a broad-spectrum
antibacterial agent, has been found to be
effective against most oral bacteria and has a
good compatibility with other compounds used
for oral home care.

47. AMINE FLUORIDE / STANNOUS FLUORIDE: The
association of amine fluoride with stannous
fluoride resulted in encouraging reductions of
morning breath odour, even when oral hygiene is
insufficient.
HYDROGEN PEROXIDE : Suarez et al reported that
rinsing with 3% H₂O₂ produced impressive
reductions in Sulfur gas that persisted for 8 hours.
OXIDIZING LOZENGES : Greenstein et al reported that
sucking a lozenge with oxidizing properties
reduces tongue dorsum malodor for 3hours.

48. TOOTH PASTES : Baking soda dentifrices have been
shown to be effective with a 44% reduction of VSC
levels 3 hours after tooth brushing versus a 31%
reduction for a fluoride dentifrice.
CHEWING GUM: chewing gum can be formulated
with antibacterial agent, such as fluoride or
chlorhexidine,thus helping in reducing malodor
through both mechanical and chemical approaches.
CONVERSION OF VSCS: Metal ions with affinity for
sulfur are efficient in capturing the sulfur
containing gases Eg; Zn ,Hg, Cu

49. MASKING THE MALODOR
 Treatments with rinses, mouth sprays and lozenges
containing volatiles with a pleasant odor have only a
short term effect.
 A typical example is mint containing lozenges.
 Another pathway is to increase the solubility of
malodorous compounds in the saliva by lowering the
ph of saliva; a larger volume allows the retention of
larger volumes of soluble VSCs.

50. CONCLUSION
 Breath malodor has important socioeconomic
consequences and can reveal important diseases.
 A proper diagnosis and determination of the etiology
allow initiation of the proper etiologic treatment.
 Although gingivitis, periodontitis and tongue coating
are by far the most common causes of malodor, a
clinician cannot take the risk of overlooking other,
more challenging diseases.
 This can be done by either a trial therapy to deal quickly
with intra oral causes or by a multidisciplinary
consultation.

51. REFERENCES
 Carranza's Clinical periodontology.
10th edition